Health inspection·February 14, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 02/13/24 at 3:41 p.m., Resident #22 said she just wanted to go sit outside on the patio . She said she would live outside if she could. She said she asked CNAs at different times to take her outside. She did not know the names of who she had asked. She said they always told her they were too busy. She said the last time she was allowed to go outside was in September 2023. She was in her room sitting on her bed . Residents Affected - Few During an interview on 02/14/24 at 9:46 a.m., CNA A said the only time Resident #22 went outside was when her family was at the facility . CNA A said Resident #22's family took her on outings. CNA A said Resident #22 had not asked her to be taken outside. She said residents were only allowed to go outside if someone went outside with them. During an interview on 02/14/24 at 9:50 a.m., LVN B said since it was cold she had not seen any residents sitting out on the patio. She said it had been since August since she carried anyone outside. She said Resident #22 was all there and she would be ok to sit outside. This meant the resident was cognitively intact. She said Resident #22 did go out with family. During an interview on 02/14/24 at 10:25 a.m., the DON said talked to Resident #22 and she never voiced to her that she wanted to go outside. She said she did go out on pass weekly with family. She said depending on the resident, they may or may not have to have supervision when they went outside. She said residents had the right to go outside to get fresh air. The DON said she if Resident #22 asked to go outside she would have expected staff to have allowed her to go outside. During an interview on 02/14/24 at 1:01 p.m., the Administrator said Resident #22 never complained about not being able to go outside to her. She said she never filed a grievance about not being able to go outside. She said Resident #22 did a lot on her own and there was no reason she could not go outside. She said if her not being allowed to go outside were true, it could affect her quality of life. She said she never knew Resident #22 to lie or make false accusations . Record review of the facility's Resident Rights policy, last revised on October 4, 2022, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .self-determination .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .be supported by the facility in exercising his or her rights . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 2 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a baseline care plan was developed and implemented for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 16 residents (Residents #289 and #388) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #289 and Resident #388. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: 1. Record review of Resident #289's face sheet, dated 02/14/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #289 had diagnoses which included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), cystitis (inflammation of the bladder, usually caused by a bladder infection) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the MDS reflected no MDS was completed for Resident #289. Record review of the care plan for Resident #289 reflected no care plans were completed. Record review of the baseline care plan for Resident #289 reflected no baseline care plan was completed. 2. Record review of Resident #388 face sheet, dated 02/14/2024, reflected a 76- year-old male who was admitted to the facility on [DATE]. Resident #388 had diagnoses which included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), diabetes mellitus type II, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the MDS reflected no MDS was completed for Resident #388. Record review of the care plan for Resident #388 reflected no care plans were documented. Record review of the baseline care plan for Resident #388 reflected no baseline care plan was documented. During an interview on 02/13/2024 at 10:00 a.m., the MDS Coordinator stated she and the other members of the interdisciplinary team were responsible for completing the baseline care plan. She explained the other members were the activity's director, the dietary manager, the social worker, the therapy department and a CNA. The MDS Coordinator stated baseline care plans were important so the team and the resident were on the same page about the care provided at the facility and the resident's goals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 3 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 02/14/2024 at 11:00 a.m., the DON said she expected the MDS nurse to complete the baseline care plan as a part of the admission process for all new admits. The DON said continuity of care was important and the baseline care plan helped follow through with the plan of care by allowing everyone to be on the same page about the resident's plan of care. Record review of the facility's policy, dated December 2021, titled Care Plans- Baseline, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The resident and their representative will be provided a summary of the baseline care plan that included but was not limited to the initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatment administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Event ID: Facility ID: 676458 If continuation sheet Page 4 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 21 residents (Resident #64) reviewed for ADLs. Residents Affected - Few The facility failed to remove facial hair from Resident #64. This failure could place residents at risk of not receiving services/care and decreased quality of life. Findings include: Record review of Resident #64's face sheet, dated 02/14/2024, reflected a 66-year- old female who was admitted to the facility on [DATE]. Resident #64 had diagnoses which included major depression (mental health disorder having episodes of psychological depression), borderline intellectual functioning (categorization of intelligence wherein a person has below average cognitive ability [generally an IQ of 70-85], but the deficit is not as severe as intellectual disability [below 70]), and chronic kidney disease (a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years). Record review of Resident #64's quarterly MDS assessment, dated 12/11/2023, reflected Resident #64 had a BIMS score of 15, which indicated no impaired cognition. Resident #64 required limited assistance with personal hygiene. Record review of Resident #64's care plan, dated 12/06/2022, indicated she had an ADL care deficit and required limited assistance with personal hygiene. The intervention was listed as providing assistance as needed to complete personal hygiene tasks. Record review of Resident #64's personal hygiene record, dated 10/13/2023 to 02/13/2024, reflected shaving occurred only twice on 10/20/2023 and 11/23/2023. During an observation and interview on 02/12/2024 at 11:10 a.m., Resident #64 was noted to have a thick goatee. Resident #64 stated she wanted her facial hair shaved every time she bathed. She stated she was bathed on Monday, Wednesday and Friday and had a bath a few hours prior. Resident #64 stated she asked the CNA to shave her, but she must have forgotten. Resident #64 stated she did not understand why the facility did not just give her the razors and she could take care of it herself. Resident #64 stated it was embarrassing to have so much facial hair. During an observation on 02/13/2024 at 1:00 p.m., Resident #64 continued to have a full thick goatee. During an observation on 02/14/2024 at 3:00 p.m., Resident #64 continued to have a full thick goatee. During an interview on 02/12/2024 at 1:30 p.m., CNA G stated she meant to shave Resident #64 when she gave her a bath but got busy and forgot. CNA G stated it was important to shave all resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 5 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0676 male and female that wanted to for the self-esteem of the resident's. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/14/2024 at 11:00 a.m., the DON stated it was important to the resident's self-esteem to have their personal hygiene needs taken care of. The DON stated Resident #64 should have been shaved with each bath. Residents Affected - Few During an interview on 02/14/202 at 1:35 p.m., the ADM said she expected the CNAs to provide ADL care to the residents. The ADM stated it was important to the resident's self-esteem and mental well-being to have personal hygiene maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 6 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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** 2. Record review of Resident #67's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #67 had diagnoses which included: Psychotic Disorder with Hallucinations (seeing or hearing things that others do not), Psychotic Disorder with Delusions (altered reality that is persistently held despite evidence to the contrary), Generalized Anxiety Disorder (severe anxiety that interferes with daily activities), Major Depressive Disorder, and unspecified hallucinations (also known as psychotic depression, hallucinations and delusional thinking). Record review of the quarterly MDS, dated [DATE], reflected Resident #67 had clear speech, was understood by others, and usually understood others. Resident #67 had a BIMS score of 8, which indicated she had moderately impaired cognition. She had inattention and disorganized thinking daily that fluctuated in severity. Resident #67 had no behaviors in the 7-day look back period and she received antipsychotic and antidepressant medication. Record review of Resident #67's, undated, care plan reflected Resident #67 used psychotropic medications related to behavior management, disease process Psychotic Disorder with Hallucinations and Anxiety Disorder with potential injury to self or others. The goal was for the resident to be/remain free of drug related complications . Some of the interventions were to monitor for side effects, educate the family/resident/caregivers about the risks, benefits, side effects, and/or toxic symptoms of Risperdal and Sertraline. Monitor for target behavior symptoms and document. Resident #67 used antidepressant medication related to depression. Some of the goals were, she would receive decreased episodes of depression and would be free from discomfort or adverse reactions related to antidepressant therapy. Some interventions were to monitor for side effects and effectiveness, monitor and report behavior. Record review of the physician's orders, dated 2/13/24, reflected Resident #67 was ordered the following: 1/18/24 - Risperdal oral tablet, 1 mg, give 1 tablet by mouth one time a day related to Psychotic Disorder with Delusions due to known psychological condition. (Risperdal is an antipsychotic medication that works by changing the chemicals in the brain.) 10/23/23 - Sertraline oral tablet 100 mg, give 2 tablets one time a day by mouth for depression. (Sertraline is a selective serotonin reuptake inhibitor [SSRI ] for treating depression.) Record review of Resident #67's MAR's, dated 12/1/2023 - 2/14/24, did not reflect any monitoring of Resident #67's behaviors or side effects of her medications, namely Risperdal and Sertraline. During an interview on 2/13/24 at 2:45 PM, the MDS Nurse said she did not see any behavior monitoring or monitoring for side effects of Resident #67's antipsychotic or antidepressant medication. She said it should be on the MAR and there was nothing on the MAR that indicated she was being monitored for side effects of her medications or her behaviors. She said behavior monitoring and side effects of medications should be documented on the MAR to monitor for adverse effects of the medication or behaviors so it could be reported to the MD . She said it was important because of Resident #67's behavioral hospital stay and her history of psychiatric issues. She said the ADON and DON were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 7 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 responsible for the MAR . Level of Harm - Minimal harm or potential for actual harm During an interview on 2/13/24 at 3:50 PM, the MDS Nurse said antidepressant side effects and behavior related to depression should have been on the MAR. She said it was not, but the DON was going to fix it and it would be on the MAR soon, along with monitoring for side effects of her Risperdal . She said the DON was going to put it on the MAR. Residents Affected - Few During an interview on 2/14/24 at 9:15 AM, LVN C said any resident on antipsychotics, antidepressants, or any mind-altering drug should be monitored for side effects and behaviors. She said side effects and behaviors could be more severe for elderly residents. She said the risk of not monitoring was more severe reactions or adverse reactions. She said if a resident had a behavior, it could be a reaction to a medication and staff could be unaware and think it was caused from something else (not the medications.) She said she did not know there was no monitoring for side effects of medications or behaviors for Resident #67. During an interview on 2/14/24 at 9:25 AM, LVN D said any resident who was on an antipsychotic, antidepressant or any mind-altering medication should be monitored for side effects and behaviors. She said it was important to monitor for the side effects of the medication to see if it helped the resident or not. She said she did not realize Resident #67 was not being monitored for side effects or behaviors of her medications. She said if the resident was not monitored, a side effect could be missed. During an interview on 02/14/24 at 9:30 AM, the ADON said any resident on antipsychotics, antidepressants or any mind-altering drug should be monitored for side effects and behaviors. She said she put in those orders yesterday (2/13/24 after State Surveyor intervention) for Resident #67. She said it was important to monitor to see if the medication was effective and monitoring the behaviors to address them before they got out of hand. She said a resident could have an infection or have a change in their mental status. She said the orders for monitoring Resident #67's side effects of her medications and her behaviors used to be in her orders, but she did not get put back when she came back from a psychiatric hospital stay . She said she was responsible to make sure the orders were there, however it was every nurse's responsibility. During an interview on 2/14/24 at 9:39 AM, the DON said it was important to monitor side effects and behaviors of any mind-altering medication to know the effectiveness of the medications, and the resident's overall well-being. She said the risk of not monitoring Resident #67 was not knowing if the medications were working, and/or her behaviors showing or not showing a good quality of life for her. She said she was responsible for making sure there were orders and making sure orders were implemented to monitor for side effects and behaviors. She said it was her job to make sure the nurses were putting in any orders that were needed. During an interview on 02/14/24 at 9:48 AM, the ADM said regarding Resident #67 or any resident it was important to monitor for side effects of medications and behaviors to look for negative side effects or negative behaviors. She said they should also monitor for positive side effects and behaviors. She said the nurses should be putting in necessary orders but ultimately the DON was responsible for making sure behaviors and side effects of medications were monitored. Record review of the facility's Antipsychotic Medication Use Policy, dated 5/11/22, provided by the DON reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 8 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order .The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications . Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA . Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in effort to discontinue these drugs and PRN orders for psychotropic drugs were limited to 14 days for 2 of 6 residents (Residents #45 and #67) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #45 did not have a PRN order for Alprazolam 0.5 mg (a prescription medication used to treat anxiety disorders and panic disorder) after 14 days without an evaluation by the physician for continued treatment. 2. The facility failed to ensure Resident #67 had behavior monitoring or side effect monitoring for her prescribed antidepressant medication (prescription medications that help treat, control, or prevent depression), and her prescribed antipsychotic medication (prescription medications that help treat, control, or prevent certain mental health problems.) These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 9 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 Findings included: Level of Harm - Minimal harm or potential for actual harm 1. Record review of Resident #45's face sheet, dated 02/13/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included combined systolic and diastolic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes mellitus (a condition that happens when your blood sugar is too high), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (involves a persistent feeling of anxiety or dread that interferes with how you live your life). Residents Affected - Few Record review of Resident #45's quarterly MDS assessment, dated 01/31/24, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. She was able to make herself understood and was able to understand others. She did not exhibit behaviors of rejection of care or wandering. Record review of Resident #45's physician's orders, dated 02/12/24, indicated Resident #45 had this order: *Alprazolam oral tablet 0.5 mg, give 0.5 tablet by mouth every 24 hours as needed for anxiety (may give 1/2 tab of 0.5 mg to equal 0.25 mg). The start date was 05/08/23. There was no end date. There was no documentation in the order for the duration of the order. Record review of Resident #45's undated care plan indicated a focus of the resident uses PRN anti-anxiety medications. Interventions included: *Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of alprazolam. *Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. *The resident is taking PRN anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips, and legs. Record review of Resident #45's MAR for February 2024, dated 02/12/2024, indicated she received the PRN Alprazolam one time in the month of February on 02/02/24. Record review of Resident #45's MAR for January 2024, dated 02/12/24, indicated she received the PRN Alprazolam a total of four times in the month of January. She received the medication on 01/03/24, 01/05/24, 01/07/24, and 01/08/24. Record review of Resident #45's MAR for December 2023, dated 02/12/24, indicated she received the PRN Alprazolam a total of three times in the month of December. She received the medication on 12/01/23, 12/02/23, and 12/28/23. Record review of Resident #45's MAR for November 2023, dated 02/12/24, indicated she received the PRN Alprazolam a total of six times in the month of November. She received the medication on 11/04/23, 11/06/23, 11/18/23, 11/21/23, 11/24/23, and 11/26/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 10 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 During an interview on 02/14/24 at 09:43 AM, LVN D said she did not know if Resident #45's PRN Alprazolam should have an end date. She said prolonged use of PRN Alprazolam could cause Resident #45 to suffer unnecessary side effects. During an interview on 02/14/24 at 10:03 AM, the ADON said Resident #45's PRN Alprazolam should have an end date on the order. She said it should have been 14 days after the order start date. She said there was a possibility Resident #45 could suffer increased side effects due to prolonged use of the medication. During an interview on 02/14/24 at 10:17 AM, the DON said she noticed Resident #45's PRN Alprazolam did not have an end date after State Surveyor intervention. She said she called the nurse practitioner, and the medication was discontinued. She said the PRN Alprazolam should have an end date at 14 days. She said the risk to Resident #45 was that she could continue getting it and could have suffered an unnecessary side effect. During an interview on 02/14/24 at 10:25 AM, the Administrator said she did not know PRN Alprazolam should have an end date at 14 days. She said prolonged use of the PRN Alprazolam could cause Resident #45 to suffer an unnecessary side effect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 11 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 21 residents (Residents #45, #5, #22 and #53) and 8 anonymous residents reviewed for palatable food. Residents Affected - Some 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings include: 1. Record review of Resident #45's face sheet, dated 02/13/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included combined systolic and diastolic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes mellitus (a condition that happens when your blood sugar is too high), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (involves a persistent feeling of anxiety or dread that interferes with how you live your life). Record review of Resident #45's quarterly MDS assessment, dated 01/31/24, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #45 was able to make herself understood and was able to understand others. She did not exhibit behaviors of rejection of care or wandering. During an interview on 02/12/24 at 9:41 AM, Resident #45 said the food in the facility was usually served cold. She said it was not a specific meal that was cold. She said most meals were cold. She said on 02/11/24 she skipped her dinner meal because she did not like it being cold. 2. Record review of Resident #5's face sheet, dated 02/14/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, depression, and high blood pressure. Record review of Resident #5's quarterly MDS assessment, dated 12/22/23, reflected she had a BIMS score of 13, which indicated no cognitive impairment. Resident #5 was able to make herself understood and was able to understand others. Record review of Resident #5's care plan, dated 11/07/23, reflected she was at risk for weight changes and malnutrition. During an interview on 02/12/24 at 9:49 a.m., Resident #5 said the food was terrible. She said she would not eat the food. She said it looked like grass to her. She tried to request different food in the past, but staff told her there was nothing else. She said the food was often cold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 12 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #22's face sheet, dated 02/14/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included muscle weakness, unspecified protein-calorie malnutrition, and high blood pressure. Record review of Resident #22's quarterly MDS assessment, dated 11/23/23, reflected he had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #22 was able to make herself understood and was able to understand others. During an interview on 02/13/24 on 8:40 a.m., Resident #22 said his breakfast was cold. He said his food was usually cold when he ate in his room. 4. Record review of Resident #53's face sheet, dated 02/14/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included muscle weakness, osteoporosis (a condition where bones become weak and brittle) and stroke. Record review of Resident #53's latest MDS assessment, dated 12/09/23, reflected he had a BIMS score of 14, which indicated no cognitive impairment. Resident #53 was able to make herself understood and was able to understand others. During an interview on 02/12/24 at 2:17 p.m., Resident #53 said the food was always cold. He said the food did not taste good and he did not like the food. He said he had never asked for anything different. During an observation and interview on 02/13/24 at 12:31 p.m., a lunch tray was sampled by 5 State Surveyors and the Dietary Manager. The meal consisted of barbeque beef, potato salad, fried okra, apple crisp, and bread. The okra was cold, and the apple crisp was bland and cold. The Dietary Manager said the okra and apple crisp were cold. She said the apple crisp could be served cold or warm but would taste better warm. During a confidential resident group interview residents said the food was usually cold when the food was passed out on the halls. They said it usually did not have a palatable flavor. They said they complained about the food. They said when they complained the food got better for a little while and then it was served cold again. During an interview on 02/14/24 at 8:41 a.m., the Dietary Manager said food should be served at the correct temperature. She said hot food should be served at 135 degrees and above. She said she encouraged residents to eat in the dining room. She said she had not heard anything about the food being cold or not tasting good. She said anytime she heard of a complaint she went to visit the resident. She said for cold food she encouraged them to eat in the dining room. She said now they started using warm plates during meal service. She said she made rounds 3 times a week. Over the week she visited with each resident. She discussed the new menus with the residents. She also asked them about their likes, dislikes, and what they preferred. She said if a resident did not like the food they might not eat. She said if the residents did not eat they were not getting the nutritional balance they may need . During an interview on 02/14/24 at 9:46 a.m., CNA A said residents complained the food was too salty, too cold, and the vegetables were always mushy. She said if a resident complained she went to the kitchen for an alternate. She said there were times the kitchen staff told her they did not have an alternate. She said she also told the kitchen staff what the complaint from the resident was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 13 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/14/24 at 9:50 a.m., LVN B said she heard the food was too salty. She said she was told the coffee was too cold. She said that was just from picky residents. She said she reported food complaints to the kitchen staff. During an interview on 02/14/24 at 10:25 a.m., the DON said she heard a complaint about the food being cold and needing to be warmed up. She said the food should smell good, look good and be warm. She said if the residents did not like the food, they might not eat it. She said food was a big part of their quality of life. During an interview on 02/14/24 at 1:01 p.m., the Administrator said when there were food complaints they talked to the resident. She said for cold food she would talk to the kitchen and the aides about passing out the trays. She said she expected food to be palatable for the residents who live in the facility. Record review of Resident Council Minutes, dated 02/28/23, indicated .Dietary .Food cold .Food can be cold, sometimes it's the worst food I've ever had. Feels like quality is slipping Record review of Resident Council Minutes, dated 03/28/23, indicated, .Dietary .cold trays, esp (especially ) morning Record review of Resident Council Minutes, dated 07/10/23, indicated, .Dietary .trays cold Record review of Resident Council Minutes, dated 07/26/23, indicated, .Dietary .cold on the trays Record review of Resident Council Minutes, dated 08/28/23, indicated, .trays are coming out cold Record review of Resident Council Minutes, dated 09/27/23, indicated, .Dietary .cold on halls Record review of the facility's Resident Nutrition Services policy, dated July 2017, reflected, .Each resident is provided with a nourishing, palatable, well-balanced diet .Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 14 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **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 that accommodate resident allergies, intolerances and food preferences for 1 of 4 residents (Resident #41) reviewed for food preference. The facility failed to honor Resident #41's preference for carrots being served too often. This failure could place resident at risk of a decrease in resident choices, diminished interest in meals, and weight loss. Findings include: Record review of Resident #41's face sheet, dated 02/13/2024 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #41 had diagnoses which included Chronic Obstructive Pulmonary Disease, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs)Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris ( arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body [arteries] become thick and stiff-sometimes restricting blood flow to the organs and tissues), Dysuria (discomfort when urinating can have causes that aren't due to underlying disease), Essential (Primary) Hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), Muscle weakness (Generalized), Repeated Falls and Anxiety Disorder, Unspecified (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong to interfere with one's daily activities). Record review of the Quarterly MDS assessment, dated 12/19/2023 reflected Resident #41 was understood and understood others. Resident #41 had a BIMS score of 12, which indicated her cognition was intact. Resident #41 required limited assistance with ADL's. Record review of Resident #41's care plan, dated 02/14/2024, in the section titled Preferences reflected Resident #41 was to be encouraged and allowed to verbalize needs and concerns. The section titled Potential for Altered Nutrition reflected Resident #41 was at risk for or had a history of weight changes and malnutrition. Record review of an order Summary Report dated 02/13/2024, reflected Resident #41 had an order for regular diet, Regular texture, Regular/Thin consistency for nutrition with an order start date of 01/18/2024. Record review of the Resident Council Minutes dated 08/28/2023 reflected residents complained about carrots 11 days in a row served. On 10/30/23 at 1:33 PM residents requested less carrots. During an observation on 02/12/24 at 12:14 p.m., a lunch menu for 02/12/24 hung on the dining room wall reflected an alternative meal of chili and carrots. A female resident was served a bowl of chili, crackers and a side of carrots. During an observation on 02/13/24 at 11:30 a.m., a lunch menu for 02/13/24 hung on the dining room wall reflected an alternative meal chicken, rice and carrots. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 15 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 02/12/2024 at 10:07 AM, Resident #41's stated for a while it was carrots or mixed vegetables every day. Resident #41 said, the facility served carrots 12 day in a row. She said some days the food was good and some days it was bad. Resident #41 said, if what the facility served was bad, she ate soup as the alternate. During an interview on 02/14/24 at 10:11 AM. CNA A stated, sometimes Resident #41 complained because the food was either cold or they had the same thing back-to-back, like carrots. CNA A stated she thought it was last week they served carrots all week long. CNA A stated she told the nurse and Resident #41 told the nurse as well, then the nurse reported it. CNA A stated, other residents complained about the food as well and they complained about the carrots also. During an interview on 02/14/24 at 10:25 AM the Dietary Manager stated, Corporate made the menus. The Dietary manager stated the reason why she thought carrots were served a lot was the resident's who received mechanical soft diets were getting them because they could not have raw vegetables. The Dietary manager stated, the facility had alternate meals and they maybe on the alternate meals. The Dietary manager stated she was unaware the resident complained about the carrots. Carrots were not on the actual menu that often, but it could be on the alternate. The facility had carrots because there were residents who didn't like green vegetables. The Dietary manager stated the facility would incorporate more cauliflower and squash now that they were aware. She stated she would also do more beets and cream corn for residents who received mechanical soft diets. Resident #41 got a lot of alternates and whomever she sat with, she wanted to eat what they ate. During an interview on 02/14/24 at 11:00 AM LVN A said Resident #41 had not complained about the food, but she had a lot of requests. LVN A stated no one told her Resident #41 complained about the food. No one on the hall complained about the food. During an interview on 02/14/24 at 11:08 AM the ADON stated Resident #41 had not complained about the food, but Resident #41 complained about several things. The ADON stated they always asked the resident what they liked before trays went out. The ADON stated Resident #41, had not complained about carrots. The ADON stated, she had not heard her complained about food just on the appearance of the food. The ADON stated she was not aware residents had carrots 12 days in a row and that would be incorrect. The ADON stated for the most part when they served the residents, they corrected their preference right then. During an interview on 02/14/24 at 11:15 AM the DON stated, Resident #41, on occasion complained in the Dining room, but they always offered her something different. The DON stated they learned today there were a lot of food complaints, but prior they were unaware. The DON stated she reviewed the grievances in the morning meetings. The DON stated she had not noticed anything in the grievances about food. Resident #41 had not complained about the carrots. During an interview on 02/14/24 at 12:49 PM, the Administrator stated they got their menus from corporate. Resident #41 had not complained about the food to her. The Administrator stated she was not aware carrots were served 12 days straight and stated. That was probably not true. The Administrator stated they had some food complaints here and there. They were working on their kitchen for 2 months. The Dietician gave lists of things to look for when she walked through the kitchen. Food complained on in grievances varied. If residents had a preference, they extended the offer of different foods. The Administrator stated they facility had done several in-services on food focus. The Administrator stated her and Resident #41 were known as friends, but Resident #41 had not complained to her about the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 16 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 0806 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy on Food Preferences reflected If the resident refused or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. The food Service Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 17 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 food service safety. 1. The facility failed to ensure all food items were labeled and dated in the Freezer #1, Refrigerator #2, Refrigerator #3, Refrigerator #5, Freezer #6, Freezer #7, Freezer #8, Refrigerator #9 and the pantry. 2. The facility failed to ensure the sugar was stored in a bin with a closed lid. 3. The facility failed to ensure the range hood was free of greasy droplets. 4. The facility failed to ensure all kitchen staff wore a hairnet appropriately. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 02/12/24 at 8:40 a.m., inside Freezer #1 were 10 packages of mini blueberry waffles were undated, 3 cups of strawberry flavored ice cream were undated, 5 packages whipped topping were undated, 1 container of crispy bread pudding bites were undated, 1 box of buttermilk pancakes were undated, 5 boxes of stuffed peppers were undated and 5 key lime pies were undated. During an observation on 02/12/24 at 8:45 a.m., inside Refrigerator #2 was 1 tub of chili was undated and 3 1/2 gallons of drinking water were undated. During an observation on 02/12/24 at 8:47 a.m., inside Refrigerator #3 was 1 tub of classic potato salad was undated and 8 gallons of drinking water was undated. During an observation on 02/12/24 at 8:48 a.m., inside Refrigerator #5, were orange, square, sliced unknown food item were undated or label, 2 packages of unknown sliced meat were unlabeled, and 1 plastic bag of an unknown white food item were unlabeled. On the bottom shelf was a metal bowl approximately half full of a cloudy liquid. Sitting inside the liquid was a plastic bag of peppers were undated and 2 bags of an unknown vegetable with no label. During an observation on 02/12/24 at 8:51 a.m., inside Freezer #6 were 5 round unknown meats were undated and not labeled, 4 round unknown meat were unlabeled, 1 large roll of an unknown red meat were not labeled or dated, 4 packages of an unknown meat link were not labeled or dated, and 4 large packages of an unknown meat were not labeled or dated. During an observation on 02/12/24 at 8:54 a.m., inside Freezer #7 was 1 bag of a vegetable mix was undated, 2 pans of sweet potato casserole were undated, 2 bags of pot pie filling was undated, 5 bags of peas were undated, 2 tubs of tomato basil soup was undated, 3 bags of a round sliced green food item were not labeled or dated and 2 bags of small round green food items were not labeled or dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 18 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 During an observation on 02/12/24 at 8:57 a.m., inside Freezer #8 were 12 packages of round white unknown food items were not labeled and undated, 1 bag of a light brown food item was not labeled or dated and 3 bags of round brown food items were not labeled or dated. During an observation on 02/12/24 at 08:59 a.m., inside the pantry the sugar bin was open to the air. There were 6 jugs of chocolate syrups were undated, 32 boxes of powdered sugar were undated, 35 boxes of corn starch were undated, 4 boxes of gluten free spaghetti were undated, 3 packages of cornbread stuffing mix were undated. During an observation on 02/12/24 at 9:05 a.m., inside Refrigerator #9 were 2 maroon bowls with plastic lids sitting on a tray with an unknown liquid inside was not labeled. During an observation and interview on 02/13/24 at 11:15 a.m., [NAME] E scooped potato salad into bowls from a tub that did not have a receive date. She said she did not know why the tub was not dated. She said it came in on the truck last Friday (02/09/24) . She said whatever staff worked on Friday (02/09/24) should have dated the potato salad when it came off of the truck . During an observation and interview on 02/13/24 at 11:48 a.m., Dietary Aide F was scooping applesauce into bowls. She had hair (bangs) approximately 2 - 3 inches in length sticking out from the front of her hairnet. She said she did not always leave her hair out from under her hairnet, and she did know all of her hair was supposed to be covered. She said she thought all of her hair was covered . During an observation on 02/13/24 at 11:55 a.m., there were multiple amber colored droplets with a greasy appearance on the front edge of the range hood. The droplets were greasy and sticky to the touch. The droplets easily wiped off of the hood. During an interview on 02/14/24 at 8:41 a.m., the Dietary Manager said food should have been dated by any kitchen staff when the truck made a delivery. She said she expected for food items to be dated and labeled. She said food items not being labeled could cause a resident to get the wrong food item. She said a food item not being dated could cause a resident to get food that did not taste fresh. She said she was unaware of the metal bowl in the bottom of refrigerator #5. She said she would have expected for the contents to have been thrown out. She said she expected the refrigerators to be checked every day for spoiled food. She said she expected all bins in the pantry to be kept closed. She said staff should get what they needed and close it. She said food bins being left open could cause contamination. She said all staff in the kitchen should be wearing hairnets and covering all hair. She said not keeping all hair covered could cause hair to get into the resident's food. She said the range hood company was at the facility the previous week to do a deep cleaning of the range hood. She said staff did clean daily and big equipment was cleaned every other day. She said she would have expected the greasy drops to have been cleaned off by the company or kitchen staff. She said the greasy droplets could drip onto a resident's plate. During an interview on 02/14/24 at 1:01 p.m., the Administrator she said the person who intakes the food was responsible for dating and labeling foods. She said the Dietary Manager was responsible for making sure food items were dated and labeled and ultimately it was her. She said residents consuming food that had not been dated could affect their health. She said foods not being labeled could affect a resident's health. She said food items in bins should have a lid and the lid be closed. She said if food bins were left open to air, something could get inside and not be clean. She said she expected kitchen staff to wear hairnets in a manner to where hair could not get into the food. She said the entire kitchen staff were responsible for cleaning equipment in the kitchen. She said she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 19 of 20 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 676458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mabank Nursing Center 18957 US Hwy 175 W. Mabank, TX 75147 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 not know how to answer how grease dropping from the range hood could negatively affect a resident. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Sanitization policy, dated October 2008, reflected, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . Residents Affected - Many Record review of the 2022 Food Code for the U.S. Food and Drug Administration reflected, .2-402 Hair restraints .food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food .3-304.12 .During pauses in food preparation or dispensing, food preparation and dispensing .in food that is not time/temperature control for safety food with their handles above the top of the food with containers or equipment that can be closes, such as bins of sugar, flour, or cinnamon .Annex 4. Establish First-In-First Out (FIFO) Procedures. Product rotation is important for both quality and safety reasons. First-In-First-Out (FIFO) means that the first bath of product prepared and placed in storage should be the first one sold or used. Date marking food as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS (temperature control storage) foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirement . Record review of a Food Preparation and Service policy, dated July 2014, reflected, .Food service employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . Record review of the facility's Food Receiving and Storage Policy, dated July 2014, reflected, .Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676458 If continuation sheet Page 20 of 20