Health inspection·September 20, 2023

F 0600 physician, Ombudsman, program manager and abuse coordinator notified. Level of Harm - Minimal harm or potential for actual harm Record review of witness statement made by LVN D on 08/30/2023 indicated, On August 31, 2023, at approximately 0730 this nurse answered a call light. Upon arrival, Resident #35 was observed laying in her bed yelling at CNA C. CNA was placing a shirt on elder. Resident #35 yelled, 'you idiot,' to CNA C. CNA C yelled back, I'm not the idiot, you're the idiot. LVN D, immediately intervened and stated, you cannot speak like that to residents. You can not call residents idiots, to CNA C. LVN D started speaking to Resident #35, telling her the next steps to get dressed and out of bed. Resident #35's demeanor quickly changed, she became cooperative and started saying thank you. Resident #35 was assisted to transfer from the bed to the wheelchair with full cooperation. Resident #35 let CNA C brush her teeth and fix her hair. LVN D then wheeled the elder from the bedroom to the dining hall for breakfast. Resident #35 denies pain and had no signs and symptoms of distress. Residents Affected - Few Record review on 09/20/2023 of Resident #35's EHR revealed no psychological evaluation. Record review of Resident #35's PIR dated 09/07/2023 revealed no contact with local police. Review of PIR revealed safe surveys (interviewing other residents taken care of by CNA C) for 10 residents. All 10 residents stated they felt safe at the facility and had not experienced abuse or neglect of any kind. Record review of staff training showed no Abuse and Neglect training since 03/2023. Interview on 09/19/2023 at 10:00 a.m., CNA C stated she was terminated over the incident with Resident #35. CNA C stated on 08/30/2023 she was assisting Resident #35 with getting dressed and up for breakfast. CNA C stated Resident #35 often became combative and yelled during care. CNA C stated on 08/30/2023, Resident #35 started yelling at CNA that she was an idiot. CNA C stated she put the call light on for assistance with Resident #35 because she was being combative and yelling that day. CNA C denied telling Resident #35 that she was an idiot. CNA C stated she did recall LVN D intervening, but she had not asked CNA C to leave the room and continued to let CNA C dress and groom Resident #35. During an interview on 09/20/2023 at 9:30 a.m., the DON stated LVN D reported verbal abuse by CNA C to Resident #35 on 08/30/2023. The DON stated LVN D overheard CNA C verbally abuse Resident #35 by telling her she was an idiot. The DON stated LVN D intervened and assessed the resident and concluded no psychosocial damage was done. The DON stated Resident #35 had Alzheimer's Disease and was unable to remember moment to moment. The DON stated that verbal abuse was still abuse and it was the policy of the facility that the residents live in an environment free from any type of abuse or neglect. During an interview on 09/20/2023 at 10:00 a.m., Resident #35 was unable to recall any altercation with a staff member. Resident #35 repeated thank you for checking on me, over and over. In a phone interview on 09/20/2023 at 12:30 p.m., the Administrator stated he did a thorough investigation. The Administrator stated he was notified promptly by LVN D of the occurrence of potential verbal abuse. CNA C was immediately suspended pending investigation. The Administrator stated he continued by doing safe surveys for the other residents to ensure they felt safe and had not experienced any signs of abuse. The Administrator stated he interviewed other employees that had been working with CNA C to ensure they had not witnessed abuse of any kind. He assigned the staff an extra in-service to complete regarding abuse, neglect, and exploitation. The Administrator stated the deciding factor for his confirmation of abuse was the definition of abuse by CMS guidelines being . 'Willful, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' The Administrator stated CNA C had never been accused of any type of abuse or misconduct prior. Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment, .VII. Reporting/Response (483.13(c)(1)(iii), 483.1 (c)(2) and 483.13 ( c )(4)): Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to HHSC immediately after the initial allegation is received Event ID: Facility ID: 676359 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. Residents Affected - Many The facility failed to ensure the floor was clean under the fryer. The facility failed to ensure a clean stove and cooking area. The facility failed to ensure a clean food warmer. The facility failed to ensure all food items were labeled and dated in the Reach in Freezer #1 and Reach in Freezer #2. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination. Findings included: Record review of an undated Daily & Weekly Salad Prep Responsibilities indicated, Daily .Sweep and mop area .Saturday: Clean and sanitize mobile warmer. Record review of an undated Daily & Weekly PM [NAME] Responsibilities indicated, Daily .sweep and mop area .ensure labeling in reach in .ensure shelves and equipment are wiped down .ensure equipment is clean .Monday .warmer box . Record review of a Repair Log dated 1/23 - 8/23 indicated the ice maker was last cleaned in 8/23. Record review of a Maintenance Work Order #60784 indicated, Clean ice machine .1. Remove ice, 2. Put some ice into ice chest for staff to use, 3. Disinfect with spray bleach, 4. Delime, 5. Clean machine according to manufactures spec . The order indicated the ice machine had been due to be cleaned on 08/08/2023. The order indicated the task had been completed by maintenance staff on 08/21/2023. Record review of a Maintenance Work Order #61322 indicated, Clean ice machine .1. Remove ice, 2. Put some ice into ice chest for staff to use, 3. Disinfect with spray bleach, 4. Delime, 5. Clean machine according to manufactures spec . The order indicated the ice machine was due to be cleaned on 09/12/2023. The order indicated the task had not been completed. During an observation on 09/18/23 at 8:56 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. During an observation on 09/18/23 at 9:00 a.m., inside Reach in Freezer #1 in the pantry there was one large, round food item with a pastry crust and orangish brown filling with no date or label. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm There were 2 large, round food items with a pastry crust. The filling was creamy looking with red swirls. There was no date or label. There was 1 plastic bag full of a brown food item with no date or label. There were 2 large round loaves of a brown food item, loosely wrapped with no date and no label. There were 2 loaves of a brown food item with no date or label. There was 1 package of light brown round food items with no label. There were multiple pink sticky spills in the bottom of the freezer. Residents Affected - Many During an observation on 09/18/23 at 9:05 a.m., inside Reach in Freezer #2, inside the kitchen, there were 5 bags of an unknown white food item with no date or label. There were 5 bags of an unknown green breaded food item with no date or label. There were 4 bags of a light brown food item with no date or label. During an observation on 09/18/23 at 9:08 a.m., inside the ice machine there was a line of a pink and black substance along a medal edge and was touching the ice in the machine. During an observation on 09/19/23 at 10:40 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. There were no changes from the observation on 09/18/23. There were fresh food splashes that had dripped down the side of the stove. During an observation on 09/20/23 at 9:16 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. There were no changes from the observations on 09/18/23 and 09/19/2023. There were fresh food splashes that had dripped down the side of the stove. During an observation on 09/20/23 at 9:30 a.m., kitchen staff were preparing food on stove top. The metal shelf over the stove top had an oily substance with droplets dripping from the shelf. During an observation and interview on 09/20/23 beginning at 9:32 a.m., [NAME] Prep B said everyone in the kitchen was responsible for dating and labeling food items. She said the morning dishwasher was responsible for dating and labeling foods as they were delivered to the facility. She said each staff member had a daily cleaning schedule. She said she was responsible for wiping down the warmer, fryer, and stove. She said the maintenance supervisor was responsible for cleaning the ice machine. A Daily & Weekly Salad Prep Responsibilities list was hanging near her station. During an observation on 09/20/23 at 9:46 a.m., the Dietary Manager said the cooks were responsible for dating and labeling food items. He said he had a staff member that was responsible for checking for undated and unlabeled food items three times a week. He said on Monday, 09/18/23 she was out with a sick family member and was not able to check for undated or unlabeled food items. He said food not being dated or labeled could affect all residents because it could cause illness from expired food. He said keeping food items dated and labeled was an on-going battle. He said maintenance was responsible for cleaning the ice machine. He said it was cleaned once a month. He said the cooks were supposed to wipe down equipment daily. He said he had a porter that came in during the afternoon that was supposed to sweep and clean the floors including under the fryer. He said unclean equipment could lead to residents getting sick because of bacteria growth. He said this included the mold in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 ice machine. He said unclean equipment could lead to cross-contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/20/23 at 10:45 a.m., the Maintenance Supervisor said maintenance staff cleaned the ice machine monthly when they de-scaled the machine. He said kitchen staff was then responsible for cleaning in between those times. He said he did document the schedule and would provide a copy. He said it was due to be cleaned for this month. Residents Affected - Many During an interview on 09/20/23 at 12:34 p.m., the Administrator said all foods should be dated and labeled. He said the culinary staff were responsible. He said if food was served past it's prime, there could be some foodborne illness. He said the ice machine should be kept clean. He said the kitchen equipment should have been kept clean. He said keeping equipment clean was the responsibility of the culinary staff. He said maintenance should deep clean the ice machine on a monthly basis. He said unclean equipment in the kitchen could attract rodents. He said there was a potential for foodborne illness. Review of an undated Food Storage and Handling facility policy indicated, It is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner .All cases are opened, unpacked and stored on shelves in the storeroom, walk-in and or freezer. New stock is placed behind previous food stock to guarantee use of older stock. A FIFO (first in/first out) inventory process is in effect .All cooked foods, pre-packaged open containers, protein-based salad, desserts and canned fruits are labeled, dated, and securely covered . Review of an undated Food Safety Labeling Procedures indicated, .To assure that all food or beverage items that are either: stored, opened, prepared or leftover in out kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries will be clearly identified at to the item name/product, the production or opened date and the use by date. To assure our customers are receiving the safest and highest quality food products possible and that our facilities meet the requirements set by local, state and federal guidelines . Review of an undated Wash, Rinse, and Sanitize policy indicated, .Food contact surfaces in continuous use must be cleaned and sanitized at least every 4 hours .Check all work surfaces .the parts of equipment and utensils that contact food, such as the interior of ice machines/ice bins .food storage or display containers, etc . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #28). Residents Affected - Few The facility failed to ensure the refrigerator for Resident #28 did not contain expired lunch meat. This failure could place resident at risk for food borne illnesses. Findings included: Record review of a face sheet dated 10/07/2021 indicated Resident #28 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including post-polio syndrome (the result of a deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), hypertensive heart (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), and insomnia (a common sleep disorder). Record review of the MDS dated [DATE] indicated Resident #28 understood others and made herself understood. The MDS indicated Resident #28 was moderately cognitively impaired with a BIMS score of 09. The MDS indicated Resident #28 did not reject evaluation or care. The MDS indicated Resident #28 required a one- person physical assist for eating. Record review of a care plan for Resident #28 dated 09/20/2023 revealed Resident #28 required a therapeutic diet. During an interview an observation on 09/18/2023 beginning at 10:00 a.m., Resident # 28 stated that he eats lunch meat from his refrigerator daily as snacks. He stated that the black forest ham in thehis refrigerator belonged to him is was hi. s and he eats from it. He stated that staff sometimes clean his refrigerator. Black forest ham lunch meat stored in Resident # 28's personal refrigerator expiration date was 6/28/2023. During an interview and observation on 09/19/23 beginning at 01:22 p.m., CNA A removed the expired food from the refrigerator. She stated that she believes CNAs are supposed to throw away expired food, but she is was not sure whose responsibility it iswas. She stated that residents could be placed at risk of illness by eating food past its expiration date. During an interview on 09/20/2021 at 10:05 a.m., Housekeeping Supervisor stated that she has been the housekeeping supervisor for four months. She stated that housekeeping and nursing staff should throw away food from personal refrigerators if they are expired. She stated that it is was housekeeping that keeps refrigerators clean. She stated that nurses and aides could throw away expired food as well if they noticed it. She stated that residents could be placed at risk of food poisoning if they eat expired food especially expired meat. During an interview on 09/20/2023 at 12:38 p.m., The Administrator stated that staff are to periodically check the fridge for spoiled food and clean personal refrigerators. He stated that housekeeping is was responsible to ensure that expired food is was thrown away and that personal refrigerators (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Retirement Community 4100 Moores LN Texarkana, TX 75503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 are clean. He stated that residents could be placed at risk for foodborne illness by eating expired food. Level of Harm - Minimal harm or potential for actual harm Record Review of facility policy titled, Food brought by Family/Visitors revised October 2017 reveals that, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The nursing staff will discard perishable foods on or before the use by date. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676359 If continuation sheet Page 8 of 8