Health inspection·June 27, 2023

F 0578 Record review of Resident #7's care plan, dated [DATE], revealed a care plan for DNR. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #7's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under section b unchecked boxes that should have indicated the legal guardian, agent or proxy on the behalf of an adult person and under the witness's section revealed no witnesses. Residents Affected - Few Resident #18 Record review of Resident #18's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (loss of cognitive function), congestive heart failure (fluid around heart), and anxiety. The face sheet also revealed under the advance directive section - ADC: Do not resuscitate - DNR. Record review of Resident #18's physician order summary dated [DATE] revealed the following order: ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #18's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #18's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician statement the date, license # and printed name were blank. During an interview on [DATE] at 09:00 AM with the ADON/MDS Nurse, she stated the admitting nurse was responsible to check the DNR form for accuracy. She verified that Residents #3, #7 and #18 had DNR orders in the EMR and verified missing information on the OOH DNR's. She stated she had been trained on how to complete a DNR form. She stated an incomplete DNR was not valid. She stated her expectations were for the DNR to be filled out completely and accurate. She stated, These DNR's was brought in by the family and could have been completed when the doctor was in facility. She stated the potential negative outcome could be having to perform CPR and go against residents wishes. During an interview on [DATE] at 12:30 PM with the Administrator, she stated the DON was responsible to check the DNR form for accuracy. She verified that Residents #3, #7 and #18 had DNR orders and verified missing information on the OOH DNRs for Residents #3, #7 and #18. She stated an incomplete DNR was not valid. She stated her expectations were for the DNR to be complete. She stated the potential negative outcome could be the resident would need to be resuscitated if the Resident's DNR was not complete. During an interview on [DATE] at 12:50 PM with LVN B, she stated a DNR form was an order to not resuscitate the resident if their heart had stopped beating. She stated when the resident was admitted to the nursing home if they came in with a DNR they check it to make sure it was complete. If they do not have a DNR and wish to be a DNR they will complete the form when the doctor was in house. She stated the resident's DNR was kept in the resident's paper chart, in the EMR and in the front of the narcotic book on the medication cart. She stated she had been trained on how to properly complete a DRN form. She stated an incomplete DNR form was not vailed. She stated if the form was incomplete, they would start CPR and that would be going against the residents wishes. During an interview on [DATE] at 01:45 PM with the DON, he stated the charge nurse, DON or person who initiated the DNR was responsible to check the form for accuracy. He stated the DNR was a do not resuscitate order based on the resident's wishes. He verified that Residents #3, #7 and #18 had DNR orders. He verified missing information on the OOH DNR's for Residents #3, #7 and #18. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 2 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0578 Level of Harm - Minimal harm or potential for actual harm there was currently no system in place to monitor DNR's for accuracy. He stated all staff had been trained on how to complete a DNR. He stated an incomplete DNR was not valid. He stated his expectations were for the DNR's to be complete and accurate. He stated the potential negative outcome could be having to go against residents wishes. Residents Affected - Few Record review of the facility's policy, DNR No Extraordinary Life-Saving Measures, undated, revealed: No guidance regarding the instructions in completing the DNR form within the policy. Record Review of the Instructions for Issuing An OOH-DNR Order (undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 3 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents had the right to send and receive mail promptly on Saturdays, in that: Residents Affected - Some Resident mail was delivered and available at the facility's US Post Office mailbox on Saturday's but was not delivered to residents until Monday. This failure could place residents at risk for a decline in their psychosocial well-being and not receiving important mail in a timely manner. The findings include: During a confidential Resident Council meeting interviews, 8 of 8 residents stated they had not seen any mail deliveries on Saturday's. One resident stated the staff go to the post office and pick up mail. On 6/26/23 at 3:58 PM an interview was conducted with the Administrator regarding mail delivery in the facility. She stated the DON picked up the mail every weekday from the US post office and passes it out. The post office building is open on Saturday, but the window service was not. The mailboxes were accessible, and the facility had a mailbox there. She added that if items were delivered to the physical address, the staff get it and give it to the residents. No one goes to the PO Box on Saturday. Staff pass out the mail once it is at the facility and that was for all days. She further stated residents do receive mail through the facility's PO Box. She stated if resident mail was received at the PO Box on Saturday, they would not get it until Monday. On 6/27/23 at 2:58 PM an interview was conducted with the Administrator regarding mail delivery in the facility. She stated the individual responsible for ensuring residents received their mail was the Administrator. Her expectation was that she expected residents to get their mail daily. Regarding what could result from residents not receiving their mail in a timely manner, she stated a decline in quality of life. Record review of the current website for the local post office US Postal Service (https://tools.usps.com/find-location.htm?location=1372122) revealed the following documentation, .Hours .Last Collection Hours - Mon-Fri 4:00 pm, Sat 8:45 am . Lobby Hours - Mon-Fri 12:01 am-11:59 pm, Sat 12:01 am-11:59 pm . PO Box Access Hours - Mon-Fri 12:01 am-11:59 pm, Sat - 12:01 am-11:59 pm Record review of the facility's current undated policy titled Resident Mail. Section 8 - Activity Department, Policy: Resident Mail, revealed the following documentation, The healthcare center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations. Procedure: . 2. All resident mail is delivered to residents unopened on the day it is delivered to the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 4 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 4 of 13 residents (Residents #4, #6, #7, #13) reviewed for PASRR screening, in that: Resident #4 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of unspecified psychosis. Resident #6 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive disorder. Resident #7 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive disorder. Resident #13 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive disorder. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #4 Record review of the Order Summary Report dated 6/25/23 for Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old with the following diagnoses of unspecified, psychosis, not due to a substance or non-physiological condition, mild cognitive impairment of uncertain or unknown ideology, and psychotic disorder, with delusions, due to non-physiological condition. Further record review of the Order Summary Report revealed the resident had no orders for psychoactive medications and no primary diagnosis of Alzhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #4 with an assessment date of 2/4/20 revealed that Section C0100. Mental illness documented, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the significant change MDS assessment for Resident. #4, dated 3/17/23 revealed in section A1500 that the resident had not been evaluated by level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Further record review revealed that the resident had a BIMS score of four indicating cognitive impairment. The active diagnoses listed reflected the resident had a psychotic disorder (other than schizophrenia). Record review of the current care plan for Resident #4 revealed a Focus Resident #4 has potential for mood problem related to diagnoses of psychotic disorder with delusions and delirium, due to known physiological condition; benign neoplasm of the brain, and as a specified psychosis. Date initiated 2/11/20. Revision on: 2/27/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 5 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0644 Resident #6 Level of Harm - Minimal harm or potential for actual harm Review of Resident #6's face sheet dated 6/25/23 revealed an [AGE] year-old-female with an admission date of 07/21/21 with primary admitting diagnosis dated 07/21/21 to include major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and no primary diagnosis of Alzhimer's/Dementia. Residents Affected - Some Review of Resident #6's PASRR assessment Level 1 Screening dated 07/21/21, under Section C0100 revealed documentation indicating Resident #6 did not have a mental illness. The PASRR Level I screening was also certified by the Assessor on 07/21/21 indicating the information was true and accurate. Record review of Resident #6's Quarterly MDS assessment, dated 03/21/23, revealed Resident #6 had a BIMS score of 02, which indicated the resident's cognition was severely impaired. Section I (Active Diagnoses revealed a diagnosis of depression. Review of Resident #6's Annual MDS assessment dated [DATE], revealed in section A1500 revealed the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Record review of Resident #6's care plan revealed a focus: [Resident #6] has a major depressive disorder diagnosis date initiated 08/03/21. Record of Resident #6's physician's orders dated 06/25/23 revealed a diagnosis of major depression disorder. The orders reflected the resident was prescribed Lexapro 10mg by mouth in the afternoon, dated 4/26/23. Record review of Resident #6's physician's progress noted dated 4/3/23 revealed resident problems to include major depression disorder. Resident #7 Record review Resident #7's Order Summary Report dated 6/25/23 revealed that Resident #7 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of, major depressive disorder, psychotic disturbance, mood, disturbance, and anxiety . Further record review of the Order Summary Report revealed an order for antidepressant Venlafaxine ER oral tablet extended release 24-hour 150 mg (Venlafaxine, HCl) give one tablet by mouth one time a day for anxiety. Order dated 6/15/23 and start date 6/16/23. The Order Summary Report further revealed no primary diagnosis of A;zhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #7 revealed an assessment date of 3/22/21. Further record review revealed that under Section C0100. Mental illness it documented, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the admission MDS assessment dated [DATE] for Resident #7 revealed in section A1500 that the resident had not been evaluated by level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The resident had a BIMS score of 6, which indicated cognitive impairment. Under active diagnoses the resident was documented as having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 6 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0644 depression (other than bipolar). Level of Harm - Minimal harm or potential for actual harm Record review of the current care plan for Resident #7 revealed a Focus: Resident #7 receives anti-depressant venlafaxine HCL ER. Date initiated: 10/25/19. Created on: 10/25/19. Further record review revealed a Focus: Resident #7 has a diagnosis of major depressive disorder, recurrent, moderate. Prescription for venlafaxine HCL ER 150 mg Q a.m. Date initiated 7/31/19. Revision on: 11/12/19. An additional Focus reflected: Resident #7 receives anti-depressant medication (Effexor) related to depression. Date initiated 8/9/19. Revision on: 8/9/19. Residents Affected - Some Resident #13 Record review of Resident #13's Order Summary Report dated 6/25/23 revealed Resident #13 was admitted to the facility on [DATE] and was [AGE] years old with the following diagnoses of unspecified mood (affective) disorder, major depressive disorder, single episode, in partial remission, other specified depressive episodes, major depressive disorder, recurrent unspecified, anxiety disorder, unspecified . Further record review of the Order Summary Report revealed the resident had orders for the following medications: Anti-anxiety/ Anxiolytic Buspirone HCl oral tablet 10 mg (Buspirone HCl). Give one tablet by mouth two times a day for anxiety disorder. Ordered 84/18/23. Start date 4/18/23. Depakote oral tablet delayed release 125 mg (divalproex sodium). Give one tablet by mouth two times a day for mood disorder. Ordered date 4/18/23. Start date 4/18/23. Antidepressant Duloxetine HCl oral capsule delay release sprinkle 40 mg (duloxetine HCl) give one tablet by mouth one time a day for major depressive disorder. Order date 4/18/23. Start date 4/19/23. Further reveiw of the Order Summary Report revealed resident no primary diagnosis of Alzhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #13 had an assessment date 04/18/23. Further record review of Section C0100. Mental illness revealed the following, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the admission MDS assessment for Resident #13, dated 4/25/23 revealed in section A1500 that the resident had not been evaluated by a level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The resident had a BMS score of 15 which indicated cognition is intact. Under active diagnosis the resident was listed as having anxiety disorder and depression, (other than bipolar). Record review of the current care plan for Resident #13 revealed a Focus: the resident uses anti-anxiety medication's related to anxiety disorder. Date initiated: 4/27/23. Created on: 4/27/23. The resident's current care plan had another Focus: the resident uses anti-depressant medication related (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 7 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0644 to depression. Date initiated: 4/27/23. Created on: 4/27/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/27/23 at 09:00 AM with the ADON/MDS Nurse, she stated she was responsible for PASRR accuracy. She stated she was not aware that major depressive disorder was a qualifying diagnosis to trigger a positive PL1. She verified Resident #6 was admitted on [DATE] with a diagnosis of major depressive disorder. She verified Resident #6's PL1 was negative and dated 07/21/21. She stated she was responsible for PL1 corrections. She stated her expectations was for the PL1 to be accurate. She stated, Ttraining is available but whether I made it or not is not confirmed. She stated the potential negative outcome could be lack of services and not knowing how to treat residents correctly. Residents Affected - Some On 6/27/23 at 2:03 PM an interview was conducted with the ADON/MDS Nurse regarding the inaccurate PASRR PL 1's conducted for Residents #4, #7, and #13 when they had mental illness diagnoses. She stated, she did not realize that the residents should have been documented as positive PL 1 due to their mental illness diagnosis. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the ADON/MDS nurse was responsible for the PL1 on admission and corrections. She stated the ASDON/MDS Nurse hads been trained on PASRR. She stated she was not aware major depressive disorder was a qualifying diagnosis. She stated the potential negative outcome could be the resident not receiving services they wereare entitled to receive from PASRR. During an interview on 06/27/23 at 01:45 PM with the DON, he stated the ADON/MDS nurse was responsible for the PL1. He stated he has had training on PASRR. He stated the potential negative outcome could be not being able to treat residents properly. Record review of the facility policy titled Preadmission Screening and Resident Review (PASRR), undated, revealed the following: It is the policy of the facility to ensure the all residents are screen and appropriately addressed via the PASRR process as outlines by regulations. The results of this process will be used to develop, review and revise the residents care plan. This facility will not admit any new residents with: 1. A mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, a. that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, whether the individual requires specialized services; or Coordination of the results and recommendations of the PASRR screen into a resident's assessment, care planning, and transitions of care will be performed to achieve the resident's highest practicable level of well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 8 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0644 Procedure: Level of Harm - Minimal harm or potential for actual harm 1. The facilities designated staff will review all potential admission for the possible positive PASRR conditions and ensure that CMS Preadmission guidelines are followed. Residents Affected - Some Record review Detailed Item by Item Guide for Referring Entities to Complete the PASRR Level Screening Form, dated June 2023 from Texas HHS website https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/resources/pasrr/pasrr-item-by-it revealed the following: Section C: PASRR Screening Items C0090 through C0300 Page 14 Examples of MI diagnoses are: Mood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 9 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 13 residents (Residents #19) reviewed for care plans as follows: Resident #19 did not have a care plan for ADL Functional/Rehabilitation Potential. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Record review of Resident #19's face sheet, dated 06/25/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoseis to include atrial fibrillation (irregular heart beat), hypertension (high blood pressure), atherosclerotic heart disease (narrowing of the arteries), muscle weakness, difficulty walking, and repeated falls. Record review of Resident #19's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the Resident #19's cognition was not impaired. Section V CAA summary revealed ADL Functional/Rehabilitation Potential triggered and was marked yes to be included in the care plan . Section G Functional status revealed Resident #19 required extensive assistance with one person assist for bed mobility and personal hygiene. Resident #19 requires extensive assistance with two persons assist for transfers, dressing, and toilet use. Resident #19 was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer. Resident #19 requires a wheelchair for mobility. Record review of Resident #19's care plan, dated 03/13/23, revealed no care plan for ADL Functional/Rehabilitation Potential. During an interview on 06/27/23 at 09:00 AM with the ADON/MDS Nurse, she stated she was responsible for care plans. She stated the care plan was developed based off triggered CAA's. She stated there was no reason a triggered care area should not be care planned. She stated the care plan was to guide and direct staff. She stated the care plan was used by all staff. She stated Resident #19 did not have a care plan for activities of daily living . She stated she started working on a care plan for ADL's and then went to another area. She stated, Some of the ADL care area was combined with other care areas but it does not address everything. She stated there was not a system in place to follow up on care plans. She stated her expectations of what should be included in the care plan was much as possible and more. She stated she had been trained on how to develop care plans. She stated the potential negative outcome could be missing information or safety for the resident. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the MDS nurse and DON were responsible for care plans. She stated she plays no role in the development of the care plans. She stated she can make suggestions. She stated the care should be resident centered. She stated she does not know about triggered care areas. She stated the care plan was used to provide care the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 10 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0656 Level of Harm - Minimal harm or potential for actual harm residents need safely. She stated the nurses and MDS use the care plan. She stated there was no system in place to follow up on care plans. She stated she does not know why the triggered care area was not care planned. She stated she expectations was for the care plan to be accurate. She stated the staff have been trained on care plans. She stated the potential negative outcome could be incorrectly caring for the resident or miss something important related to the care of the resident. Residents Affected - Few During an interview on 06/27/23 at 12:50 PM with LVN B she stated the care plan was the overall plan, goals and how to care for each resident. She stated care planned ADL's show how each staff member care for the resident. She stated, It tells us if the resident was a 2 person assist or 1 person assist. She stated, The care plan had goals which lets us know if the resident was declining or not. She stated she had been trained on care plans. She stated the potential negative outcome for missing care areas could be not caring for the resident appropriately, not meeting their needs and not being able to tell if they were adjusting as needed . During an interview on 06/27/23 at 01:45 PM with the DON, he stated the ADON/MDS nurse and DON were responsible for care plans. He stated his role was developing and implementing the care plan. He stated the care plan was developed using the admitting diagnoseis and ADL's. He stated all triggered care areas should be care planned. He stated, The care plan was used to make sure we our caring for the resident they we are supposed to. He stated information that should be included in the care plan was admitting diagnoseis, behaviors, triggered care areas, certain medications and the resident's wishes. He stated the potential negative outcome could be not knowing a decline. He stated there was a system to follow up on care plans. He stated he was trained on how to develop care plans. Record review of the facility's policy, Comprehensive Care Plans, undated, revealed: Procedures: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and the timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the residents highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 11 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident with a urinary catheter (Resident #27); in that: The facility failed to ensure catheter related physician's orders were followed and failed to position the catheter drainage bag and tubing in a manner that promoted gravity flow and prevented infections. These failures could place residents at risk for urinary tract infections. The findings include: Record review of the Order Summary Report dated 6/25/23 for female Resident #27 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of obstructive and reflux uropathy (obstruction of urine flow disorder), chronic pulmonary embolism (lung clotting disorder), Alzheimer's disease, unspecified (mental disorder), and aphasia following cerebral infarction (communication disorder following a stroke). Record review of the Order Summary Reports for Resident #27 dated 6/25/23 revealed the following order: Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria (blood in urine), or leakage around the catheter every shift. Order status - Active. Order date - 3/11/23. Start date - 3/11/23. Record review of the Order Summary Reports for Resident #27 dated 6/25/23 revealed the following order, Use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate sites of securement daily, and PRN every shift. Order status - Active. Order date 3/11/23. Start date 3/11/23. Record review of the significant change MDS assessment for Resident #27 dated 4/5/23 reflected the resident had an indwelling catheter. The resident had no BIMS score and was documented as cognitively severely impaired. Record review of the current care plan for Resident #27 reflected a Focus of, The resident has indwelling catheter: related to infection, obstructive uropathy, poor fluid intake, pressure sore. Date initiated: 3/22/23. Revision on: 3/22/23. Interventions included, Monitor for signs and symptoms of discomfort on urination and frequency. Date initiated: 3/22/23 . Monitor/document for pain/discomfort due to catheter. Date initiated: 3/22/23. Record review of the April 2023 MAR for Resident #27 revealed there was an order for Bactrim DS oral tablet 800-160 mg. Give One tablet by mouth two times a day suspected UTI for five days. Start date 4/17/23. Further record review of the MAR revealed that the medication was given from 4/17/23 through 4/22/23. Record review of the Progress Notes for Resident #27 dated 4/20/23 at 10:15 PM, Nursing Note. Note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 12 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few text: 16 French Foley catheter inserted per (physician) order for prolonged urinary retention . Catheter tubing secured to left upper thigh with Stat Lock (securing device). Drainage bag, attached, tubing, coiled loosely with no kinks and bag is below the bladder level on the bed frame with 100 cc light yellow immediate return noted, resident tolerated without complaint. Record review of the facility document titled Case Detail - Quick View revealed the following documentation regarding Resident #27, infection details, Onset date 4/17/23. Infection type. Bacterial. Infection - unknown. Infection site - urinary tract. Signs and symptoms - urinary complaints. Create date - 4/17/23 . Associated documentation. Record type - pharmacy order. Description - Bactrim DS oral tablet 800-160 mg. On 6/26/23 at 9:01 AM Resident #27 was observed in bed and the bed was in a low position. The catheter drainage bag was attached to the bed and the tubing was looped and was not positioned for gravity drainage/flow. During an observation on 06/26/23 09:28 AM revealed CNA A provided catheter care to Resident #27. Resident #27 had a catheter in place attached to a closed drainage bag. The tubing was not attached to the resident's leg. The tubing and catheter tubing laid over the left leg and was not secured. The tubing laid on the bed and the closed drainage bag hung on side of bed. On 6/26/23 at 1:06 PM Resident #27 was observed in a low positioned bed. Her catheter drainage bag and tubing were contacting the floor. Her urine was slightly cloudy and contained sediment. The tubing was looped low, below the drainage bag inlet and not in a position for gravity flow. The resident had a slight urine odor. On 6/26/23 at 4:30 PM an observation was made of Resident #27 in her low positioned bed. The catheter drainage bag and tubing were contacting the floor. The tubing was also looped in a manner that would not provide for gravity flow. On 6/26/23 at 4:33 PM an observation and interview were conducted with CNA A regarding Resident #27's catheter drainage bag and tubing. Observation of the resident revealed she was in a low positioned bed, and there was no evidence of any device attached to the resident to prevent the tubing from moving. At that time the CNA stated, to secure/stabilize the tubing, staff twisted the tubing connector and attach the tubing to the bed and clip it on the sheet. She stated the resident moved around in bed and that was the reason the resident's tubing was not being secured as ordered. She stated Resident #27 had the securing leg straps but tore them off. She added she only used the clip on the sheet to keep the tubing in place. She further stated staff lowered the resident's bed to prevent falls and had noticed that this caused the catheter drainage bag to contact the floor at times. She added that staff had not asked the DON for guidance for the issue of the drainage bag contacting the floor. Regarding what could happen if the catheter drainage bag and tubing contacted the floor, she stated residents could get infections. On 6/26/23 at 4:45 PM an interview was conducted with the DON regarding Resident #27's catheter. The DON stated if the drainage bag and tubing were touching the floor, there should have been a barrier between them and the floor; the bag and tubing should now be changed out. Regarding what could result from the tubing and catheter drainage bag contact in the floor, he stated, microorganisms could get in the tubing and in the bag. He added, staff would use a strap to secure the tubing as ordered. He added that the resident used to pull on the catheter tubing. He stated he was not aware of the bag and tubing contacting the floor and was not aware that the resident did not have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 13 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0690 stabilizing/securing strap/device as ordered. Level of Harm - Minimal harm or potential for actual harm On 6/27/23. 10:46 AM an interview was conducted with the DON related to catheter care and services. Regarding if Resident #27 had had any UTIs, he stated not lately, but staff had noticed sediment in her urine when they changed her catheter yesterday (6/26/23), so they got a UA. He added Resident #27 had a UTI in April 2023, which was her first one. Regarding if he had conducted any training or in-services with staff regarding catheter care, he stated, he was going to do one, but had not prior to the survey. Regarding why he felt the catheter issues occurred, he stated, it was just an education thing; staff not educated properly. He added, he was aware of the order for the strap device and had initiated the order because he was told the resident tugged at the tubing. He stated the resident had not had any issues with the strap since it was reapplied. Regarding whom was responsible for ensuring that catheter care was conducted as ordered and correctly, he stated, the charge nurse, and himself/DON. He stated he expected the CNAs to report issues and would expect, if issues were found, to do a UA and change the bag. Regarding what could result from the catheter issues observed, he stated, UTIs, septicemia (bacterial infection), resulting in dehydration. Without wearing the strap, it could have caused the tubing/catheter to become dislodged, and the resident could sustain trauma. He added it would be hard to keep a catheter in place in the future. Residents Affected - Few On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding catheter care, she stated the DON was responsible. She stated she expected staff to make sure the catheter care was conducted correctly. She added the issues could result in the resident experiencing UTIs. Record review of the facility's current undated policy, titled Anchoring Catheter, Section 16 - Nursing, revealed the following documentation, Policy: Anchoring - Catheter Bags. To ensure that all catheter bags are anchored appropriately, they do not touch the ground and, as much as possible, remain out of plain, sight for dignity purposes. Procedure: When in bed: hang on the opposite side of the bed outside of a clear line of sight when possible. When in wheelchair: to be placed in privacy bag, that should be attached to the wheelchair. If there is no privacy bag, please let the DON or ADON know so that we can order one and ensure it is in place. This is imperative for infection, control purposes, and to maintain resident dignity at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 14 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0692 Provide enough food/fluids to maintain a resident's health. 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 offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 1 of 1 resident (Residents #5) on a therapeutic diet, in that: Residents Affected - Few The facility failed to provide Residents #5 with her physician ordered 2g sodium therapeutic diet for 3 of 3 meals (6/25/23 Supper and 6/26/23 - Lunch and Supper). The Dietary staff were not aware of the diet and were serving the resident foods that were high in sodium. This failure could place residents at risk for hunger, weight loss, and chemical imbalances. The findings include: Record review of the Order Summary Report dated 6/25/23, for female Resident #5 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of, essential, primary hypertension (high blood pressure), edema (fluid retention), unspecified, unspecified systolic (congestive), heart failure (heart disorder), acute, pulmonary edema (lung fluid retention), nonrheumatic, aortic, (valve) stenosis (heart disorder), hypoosmolality and hyponatremia (disorder of fluid and electrolyte balance), chronic respiratory failure (breathing disorder). Record review of the Order Summary Report for Resident #5 revealed a diet order of, 2 g sodium diet. Regular texture, regular/thin consistency, for 2 g sodium/2 L fluid restriction. Order status - active. Order date - 2/16/23. Start date - 2/16/23. Record review of the Order Summary Report for Resident #5 revealed an order for, Daily weight, and notify MD if greater than 7 pounds fluid gain/24 hours every day shift. Order status - active. Order date - 3/20/23. Start date - 3/21/23. Record review of the quarterly MDS assessment dated [DATE] for Resident #5 revealed no documentation of the resident having a therapeutic diet. Active diagnoses listed were heart failure, hypertension, and hyponatremia. The resident had a BIMS score of nine indicating moderate cognitive impairment. Record review the current care plan for Resident #5 revealed a care plan Focus of Diet: HSG, regular diet, HSG, regular texture, regular consistency. Date initiated 6/14/22. There was no current care plan, addressing the resident's 2g sodium diet. Record review of the Nutrition Status Review for Resident #5 dated 6/21/23 revealed the resident was on a low sodium/regular texture and fluids 2200 ml fluid restriction diet. The report further reflected there were no current labs available, and orders meet estimated needs overall. Continue current diet orders. On 6/25/23 at 4:38 PM an interview was conducted with the Administrator. At that time, she presented the facility diet spreadsheets (with diet extensions) that were requested for Sunday thru Tuesday (6/25/23 6/27/23). She stated, those were the only diets the facility served. Record review of the diets listed on the presented spreadsheet (with extensions)on 6/25/23 revealed only regular, mechanical soft, and purée diets were documented. There was no guidance or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 15 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0692 listing for a 2g sodium diet. Level of Harm - Minimal harm or potential for actual harm The following observations and interviews were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM: Residents Affected - Few On 6/25/23 at 4:51 PM, an interview was conducted with Dietary Staff B regarding the meal she was serving. She stated she just made it up because they did not have the items on the menu. She stated the combination/casserole dish contained cheese, onions, potato tots, and hamburger meat. She added it was made with 5 pounds of hamburger, onions, a can of cream of chicken soup, small cream of mushroom soup, a bag of tater tots, shredded cheese and diced potatoes. On 6/25/23 at 5:02 PM, Dietary staff B was observed preparing a meal tray for Resident #5 which included corn, stewed tomatoes, tater tot casserole, tea and water. On 6/25/23 at 5:46 PM an interview and observation were conducted with Dietary Staff B regarding how she made the foods that she served. She stated for the casserole she added salt, pepper, garlic, and onion powder and she added a couple of tablespoons of sugar. Also, for the corn, she added butter and 3 tablespoons of sugar. She stated the tater tots came in a generic and label bag, which was observed in the walk-in freezer. She stated for her meal she had not checked the sodium levels/content for the meal that she prepared. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed salt, canned soup and cheese were high sodium items to limit or avoid. On 6/26/23 at 12:13 PM an observation was made of the Dietary Manager preparing Resident #5's tray. The resident was served corn bread, cabbage, macaroni & cheese, and sausage and peppers. The tray card reflected, Regular diet. On 6/26/23 at 12:17 PM Resident #5 was observed seated in the dining room and was served the meal tray with water and tea. The resident was obese, on oxygen, wore glasses, fed herself and used a wheelchair. On 6/26/23 at 12:19 PM an interview was conducted with the Dietary Manager regarding what she used to make the food for the noon meal. She stated the sausage and peppers include Polish sausage, salt, creole seasoning, beef broth, onions, peppers; the macaroni and cheese was prepared in water using salt, noodles, cheese sauce, parsley, salt and pepper; and the cabbage included cabbage, onions, bacon, salt, pepper, garlic powder. Record review and observation (6/26/23 at 12:19 PM ) of the creole seasoning labeled [NAME] More Spice Creole Seasoning revealed that the seasoning had 290 mg of sodium in a 1/4 of a teaspoon. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed sausage, salt, cheese, bacon and broth were high sodium items to limit or avoid. Interview on 6/26/23 at 8:11 AM, the Dietary Manager stated she had not conducted any in-service for the dietary staff since taking the position approximately 2 months ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 16 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/26/23 at 12:19 PM an Interview was conducted with the Dietary Manager. She stated she met the Dietitian briefly a week ago. She added communication was not that great, and she hoped to make it better. Regarding the diet spreadsheets she stated she had never seen them. She further stated staff were going by the Week At a Glance Menus which did not contain any guidance for special diets. Regarding the diet manual which would offer guidance for therapeutic diets, she stated she thought she would learn about the manual when she started her Dietary Manager course. No Diet Manual was found by the Dietary Manager. Record review of the facility's Week At a Glance menus titled, Menu: Copy of Homestyle 5 PB S/S 2023 menus for Week 1, Week 2, Week 3, and Week 4 (June 2023) revealed the following documentation, The meal item shown are those served on a regular diet. If your physician has ordered for you a therapeutic or texture altered diet, you may be served a different menu item, a different portion of the menu item or the item may be eliminated entirely in order to comply with your current diet order Record review of the undated Diet Order Book for the dietary department revealed no documentation for diets for Resident #5. On 6/26/23 at 4:45 PM an interview was conducted with the DON regarding why Resident #5 was on a low sodium diet. He stated she was on absolute restrictions (fluid). The low sodium diet was to prevent fluid buildup. He added the resident had lots of CHF and COPD. On 6/26/23 at 4:55 PM an observation was made of Resident #5's meal tray on the hall tray cart. The resident received strawberry ice cream, two soft tacos, corn with cheese and a sour cream packet. Record review of the supper tray card for Resident #5 dated 6/26/23, revealed the following: Diet: regular. Diet texture: regular. Beverages: water - 8 fluid ounces; coffee, 8 fluid ounces; sweet tea - 8 fluid ounces On 6/26/23 at 5:03 PM an interview was conducted with the Dietary Manager as to what she used to make the meal foods. She stated the soft taco included salt, pepper, garlic, and hamburger; and the corn included bell pepper, corn and butter. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education. 2 G Sodium Diet last updated on January 23, 2023, revealed salt was a high sodium items to limit or avoid. On 6/27/23 at 9:30 AM observations and interviews were conducted with the Dietary Manager regarding issues found in the dietary department. Regarding therapeutic diets the Dietary Manager stated she was not aware that Resident #5 had a 2g sodium diet. She stated dietary staff printed the tickets/tray cards, and the diets were automatically in the computer system. Regarding how she was made aware of diet changes she stated it was by word of mouth. Observations of the dietary computer display for Resident #5's diet and record review on 6/27/23 at 10:25 AM revealed Resident #5 was documented as being on a regular diet. She added she did not know who input the diet information; Dietary staff D or nursing staff. She stated she was not aware of Resident #5's fluid issues. Regarding if she had any documentation of any guidance on a 2 g sodium diet, she stated as of right now no. She added she never found the diet manual and had no access to know where it was. Regarding what could result from residents not receiving the appropriate 2g sodium therapeutic diet, she stated swelling and decreased circulation; not good for the heart. Regarding whom was responsible for ensuring that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 17 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapeutic diets were served correctly, she stated herself with the help of nursing and therapy. Regarding why the issue happened, she stated just being unaware; thinking all residents were on regular diets; shorthanded and not aware. On 6/27/23 at 11:06 AM the DON was interviewed regarding dietary order changes and how the information was communicated. Regarding Resident #5, he stated, she was still on fluid restrictions and it was lifted some. He added she was weighed daily and any increases in weight, edema, and crackles (lung sounds) was reported to the physician. Regarding how the facility communicated diet changes, he stated if there was a change, nursing staff reported it to dietary staff. Nursing also printed out the order and took it to dietary. Regarding who input the data for diet orders changes, he stated nursing. Dietary should be able to pull up the diet order report in the dietary department since they printed diet cards. He added he assumed the diet information transferred over to the dietary computer system. Regarding what could result from the resident not receiving the appropriate 2g sodium diet, he state, she would retain fluid; fluid overload, exacerbation of COPD and CHF. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding therapeutic diets, she stated the DON and Dietary Manager were responsible. She stated she expected staff to follow the diet ordered. Regarding the result of the issue, she stated residents could experience a clinical decline. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed the following documentation, This information explains what you can eat while you're following a 2g sodium diet. About the 2 g sodium diet. Sodium is a mineral that helps balance fluids in your body. It's found in almost all foods. On this diet, you limit the total amount of sodium you eat or drink to 2 g, or 2000 mg daily. 1 teaspoon of salt contains 2300 mg of sodium, so you'll need to take in less than this amount per day. The diet can be used to manage: heart disease, high blood pressure, kidney disease, poor liver function, weight gain from water retention, (such as swelling in your legs) . High Sodium Foods. The following is a list of high sodium foods. Limit these foods while following your diet. When reading the nutrition facts labels, you'll be surprised how much sodium is in them. Many of these products are available in a low sodium version, so try to use those. Food Group. Dairy - High sodium item to limit or avoid - Cheeses:. Food Group - Meats, and fish. High sodium items to limit or avoid Smoked, cured, dried, pickled, canned, and frozen processed meats. Deli meats, such as corn beef, salami, ham, bologna, frankfurters, sausage, bacon, chipped beef, and regular roasted turkey. Food Group - Vegetables and vegetable juice. High sodium item to limit or avoid - Canned or jarred, vegetables and vegetable juices. Canned and instant soups . Frozen vegetables in butter sauces. Broth or bullion. Food group - condiments, High sodium items to limit or avoid - Onion salt, garlic salt, and other seasonings containing salt Record review of the facility's undated policy titled Special Diets. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Special Diets. Procedures: 1. Special diets are prepared as ordered by the physician 3. All meals will be prepared by good nutritional standards, according to the food pyramid, and the USDA guidelines, which include: . c. Limited use of salt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 18 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 8 out of 30 (05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were three RN's employed at the facility. Record Review of time sheet provided by the Administrator for the time period 05/28/23-06/25/23 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the DON and Administrator were responsible for RN coverage. She stated if there was not an RN available, the staff was to contact the administrator or DON. She stated the facility's policy on RN coverage was to have a RN 8 hours every day. She stated the importance to have an RN on duty was because there was thing in their scope of practice that LVN's cannot do. She stated the potential negative outcome could be if there was something they needed and the LVN cannot do, it would affect them in that way. She stated they have advertising on Facebook and indeed. She stated they could use agency if needed. She stated her expectations was to have an RN in the building every day . She stated there was no system in place to monitor RN coverage. She stated the scope of the nurse was different between the RN and LVN . She stated the DON's working hours was Monday through Friday 8am-5pm, but that was subject to change if he was needed to work the floor. During an interview on 06/27/23 at 12:50 PM with LVN B, she stated if there is not a RN in the building, she would call the DON for any needs. She stated the scope of practice is different between the RN and LVN. She stated she is not able to do higher-level assessments, IV's or pronounce residents. She stated most of the time, they call the hospice nurse to pronounce if there is not an RN in the building. During an interview on 06/27/23 at 01:45 PM with the DON, he stated the administrator and DON were responsible for RN coverage. He stated he could not find any days he worked on the weekend. He stated he does not have a RN that works the weekend. He stated he knew the requirement was to have an RN 8 hours every day but was told him being on call was enough. He stated the importance of an RN was for assessments that LVN's was not allowed to do, wound staging, and higher-level assessments. He stated the potential negative outcome could be residents not receiving the proper treatment. He stated they have not had been advertising for a RN weekend nurse, but were now . He stated an ad for weekend RN was put on Facebook and Indeed on 6/27/23. He stated they used agency in the past but have not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 19 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0727 Level of Harm - Minimal harm or potential for actual harm used them since he started in February. He stated his expectations was to have an RN 8 hours a day. He stated his working hours are 8-5 or 9-5 Monday through Friday. Record review of RN job posting on indeed.com (undated) did not specify the facility was seeking a weekend RN. The Job posting specifically stated they were seeking a full time RN charge nurse. Residents Affected - Many Record review of the facility's policy, RN Coverage, undated, revealed: The facility will ensure there is registered nurse coverage at least eight(8) hours per day, seven (7) days per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 20 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on a comprehensive assessment, that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for blank of blank residents on psychoactive medication's (Resident #1), in that: The facility failed to ensure that Resident #1 had orders for psychotropic medications (lorazepam (brand name Ativan)) that did not contain PRN orders beyond 14 days without a start date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. The findings include: Resident #1 Record review of the Order Summary Report for female Resident #1 dated 6/25/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of heart failure (heart disorder), generalized anxiety disorder (mental disorder), obsessive compulsive disorder (mental disorder) unspecified, unspecified dysphagia, oropharyngeal phase unspecified (swallowing disorder), and macular degeneration (vision disorder). Record review of the quarterly MDS assessment for Resident #1 dated 4/1/23 revealed no documentation of the resident receiving an anti-anxiety medication in the last seven days. The residents BIMS score was 15 indicating the resident was cognitively intact. Record review of the current care plan for Resident #1 revealed the care plan addressed Celexa, anti-depressant, but there was no documentation that the Ativan was addressed. Record review of the Order Summary Report for Resident #1 dated 6/25/23 revealed the following physician orders, Lorazepam Intensol - oral concentrate, 2 mg/milliliter (lorazepam) give 0.25 ml by mouth every two hours as needed for restlessness, anxiety/ Dyspnea. Order status - active. Order date - 5/22/23. Start date - 5/22/23. Record review of the Consultation Report from the current Pharmacy Consultant dated 5/1/23 through 5/31/23 revealed the following documentation, The following residents were reviewed, and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment, that at such time, the residents medication regimens contain no new irregularities, (As defined in 42 CFR 483, Subject part B - Requirements For Long-Term Care Facilities) . [Resident #1]. Reviewed 5/8/23 . Record review of the Gradual Dose Reduction Tracking Report dated 5/8/23 by the pharmacy consultant revealed the following documentation, . Resident #1. Medication lorazepam (Ativan) . Therapy start 6/29/22. Routine order? No. PRN order? Yes. Last GDR request 10/10/22 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 21 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Progress Notes for Resident #1 revealed that the resident was administered PRN lorazepam on the following days and times between 6/1/23 and 6/24/23: 6/3/23 (2 times), 6/4/23 (2 times), 6/6/23 (2 times), 6/9/23 (one time), 6/10/23 (2 times), 6/11/23 (2 times), 6/14/23 (2 times), 6/16/23 (1 time), 6/17/23 (3 times), 6/19/23 (2 times) and 6/24/23 (1 time). The resident was administered lorazepam 20 times on 11 days. Further record review of the Progress Notes revealed no documentation of reassessment for the PRN lorazepam ordered by the physician. Additional record review of the Progress Note dated 6/18/23 at 10:06 revealed the following documentation, .Note text: . She takes her pills whole and takes PRN Ativan due to hallucinations There was no other documentation noted related to the Ativan. On 6/27/23 at 11:06 AM an interview was conducted with the DON. Regarding the PRN psychoactive medication orders, he stated, PRN Psychotropic medications should be reviewed every 14 days. Staff would review and call the hospice doctor. Typically, it was not used very often. Regarding what could result from the resident using the PRN psychotropic medication past the 14 days without review, he stated if used on a regular basis, the resident could experience extrapyramidal symptoms (movement dysfunction), psychotropic medication adverse reactions, and psychological issues. Regarding whom was responsible for ensuring that psychotropic medications were not used PRN without review in 14 days, he stated, the charge nurse should review every 14 days. The doctor should be called if there were issues. Regarding why the residents order for psychotropic medications PRN was more than 14 days, he stated, staff missed the issue and if staff reviewed the issue, it was not charted. He felt this was the norm of staff not documenting reviews of medications. Regarding if he conducted any reviews of physician orders, he stated, staff do reviews with the pharmacy consultant and look at them together. He added staff should have caught this issue. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding PRN Psychoactive medications ordered more than 14 days and not reviewed, she stated the DON was responsible to ensure psychoactive medications were not given PRN without being reviewed. She stated she expected staff to give medications correctly. She further stated residents could experience negative effects of the medication as a result of this issue. Record review of the facility's current undated policy, titled Psychotropic Drugs, revealed the following documentation, Policy: Psychotropic Drugs. It is the policy of this facility to appropriately utilize and monitor the use of psychotropic drugs throughout the tenure of a residents stay. To accomplish the successful implementation of this policy, the facility will use its established Quality Assurance Performance Improvement, (QAPI) program to monitor their use. Procedures: the facility will ensure, through a comprehensive assessment of a resident, the following: . 4. PRN orders for psychotropic drugs will be limited to 14 days unless the prescriber believes that the medication should be extended past 14 days and has documented their rationale in the medical record including the duration for the PRN order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 22 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for thefacility's only kitchen reviewed for dietary services. The facility failed to ensure the designated Dietary Manager completed the required dietary managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager revealed a document titled Change In Status. The document stated, Date of change, 5/29/23 and stated that the Dietary Manager's position in housekeeping had now been changed to the Dietary Supervisor. The document was signed 5/30/23 by the Dietary Manager. Further record review of the personnel file for the Dietary Manager revealed a listing of education. There was nothing listed in the area titled Vocational or trade training. The Former Employers listed revealed that in 2022 the Dietary Manager had worked as a chef from 2/2022 through 3/2023 and 3/2021 through 3/2022. There was no documentation in the personnel file that indicated that she had completed the required training for Dietary Manager and was a Certified Dietary Manager. Record review of the facility's Dietician documentation revealed that the Dietician was contracted and not full-time. Record review of the Food Handlers documentation/certification revealed that the Dietary Manager had completed the Food Handlers of Texas Food Handlers Program successfully on 7/28/22; date of expiration 7/28/24. On 6/25/23 at 4:38 PM, an interview was conducted with the Administrator regarding the Dietary Manager qualifications. She stated, the Dietary Manager had not taken the required DM course. She stated she started in the housekeeping department. On 6/26/23 at 8:15 AM, an interview was conducted with the Dietary Manager. Regarding the status of her Dietary Manager course, she stated, she had not completed payment for the course and had been Dietary Manager approximately two months. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding the Dietary Manager qualifications, she stated the person responsible was the Administrator. She stated she expected the Dietary Manager to become certified. As far as the result of this issue affecting residents, she said the Dietary Manager not being as knowledgeable about important dietary issues. Record review of the undated facility document titled Job Description. Dietary Service Manager, revealed the following documentation, The following is a non-exhaustive criteria that relates to the job of a dietary service manager, and it is consistent with the business needs of the facility. These (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 23 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0801 Level of Harm - Minimal harm or potential for actual harm are legitimate measures of the qualifications for Dietary Service Manager, and or related to the functions that are essential to the job of a Dietary Service Manager. Basic knowledge: current Certified Dietary Managers license. Statement: this position reports directly to the Administrator . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 24 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that the menu was followed and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for residents, for (Residents #5, 12, 17 and 26), in that: 1. The facility failed to ensure residents received consistent serving sizes as called for on the menu and approved by the Dietician during 2 meal observations. 2. The facility failed to ensure diet guidance for all diets ordered was represented on the diet spreadsheet and had Dietician approval. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: During the confidential Resident Council Meeting interviews, three of eight residents voiced concerns related to the menus. Residents stated that the menus that were posted were not always what they were served. During individual confidential interviews, one of seven residents voice concerns with the menu. The resident stated that sometimes the dietary staff could not get organized and get their act together (organized) regarding what foods were served. The resident voiced dissatisfaction with the meal selections and stated that on Father's Day they received a ham sandwich meal. During the entrance conference on 6/25/23 at 10:47 AM, copies of all current menus including therapeutic menus were requested for all days of the survey. Initially, the facility presented Week At A Glance menus which listed only regular diets and did not include other diets served as with a therapeutic spreadsheet. On 6/25/23 at 4:38 PM, an interview was conducted with the Administrator. At that time, she delivered the facility's dietary spreadsheets that were requested. She stated, they were the only diets the facility had or served (regular, mechanical soft, and puree). Record review of the Diet Type Report dated 6/25/23 documented that there were residents with other special diets beyond what was listed on the diet spreadsheets - 2 gram sodium (Resident #5), CCD (carbohydrate counting diet - Residents #12 and #17), and LCS (low concentrated sweets - Resident #26). Record review of the diets listed on the presented facility diet spreadsheets revealed only regular, mechanical, soft, and purée were documented and there was no listed guidance for the 2 gram sodium, carbohydrate counting diet, or low concentrated sweets diets. Record review of the Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 15) Lunch (6/25/23) menu revealed the following: Regular diet: parmesan crusted chicken 3 oz, roasted potatoes 4 ounces spoodle, green bean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 25 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 casserole 4 oz spoodle. Level of Harm - Minimal harm or potential for actual harm Mechanical soft diet: ground parmesan crusted chicken with gravy #8 scoop, mashed potatoes with gravy #8 scoop/2 ounce gravy, chopped soft green bean casserole 4 ounce spoodle. Residents Affected - Some Record review of the Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 15) Lunch, reveal the following: Smothered chicken, roasted potatoes, green bean casserole and roll. - The following observations were made during a kitchen tour on 6/25/23 that began at 11:22 AM and concluded at 12:35 PM: Observation of the service line at 12:07 PM revealed the following: Sliced Baked Chicken served with a 4 ounce ladle (Regular diet) Mashed potatoes served with a #8 scoop (Regular diet and Mechanical Soft Diet) Green beans (regular not a casserole) served with a 6 ounce (3/4 cup) ladle (Regular diet and Mechanical Soft Diet) White gravy - served with a #10 scoop. Mechanically altered chicken served with a #6 scoop (5/8 cup) (Mechanical Soft Diet). Bite-size chicken served with the #6 scoop (5/8 cup). No roasted potatoes, parmesan chicken or smothered chicken, or green bean casserole were present as call for on the either the Diet Spreadsheet Menu or Week At A Glance Menu. The Dietary Manager served the meal, and the meal portions were one scoop of each. Incorrect size servings were given - residents should have received a 4 ounce serving of green beans instead of 6 ounces, residents should have received 4 ounces of mechanically altered chicken instead of a #6 scoop which was 5/8 cup. Residents being served Bite sized chicken should have received a 4 ounce serving instead of a 5/8 cup serving. Record review of the Diet Type Report dated 6/25/23 revealed that there were no residents with orders for large or double portions. Record review of Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 15) Supper (6/25/23), revealed the following: Regular diet: beef and macaroni #6 (5/8 cup) spoodle, tossed salad 8 ounce spoodle/2 tablespoons dressing, buttered peas 4 oz spoodle. Mechanical soft diet: Beef and macaroni #6 scoop, chopped soft cooked vegetable 4 ounce spoodle, buttered peas 4 ounce spoodle Record review of Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 15) Supper revealed the following: cheese tortellini and red sauce, Italian blend vegetables, garlic bread (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 26 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM. An observation and interview were conducted on 6/25/23 at 4:51 PM with Dietary staff B. Regarding the meal she was serving, she stated, she just made it up because they didn't have anything. Meaning the foods were not present for the items on the menu. Observation of the service line revealed that there was soup present, and there was a combination dish that she stated had cheese, onions, potato tots, and hamburger meat. She stated that the casserole was made with 5 pounds of hamburger, onions, a can of cream of chicken, soup, small cream of mushroom soup, bag of tater tots, shredded cheese and diced potatoes. Also on the service line was ham and cheese sandwiches, corn served with a 2 ounce ladle, and stewed tomatoes served with a 2 ounce ladle. No beef and macaroni, tossed salad with dressing, buttered peas, cheese tortellini and red sauce, Italian blend vegetables, and garlic bread were present as called for on the either the Diet Spreadsheet Menu or Week At A Glance Menu. Dietary staff B served the meal, and the meal portions were one scoop of each. There was no documentation available as to the appropriate/correct serving sizes for the meal served. An interview was conducted on 6/25/23 at 4:57 PM with Dietary staff B. Regarding how long the facility had been serving foods that were not on the menu and had to use other foods, she stated that it was quite often but did not specify a length of time. She added, she was the make up menu woman meaning she could make up a menu from a variety of foods quickly. Regarding if she had seen the diet spreadsheet, she stated had never seen them. She further stated that the Week at A Glance menu was the main menu used for this evening. On 6/25/23 at 5:25 PM, an observation and record review of the posted Lunch Menu Sunday, June 25 was baked chicken, cornbread stuffing, green beans, dinner roll, cobbler. The posted Dinner Menu Sunday, June 25 was tater tot casserole, corn, stewed, tomatoes, sherbet. On 6/26/23 at 8:11 AM, the Dietary Manager at that time, stated that she had not conducted any in-service for the dietary staff since taking the position (approximately 2 months). Record review Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 16)(6/26/23) Lunch revealed the following: Regular diet: Sliced smoked sausage 3 ounce, macaroni and cheese 4 ounce spoodle, buttered cabbage 4 ounce spoodle. Mechanical soft diet: ground sausage cuts with sauce #8 scoop, macaroni and cheese 4 oz spoodle, soft buttered cabbage 4 ounce spoodle. Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 16) (6/26/23) Lunch, Polish sausage with Peppers and onions, macaroni and cheese, seasoned cabbage. On 6/26/23 at 11:22 AM, an observation of the posted menu revealed the following: (6/26/23) Lunch Polish sausage with pepper and onions, macaroni and cheese, seasoned cabbage, cornbread, and frosted cake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 27 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 Dinner: soft taco with lettuce, tomato and cheese, fiesta corn, and strawberry ice cream. Level of Harm - Minimal harm or potential for actual harm - The following observations were made during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:19 PM. Residents Affected - Some On 6/26/23 at 11:53 AM an observation was made of the service line: Cabbage served with a 4 ounce ladle. Macaroni and cheese served with a #10 scoop (3/8 cup) and then midway of meal service, the dietary manager changed to the #6 scoop (5/8 cup). Sausage and peppers served with a 3 ounce ladle and then midway of meal service the Dietary Manager changed it to an 8 ounce ladle. Corn bread Ground sausage served with a 4 ounce ladle Mashed potatoes no utensil present Cake at least a 2 inch square Gravy served with a 2 ounce ladle The Dietary Manager served the meal, and the meal portions were one scoop of each. Incorrect/inconsistent sized servings were given - residents should have received a 4 ounce serving of macaroni and cheese instead of a 3/8 cup then a 5/8 cup. Residents should have received an 3 ounce serving of sausage for the meal, but later in the meal, residents received 8 ounce servings. Record review of the Diet Type Report dated 6/25/23 reveal that there were no residents with orders for large or double portions. During an tnterview and record review were conducted with the Dietary Manager on 6/26/23 at 12:19 PM, she stated she met the Dietitian briefly a week ago. Regarding why she had changed scoop sizes in the middle of the meal, she stated, she eyeballed it. She stated residents did not like big portions on their plates and she knew resident preferences. She added, communication was not that great and hoped to make it better. Regarding the diet spreadsheets, she stated, she had never seen them. This was after the surveyor has shown her the diet spreadsheet. She further stated that staff were going by the Week At A Glance Menus which did not contain any guidance for serving sizes or special diets. Regarding substitutions, she stated there was no substitutions list. She stated that she had not contacted the Dietitian for guidance with menu substitutes, or when substitutes were made. Record review of the one substitution documentation that she had revealed that it was on 6/15/23. She stated there were no other pages with any substitution documentation. She further stated that the Dietitian had not gone over substitution system/guidelines. On 6/27/23 at 9:30 AM observations and interviews were conducted with a Dietary Manager regarding issues found in the dietary department. Regarding following the menus and menu issues, she stated staff were going by the Week At A Glance menu, without scoop sizes documented. She added she was told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 28 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some by Dietary Staff D these menus were what they always had, and she had been employed in dietary for 2 years. She further stated that staff did not always have the foods that were listed on the menu. She stated in the past month they had done better getting what was needed. She added the issue was the budget and that was why dietary did not have the ingredients for the casserole. She stated a lot of time, ordered foods did not get sent and items were removed to save money. On the Week 2's menu, she substituted okra for other food items because they had a lot of okra. She further stated she was told by Dietary Staff D that lots of things are marked out on the Week 2 menu because they did not have it. She stated roasted potatoes were on the menu for Sunday Week 3 and were removed by management. Regarding the two different Menus At A Glance, one was Homestyle 5 PB and the other Homestyle 4 PB, which the spreadsheets were derived from, she stated, she had never seen the diet spreadsheets. She further stated that she did not know she had to check with the dietitian for substitutes and meal changes. Regarding if she had checked the recipes for guidance, she stated she had not followed the recipes and had just gone by memory. She stated she had gone by what she had known. Regarding therapeutic diets the Dietary Manager stated that she was not aware that Resident #5 had a 2gram sodium diet. Regarding why staff were unable to follow the menu, she stated circumstances, lack of proper leadership, dietary accreditation (Dietary Manager certification). Regarding what could result from not following the menu, she stated, it could make residents sick by getting the wrong foods. Regarding whom was responsible for ensuring that the menu was followed, she stated, the Dietary Manager with proper communication with nursing. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding following the menu, she stated that those responsible were the Dietary Manager and then Administrator. She stated she expected the staff to follow the menu. Regarding what could result from this issue, she stated the residents may not get the nutritional servings that they require. On 6/27/23 at 3:05 PM, an interview was conducted with the Consultant Dietitian for the facility. She stated that the last visit was the first time she had seen the Dietary Manager. She planned to go out the following month. She was asked if dietary staff were reporting that menu changes to her. She stated, dietary staff asked her about some menu changes. She added dietary staff had not informed her in the past of food changes. She further stated dietary department had a program with all of this (menu) information and the problem was organization and guidance. Record review of the document titled Resource: Menu Substitution Form, revealed that on 6/15/23, the schedule food item was stewed tomatoes, and it was substituted with corn. Reason for substitution, Corn goes better with chicken. Cooks choice. Employees who initialed the documentation was CH. There was no Registered Dietitian signature. The area was blank for the signature. There was no further documentation of any other substitution or menu changes other than the one on 6/15/23. Record review of the Dietitian Consultant Report dated 6/21/23, documented the following comment . Menu planning/alternates/recipes . Comments. Any changes to menu to be reviewed/signed by RD . Record review of the Dietitian Consultant Report dated 5/15/23 revealed the following documentation, . Other concerns. Noted new menus with no diet extensions, when asked - a.m. cook was unaware of extensions existed. Facility in open window for their annual state survey, recommend for owner, who change the menus, to print out extensions as they required RD approval/signature. Also recommend to have Diet manual updated with signature along with menus and extensions . Signed Consultant Dietitian. 5/31/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 29 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility undated policy titled Menus, . Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Menus. Purpose: menus will be prepared in advance, be nourishing, palatable, well balanced, and will meet the daily nutritional and special dietary needs of the residents. Procedure: 1. The Dietitian will approve all menus. 3. If any meal served varies from the planned menu, the change and the reason for the change will be noted on the posted menu in the kitchen and/or in the record used solely for recording such changes. 4. Menus will provide a variety of foods and indicate standard portions at each meal. Menus will be varied for the same day of consecutive weeks. When a cycle menu is used, the cycle will be of no less than three weeks duration and revised quarterly. 6. Menus will be prepared in advance. Event ID: Facility ID: 676389 If continuation sheet Page 30 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals observe for 2 of 2 residents with orders for puréed diet (Residents #1 and 24); in that: The facility failed to provide food that was in a form to meet resident needs, 2 of 2 meals observed (6/26/23 - Lunch and Supper) for 2 of 2 residents with the orders for puréed diets (Residents #1 and 24). This failure could place residence at risk of decreased food intake and choking. The findings include: Resident #1 Record review of the Order Summary Report for female Resident #1 dated 6/25/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of heart failure, unspecified, dysphasia, oropharyngeal phase, unspecified (swallowing disorder), macular degeneration (vision deficit), and moderate protein-calorie malnutrition (Protein deficient nutrition disorder). Further record review of the Order Summary Report dated 6/25/23 revealed a diet order of, regular diet. Puréed texture, regular/thin consistency, fortified foods with meals times 30 days or 10/7/22 for hospice. Order status - Active. Order date - 8/15/22. Start date - 8/15/22. Record review of the quarterly MDS assessment dated [DATE] documented under Swallowing Disorder that the resident experienced coughing or choking during meals or when swallowing medications. The residents BIMS score was 15 indicating the resident was cognitively intact. Record review of the current undated care plan for Resident #1 revealed the following Focus, I have a puréed diet, but eat what I choose, despite what's recommended. I enjoy eating, but my son brings to eat, and I enjoy, snacking throughout the night on foods that my son brings me. Date initiated: 5/2/19. Created on: 5/2/18. Created by DON. Revision on: 4/12/23. Revision by: ADON . Record review of the Nutrition Status Review for Resident #1, dated 3/20/23, revealed that the resident was ordered a regular diet/purée texture, regular consistency. Further record review of the document revealed the following, continue current diet orders. Record review of the Diet Type Report dated 6/25/23 documented that Resident #1 had a Diet Type regular, Diet Texture - puréed and Fluid Consistency - regular/thin . Resident #24 Record review of the Order Summary Report for female Resident #24 dated 6/27/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Alzheimer's disease, unspecified (cognitive disorder). Further record review of the Order Summary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 31 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Report revealed a diet order, of HSG puréed diet regular texture, regular/thin consistency, may have regular snacks, if requested for EDENTULOUS. Order status - Active. Order date - 5/12/22. Start date 5/12/22. Record review of the quarterly MDS for Resident #24 dated 3/20/23 revealed no documentation of dental issues. The residents BIMS score was 8 indicating the resident had moderate cognitive impairment. Record review of the current care plan for Resident #24 revealed a Focus that stated, Diet: regular purée with regular liquids. Date initiated: 5/12/22. Created on: 5/12/22. Interventions included the following alternate choices will be given. Date initiated: 5/12/22. Created on: 5/12/22. Revision on: 7/15/22. Further record review of the current care plan revealed a care plan Focus of, The resident has no teeth and is satisfied without teeth. Date initiated: 12/28/22. Created on: 12/28/22 . Record review of the Dietitian's Progress Note dated 5/15/23 revealed the following documentation, Note Text: current diet is regular diet. Diet texture of puréed diet. Fluid consistency is regular/thin. No signs/symptoms of dehydration. Current diet is appropriate. Recommendations/interventions. Continue current diet orders. Record review of the Diet Type Report dated 6/25/23 revealed that Resident #24 had a Diet Type - HSG purée, Diet Texture - regular, Fluid consistency - regular/thin. On 6/26/23 at 8:11 AM, an interview was conducted with the Dietary Manager. She stated that she had not conducted any in-service for the dietary staff since taking the position of Dietary Manager. The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:35 PM: On 6/26/23 at 11:53 AM the service line was observed: Puréed, macaroni and cheese stored in a bowl on the service line. Puréed sausage in a bowl on the service line and it appeared very coarse in texture. Puréed cabbage stored in a bowl on the service line. Observation on 6/26/23 at 12:05 PM revealed pureed meal trays for Residents #1 and #24 were observed served by the Dietary Manager. The foods were placed in divided plates for both residents. The pureed sausage was very coarse on both trays. The surveyor requested to test a sample of the purée. The results of the test were as follows: Puréed cabbage - no issue Purée macaroni & cheese - still had some whole pieces of pasta. Puréed sausage - very coarse and grainy with gristle. An interview was conducted with the Dietary Manager on 6/26/23 at 12:19 PM regarding purée training, she stated she had met the Dietitian briefly a week ago. She added she had been trained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 32 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to purées, but not at this facility. She stated that a purée should have a pudding-like consistency. Regarding the diet manual, which would have guidance regarding puree diets, the Dietary Manager stated she thought she would learn about it when she started her Dietary Manager course. No Diet Manual was located by the Dietary Manager. On 6/26/23 at 1:12 PM, an interview was conducted with the DON as to why Residents #1 and #24, were on puréed diets. He stated, Residents #24 was edentulous (no teeth). Resident #1 was on hospice and had been on puréed foods and had swallowing difficulty. He added even her medications were crushed. On 6/26/23 at 4:59 PM, an observation was made of the kitchen. The Dietary Manager had prepared two servings of puréed foods, one each for Resident #1 and Resident #24. The puréed taco looked very coarse on the service line. Surveyor requested to test the puréed foods. The results of the test were as follows: Puréed soft taco (beef and flour tortilla) - very coarse with bits of gristle Purée corn - contained skins and hulls. On 6/27/23 at 9:30 AM, an interview was conducted with a Dietary Manager regarding puréed foods. Regarding what could result from foods not being puréed appropriately, she stated choking, asphyxiation. She stated when puréeing foods, she needed to check the blades too. Regarding if she had talked to the Dietitian about purees, she stated no. Regarding who was responsible for ensuring that foods were in the appropriate puréed form, she stated, the cook, and the person above the cook, the Dietary Manager. Regarding why she felt these issues occurred, she stated, human error; not vigilant enough; assuming the consistency was okay. She added she received puree training other places. She further stated there were posted guidelines for puréeing at the kitchen processor area, which she had not noticed until a couple of weeks ago. Observation of the processor area revealed that there were two documents posted related to pureeing foods. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding food form, she stated that the Dietary Manager and the Administrator were responsible. She stated she expected the purée to be produced correctly. She stated the result of these issues could cause the resident to have trouble swallowing. Record review of the posted guidance for purées revealed the following documentation on one posting, Hints for Pureeing Foods. 3. Avoid pureeing the original food with too much liquid. Puréed foods should be the consistency of applesauce to mashed potatoes, unless there is tolerance for something thinner. 5. Bread may be added to other food items to include nutrients from this food group, however, it will dilute the flavor of original food items. Serving sizes must be increased when bread is added to food items in order to preserve nutritional content of the meal. Record review of the second posted guidance related to purées revealed the following documentation, Purée, consistency. Guidelines for texture modification: puréed foods. Pureed foods must be soft, smooth, and be of a pudding or mousse like texture, (no water separation liquids can be added back if the finished purée is not the correct consistency) . Chop or dice larger pieces of food, such as meat, before placing into the food processor. Blend food item until fine and smooth. If the food item is not smoothing out or appears to dry, add back reserved liquid 1 tablespoon at a time until desired. Mousse-like texture is achieved. Where applicable, followed recipe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 33 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0805 instructions for purée if, mixed dishes, such as casseroles. Level of Harm - Minimal harm or potential for actual harm Record review of the facility provided document current undated, titled Puréed Food Guideline revealed the following documentation, Instructions for Preparing Puréed Foods: . 3. Add appropriate liquid, (example: reserved liquid, broth, juice, milk), if needed to assist with purée. Purée with a blender or food processor until smooth. 5. Puréed foods should be a smooth consistency. The food should appear smooth like pudding or mashed potatoes. There should be no lumps or particles. Note: it is not recommended to purée the following items. Tough skins or casings. Corn* . *Commercially made products are available. For more information, contact your sales representative. Residents Affected - Few Record review of the facility's current undated policy titled Special Diets. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Special Diets. Procedures: 1. Special diets are prepared as ordered by the physician. 2. Special diets available include. e. Mechanically altered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 34 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 Residents Affected - Many 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 for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure Dietary staff used pasteurized eggs in under cooked egg dishes (soft cooked/sunny side up/over easy eggs), 2) The facility failed to ensure Dietary staff stored foods in a manner to prevent contamination, 3) The facility failed to ensure Dietary staff maintained adequate chlorine sanitizer levels in the low temperature dish machine. 4) The facility failed to ensure Dietary staff ensured food contact surfaces were clean, 5) The facility failed to ensure Dietary staff performed sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 6) The facility failed to ensure Dietary staff used good hygienic practices (personal foods in food storage and prep areas), 7) The facility failed to ensure Dietary staff stored personal items in a manner to prevent contamination of food contact equipment. 8) The facility failed to ensure Dietary staff ensured that foods were not held past the manufacturers recommended expiration date. These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 11:22 AM and concluded at 12:35 PM: There were three flies, crawling on the toaster oven while the fly zapper/electronic extermination unit was on. Dietary Staff A was washing her hands. She turned off the water with her bare hands, then dried her contaminated hands on a paper towel and donned on a pair of gloves. She then poured coffee and handled sugar packets. The Dietary Manager was observed washing her hands and she turned off the water with a paper towel, but then she dried her hands and arms with the soiled paper towel. During an observation and interview on 6/25/23 at 11:32 AM. The Dietary Manager tested the dishwasher and she attempted to test the dishwasher sanitizing rinse with a quaternary sanitizer test strip. At the time, the Dietary Manager was not aware that the dishwasher was a low temperature chlorine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 35 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 sanitizing dish machine until the surveyor pointed out that the sanitizer container label documented that it was a chlorine sanitizer. The Dietary Manager stated that the sanitizer for the dishwasher was quaternary sanitizer. She then stated this sanitizer was not the same as at another facility. She then looked at the quaternary test strips and asked, What are these used for? This was after the surveyor told her that there were different (chlorine) test strips for the dishwasher. Residents Affected - Many The dishwasher was then tested by the dietary manager a third time with chlorine test strips and the temperature was 110°F and the level of chlorine sanitizer rinse was 200 ppm which was a toxic level of chlorine. During an interview with the Dietary Manager on 6/25/23 at 11:37 AM, she stated she had not seen the dishwasher being serviced in the last two months that she had been there. Record review of the dishwasher test log revealed the last time the dishwasher was tested was 6/22/23. The Dietary Manager again washed her hands, turned off the sink with a paper towel and then dried her hands and arms with the soiled paper towel. Observation of the walk-in freezer revealed that there were 12 bags of ice on the floor and there was available shelf space to place these bags of ice on a shelf. Observation of the walk-in refrigerator revealed that there was a pan containing large tubes of raw hamburger that were thawing. There was pooling blood in the pan. The pan was stored above bottles of drinking water that were stored on the floor. There was room available to move these bottles of water away from the pan of thawing meat. There was a personal drink on an upper walk-in rack with bread that was labeled with [Dietary Staff D]. name. There was a buildup of dirt on the underside of the racks in the walk-in refrigerator. In the walk-in refrigerator, there was half a case of Sysco Strawberry Banana Shakes that had a date on the box of 4/6/23. There was also a full case of Sysco Strawberry Shakes that was dated 4/20/23. There was a case of Sysco Chocolate Shakes label 4/6/23 also present. The underside of the upper shelf of the stove had dried spills. On 6/25/23 at 11:58 AM, an interview was conducted with the Dietary Manager. Regarding the flies in the kitchen, she stated the flies increased in the past month. Regarding what caused the fly increase, she stated, the big back door was open at times and then there were a lot of donations coming in due to the tornado. There were 4 flies crawling on a prep table and the fly zapper in the kitchen and at the back door entrance in the auxiliary hall were on. While taking temperatures on the service line, the Dietary Manager took temperatures of the chicken and bite-size chicken by picking up the individual pieces with her gloved hands then placed it back in the pan to be served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 36 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 Residents Affected - Many - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM: One of two drink guns was submerged in a liquid in a red bucket. During an interview on 6/25/23 at 5:04 PM, Dietary staff A was asked what was in the red bucket. She stated, it was just water. There was an accumulation of dry spills on the underside of the steam table top. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 8:05 AM and concluded at 8:40 AM: During an interview and observation on 6/26/23 and 8:09 AM, the Dietary Manager stated that the Maintenance Supervisor had placed a call to the dishwasher machine repairman about the chlorine level of the dishwasher. She further stated, the cook had checked the level last week and stated it was OK. A large bowl and a pan had been washed in the dishwasher. The level was tested and 200 ppm chlorine. During an interview on 6/26/23 at 8:11 AM, the Dietary Manager stated she was not aware that the bowl and pan had been washed in the dishwasher that morning. She further stated that she had not conducted any in-service for the dietary staff since taking the position as Dietary Manager. The Dietary Manager was observed walking in the stove area, drinking a bottle of water. She placed the bottle on a dirty dish cart at the three-compartment sink and then started doing the dishes. Observation of the walk-in refrigerator revealed that the pan with thawing, bloody hamburger meat was still stored above bottles of water and there was even more blood in the pan. Observation in the walk-in refrigerator revealed a case of raw eggs present was not pasteurized eggs. During an interview on 6/26/23 at 8:20 AM, the Dietary Manager stated she used the raw eggs to prepare over easy eggs every morning for Resident #17. During an interview on 6/26/23 at 8:22 AM, the Dietary Manager stated she thought the eggs she received were pasteurized. On 6/25/23 at 8:25 AM, the Dietary Manager stated the dishwasher sanitizer level should be 50 to 100 ppm chlorine. She stated that she was not aware that 200 ppm Chlorine was a toxic level. On 6/26/23 at 8:30 AM, an interview was conducted with the Dietary Manager. Regarding the dates on the boxes of shakes, she stated the dates were the time that the shakes came in and were placed in the walk-in. She stated that the two resident who used the shakes did not drink them. She further stated she was not aware of the labeling on the shakes that documented once thawed the shakes should be used within 14 days per manufacture instructions. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:19 PM: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 37 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 Residents Affected - Many There was a personal drink in a red cup, covered with a small Styrofoam plate. The cup was located on a lower shelf of a food preparation table and next to bags of potato chips and corn chips. There were flies landing on food equipment. - The following observations were made, and interviews conducted during a kitchen tour on 6/27/23 that began at 9:26 AM and concluded at 9:30 AM: There was a cell phone lying on the prep table and leaning against a bag of pasta. There was a fly crawling on the sugar bin and another one flying around in the kitchen. There was a personal drink on the lower shelf of a preparation table at the service line and covered with a small Styrofoam plate. On 6/27/23 at 9:30 AM interviews and observations were conducted with a Dietary Manager regarding issues found in the dietary department. Regarding pasteurized eggs, she stated pasteurized eggs were expensive, and the facility only had one person eating them. She was then explained that the nursing home had a highly susceptible population and that raw eggs cannot be used for sunny side up type dishes. She stated, Sunday was the last time Resident #17 received over easy eggs. Regarding the last time that the walk-in refrigerator racks were cleaned, she stated staff had not cleaned them in the last two months. She added, she was in the middle of creating a chores chart and the cleaning of the racks was not on it. Regarding the shakes and the expiration on them, she stated she was not aware of the 14-day limit. She further stated that she had not trained any new employees yet. Regarding the flies, she stated, the flies had been at this level for the two months she had been here. She added then the tornado came the facility had people bringing in donations, and the problem worsened. At that time, the dishwasher was tested, and it dispensed 50 ppm chlorine and the temperature was 110°F. Observation of the gauge/temperature label documented, Wash/rinse 120°F minimum. The Dietary Manager stated that she was not aware that the hot water needed to be 120°F. Regarding how the issues in the dietary department could affect residents, she stated, unhygienic practices and germs. The dishwasher not working could spread germs around; residents could get sick. Regarding whom was responsible for ensuring that dietary duties were conducted correctly, she stated, herself and staff. She added that she had not taken the required Dietary Manager course. Regarding why she felt these issues happened, she stated, leadership, and not staying on top of things. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding dietary sanitation, she stated that the Dietary Manager and Administrator were responsible. She stated she expected staff to know the correct dietary procedures. She also stated that nursing home residents were highly susceptible and could be affected from those issues related to dietary sanitation in the dietary department. Record review of the Dish Machine Log for June 2023 revealed that the last time the dishwasher was checked was on 6/22/23 dinner meal where the wash was 120°F. The rinse was 120°F and the parts per million chlorine was 100. Further record review of this document revealed the following, .Standards . Chemical sanitizing low temp: Wash: 120 to 140°F. Rinse: 120 to 140°F . Manufacture recommended PPM: (blank). No documentation in this area. The document further stated, . Always defer to manufactures guidelines regarding temperature and correct chemical concentration for use . Record review of the Code Of Federal Regulation, Title, 21, Volume 3, CITE: 21, CFR 178.1010, TITLE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 38 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 Residents Affected - Many 21 - FOOD AND DRUGS, CHAPTER 1 - FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SUBCHAPTER, B - FOOD FOR HUMAN CONSUMPTION (CONTINUE), PART 178 - INDIRECT FOOD ADDITIVES: ADJUVANTS, PRODUCTION AIDS, AND SANITIZERS, Subpart B - Substances Utilize To Control The Growth Of Microorganisms, SCC. 178.1010 Sanitizing Solutions, current as of 7/06/23, revealed the following documentation, .Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions: (a) Such sanitizing solutions are used, followed by adequate draining, before contact with food. (b) The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. (1) An aqueous solution containing potassium, sodium, or calcium hypochlorite, with or without the bromides of potassium, sodium, or calcium . c)The solutions identified in paragraph (b) of this section will not exceed the following concentrations: (1) Solutions identified in paragraph (b)(1) of this section will provide not more than 200 parts per million of available halogen determined as available chlorine. Record review of the Sysco shakes cartons revealed the following documentation, Handling instructions: store frozen. Thaw under refrigeration, (40°F or below). Shake well before using. Open top, then pour and serve. After thawing, keep refrigerated. Use within 14 days after thawing. Record review of the website document, Food Safety in Nursing Homes: A Beginner's Guide (https://foodsafepal.com/food-safety-nursing-homes/) . January 30, 2023, revealed the following documentation, . Guidelines for Food Safety in Nursing Homes. Regardless of the population you serve, following safe food handling practices is essential. However, because nursing home residents are considered a highly susceptible population, there are additional food safety precautions you must take to reduce the risk of foodborne illnesses . Raw and undercooked eggs, meats, and seafood. Eggs have the potential to carry Salmonella, which can survive if they are not cooked through. For this reason, you cannot serve eggs where the yolk is runny like over-easy or sunny-side-up eggs to nursing home residents. However, you can make them using pasteurized eggs, which are heat-treated to kill off Salmonella and other bacteria that may be present . Record review of the current undated policy titled Employee Hygiene. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Employee Hygiene. Procedure: 1. Employees must keep their hands, arms and fingernails clean. 5. Employees may not eat, drink or use tobacco in any area where food preparation is occurring. Employees may drink from a closed container if the closed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 39 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 container prevents contamination. Level of Harm - Minimal harm or potential for actual harm Record review of the undated facility policy, titled Storage of Food and Refrigeration, . Section 9 Dietary/Food Services, revealed of the following documentation, Policy: Storage of Food and Refrigeration. Procedure: 1. 2. Store raw meats on the bottom shelf to prevent contamination of other perishable items. 4. All containers must be labeled with the contents and the date food item was placed in storage. 6. Food items that remain sealed from the supplier may be held until the expiration date if unopened . Residents Affected - Many Record review of the undated facility policy, titled Thawing Food. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Thawing Food. Procedures: food that is frozen, should be thawed in such a manner as to prevent the temperature of the food from rising above 41°F. Method for thawing food. 1. Under for refrigeration. b. Meats to be thawed must be placed on the lower shelf in the refrigerator to prevent contamination of other foods with meat juices . Record review of the undated facility policy, titled Section 9 - Dietary and Food Service, revealed the following documentation, Policy: Equipment Sanitation. We will provide clean and sanitized equipment for food preparation. Facility will clean all food service equipment in a sanitary manner. Procedure: 1. Equipment must be thoroughly sanitized between using different food preparation task (E. G. Salad, preparation, raw meat, cutting and cooked meat cutting). 6. Pots and pans. f. All equipment and utensils shall be sanitized by one of the following methods: . h. Immersion for a period of at least one minute in a sanitizing solution containing: at least 50 ppm of available chlorine at temperature not less than 75°F . 7. Facilities should use an approved test kit to measure the parts per million of the chemical solutions in a pot sink on a daily basis. Records of test results shall be kept on the temperature/chemical log. Any abnormal test results shall be reported to the dietary service manager, and the solution shall not be used until at the correct ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 40 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 14 resident rooms (102, 205, 207, and 301); in that: Residents Affected - Many 1. The facility failed to ensure that the resident call system at bedside could not be cancelled from the nurse's station (Rooms 102, 205, 207, and 301). 2. The facility further failed to ensure that the call system accurately indicated the location of the registered call (rooms [ROOM NUMBERS]). These failures could place residents at risk of not receiving needed services. The findings include: On 6/26/23 at 9:10 AM, an observation was made in room [ROOM NUMBER]. The call system at the B bed was activated (dome light illuminated and audible sound emitted) and a voice came over the call system intercom and stated that someone would come to the room shortly. After this response, the call was canceled and the dome light above the room went out and there was no sound. The call had not been cancelled by anyone in the room. On 6/26/23 at 9:19 AM, an observation was made in room [ROOM NUMBER]. The call system was activated in the bedroom and a voice came over the call system intercom (LVN B) and stated, someone would come to the room shortly. At that time the call was canceled from the nurse's station and the dome light went out and there was no sound. During an interview with LVN B, at this time (6/26/23 at 9:19 AM), she stated, staff could shut the call system off in the room and from the nurse's station. She added, staff must pick up the receiver, say something, then staff hang up receiver and the system shuts off. She further stated that the call system had worked that way since her employment in 2019. On 6/26/23 at 9:22 AM, an interview was conducted with LVN A. She stated, regarding the call system, the bathroom call systems could not be reset/cancelled from the nurse station. She added staff could pick up the nurse station call system receiver, put it down, and this would shut off the resident room dome light and sound. On 6/26/23 at 9:44 AM, an observation was made in room [ROOM NUMBER]. The call system was tested and like rooms [ROOM NUMBERS], the call in the bedroom could be cancelled from the nurse's station. The dome light stopped illuminating and there was no audible sound after being cancelled from the nurse's station by LVN B. Also, at that time, the call display at the nurse station displayed 8306-1 (room [ROOM NUMBER]) on the monitor when the call was registered from room [ROOM NUMBER]. During an interview with LVN B, at this time (6/26/23 at 9:44 AM), she stated, some numbers on the display monitor did not match the rooms after there was a power outage in the past. Staff now physically look for the room dome call light in the halls to verify the correct room. On 6/26/23 at 9:47 AM an observation was made in room [ROOM NUMBER]. The call system was tested. When a call was registered from the bedroom, the call system monitor at the nurse's station displayed 8104-1 (room [ROOM NUMBER]), Routine, and the time display was 6:55. During an Interview with LVN B, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 41 of 42 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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 0919 at this time (6/26/23 at 9:47 AM), she stated, the facility had tried to fix the display issue. Level of Harm - Minimal harm or potential for actual harm Observation at this time revealed that the call registered from room [ROOM NUMBER]. LVN B picked up the receiver, then hung up and at that time this cancelled the sound, and the dome light and the call was canceled. During additional interview at this time, LVN B stated the last repairman who came, checked the call system recently, said that the facility needed a whole new call system. She further stated staff used to be able to hear the resident's response through the intercom but now that portion of the call system does not work. Residents Affected - Many On 6/27/23 at 12:21 AM, an interview was conducted with the Maintenance Supervisor regarding the call system. He stated that he was not aware of the regulation that the call system could not be canceled at the nurse's station. He added the call system could not be cancelled at a bath. Regarding the room number inaccuracy on the nurse station display, he stated the call system was out of date and obsolete and that the main control was replaced during a lightning storm years ago. He added currently the main control did not relay properly to the system. Regarding what could result from the call system not operating properly and capable of being canceled at the nurse's station, he stated residents in distress would not get services. Regarding who was responsible for ensuring that the call system operated correctly, he stated, the fire protection people. Regarding if he made rounds and checked the call systems in the facility, he stated he rounds 1 to 2 times a month. He added, he knew the importance of the call system. Regarding why this issue happened with the call system, he stated, it was the way the system was installed in 2006 where the call system could be canceled at the nurse station. He added the new call systems could not be canceled from the nurse station. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding the call system, she stated that the responsible individuals were the Administrator and Maintenance Supervisor. She stated she expected staff to answer calls. She stated that she did not know or was aware of these call system issues. The result of these issues could be unanswered calls and residents not receiving services. Record review of the facility's undated policy, titled Operational/Resident Care Policies, XRV .3, revealed the following documentation, . Resident Call Systems: The nurse's station is equipped to receive resident calls through a communication system from resident rooms at each resident's bedside and at toilet, shower, and bathing facilities. The call system in resident rooms will be accessible to alert, confined residents and confused residents and the residents will be instructed as to its availability and location . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676389 If continuation sheet Page 42 of 42