Health inspection·August 3, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete appropriate health care provisions when a resident has not provided written documentation for his/her advance directive, has not made a decision regarding his/her advance directive, or is incapacitated. 11. There are two witnesses required for all advance directive documents. Each witness must be a competent adult . No records or documents were found with two witness signatures regarding advance directives for Resident #33. Event ID: Facility ID: 676491 If continuation sheet Page 2 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 observations, interviews, and record reviews, the facility failed to ensure residents maintained acceptable means of hydration for 1 of 8 (Resident #34) reviewed for hydration. Residents Affected - Few Resident #34 did not have fluids for hydration available at the bedside during three surveyor observations from 08/01/2023 through 08/03/2023. This failure could place residents at risk for dehydration, decline in health, serious illness or hospitalization Findings included: A record review of Resident #34's face sheet documented an [AGE] year-old male originally admitted on [DATE] and a re-admission on [DATE]. Resident #34's diagnoses included Parkinson's, Lewy Bodies (neurocognitive disorder), major depression, high blood pressure, malnutrition, a visual disorder, dementia with agitation and behavioral disturbance, hallucinations, lack of coordination, anxiety, and constipation. Record review of Resident #34's care plan dated 07/23/23 documented a focus that the resident had a potential fluid deficit r/t impaired cognition and impaired mobility-date initiated 01/25/22. The goal was Resident #34 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor-date initiated 01/25/22. The interventions documented included: inform the nurse if the resident was refusing to drink fluids, nursing staff to encourage the resident to drink fluids of choice, nursing staff to ensure the resident had fluids in reach, invite the resident to activities that promote additional fluid intake, offer drinks during one-to-one visits, all initiated 01/25/22. Resident #34's care plan had a focus that the resident had an ADL self-care performance deficit initiated 01/25/22 with interventions including Eating: the resident was able to hold cup, feed self, eat finger foods independently-date initiated 02/18/22. A record review of Resident #34's MDS dated [DATE] documented a BIMS of 10. Observation of Resident #34's room, bedside table, and rolling bedside table on 08/01/23 at 2:39 pm revealed no cup, glass, mug, or other vessel with water or other beverage. Observation of Resident #34's room, bedside table, and rolling bedside table on 08/02/23 at 9:37 am revealed no cup, glass, mug, or other vessel with water or other beverage. Observation of Resident #34's room, bedside table, and rolling bedside table on 08/03/23 at 9:10 am revealed no cup, glass, mug, or other vessel with water or other beverage. Observation of Resident #34's room, bedside table, and rolling bedside table, and interview with the DON on 08/03/23 at 9:10 am revealed no cup, glass, mug, or other vessel with water or other beverage. The DON stated there was supposed to be a mug or cup at the bedside all the time. An interview with Resident #34 on 08/01/23 at 2:39 pm revealed the staff brought him things to drink only if he asked for it. Resident #34 stated his mouth and lips were dry a lot of the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 3 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 An interview with the DON on 08/03/23 at 9:33 am revealed Resident #34 used his call light when he wanted something to drink. The DON stated she made rounds throughout the day, answered call lights, and did whatever she had to do. The DON stated she was primarily on the 100 hall yesterday (08/02/23) and the day before that (08/01/23), she made rounds on the 300 hall but did not notice Resident #34 had no beverages at the bedside, and that she was actually in Resident #34's room on 08/01/23. Residents Affected - Few The facility failed to pruduce a policy on hydration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 4 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 - Some 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 for 1 of 1 kitchen reviewed and 1 of 1 nutrition room for sanitation. 1. The facility failed to ensure utensils were clean and in working order 2. The facility failed to ensure the meat slicer was kept clean 3. The facility failed to ensure the steam table was kept clean 4. The facility failed to ensure kitchen staff knew how to calibrate thermometers 5. The facility failed to ensure food items in the nutrition room refrigerator were not expired 6. The facility failed to ensure food items in the nutrition room refrigerator were labeled and dated These failures could place residents at risk of foodborne illnesses. Findings include: Observation of the kitchen during initial tour on 08/01/23 beginning at 10:47 am revealed a drawer with dirty utensils including 1 metal pastry scraper, 1 metal icing knife, and 1 small metal beater with dark brown spots all over them, 2 plastic spatulas that were cracked and had flaking pieces that fell off when touched, and 2 large plastic spoons that were melted and cracked. The meat slicer blade had similar dark brown spots around the entirety of the outer/cutting side of the blade. The steam table wells had yellowish water in them with yellow floating debris (could not see the bottom of the wells) and a thick layer of a yellowish-white flaking substance around the waterlines of all 4 wells. Observation and interview with the DS and COOK on 08/03/23 at 11:20 am during temperature checks for lunch service, the COOK was calibrating the thermometer in ice water. She stated the calibration temperature should be 35F. The DS stated the calibration temperature in ice water should be 35F. The DS stated food temperatures should be 165F-175F for all the different foods. The COOK and the DS both stated they did not know what temperature was freezing or boiling. Temperatures recorded for lunch (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 5 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 - Some service were: Asian Beef 175.9F, Mixed vegetables with beef soup 206.2F, and Spring roll, 147.7F which was placed back in the oven. The COOK re-calibrated the thermometer between each temperature taken. Observation of the Nutrition room refrigerator and interview with the DON on 08/03/23 at 04:20 pm revealed fifteen 4 oz. containers of thickened water with use by date of June 2023, eleven 4 oz. containers labeled vanilla pudding with use by date of 08/02/23, and one 4 oz., container with a similar looking substance of the pudding unlabeled and undated. The DON stated dietary was responsible for ordering, preparing food, and stocking the nutrition room refrigerator. The DON stated, I'm not going to lie, I stock the refrigerator, too. I just didn't look at the expiration dates. The DON stated she was responsible for the nutrition room. The DON stated expired food could make the resident's sick. Interview with the DS on 08/01/23 at 10:47 am revealed they had a cleaning schedule, and the steam table was cleaned every other day. The DS stated the kitchen staff did not use the utensils in the drawer and did not know why they were in there. The DS stated that the dark brown spots on the metal utensils in the drawer look like rust, and the flaking pieces of the plastic utensils could get in the food and make someone sick or break a tooth. An interview with the COOK on 08/01/23 at 10:52 am stated the staff did not use the utensils in the drawer and did not know why the utensils were in the drawer. Record review of the facility instructions for Digital Thermometer Calibration documented .the temperature should read 32F when calibrated using the freezing point method, and 212F when using the boiling point method. Record review of the facility's Daily Services Policy and Procedure Manual dated 2012, Daily Food Temperature Controldocumented under Procedure: 4. All hot foods shall be cooked and held for service at temperatures of 140F or above. 5. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165F and held for at least 15 seconds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 6 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain a infection prevention program to provide a safe and sanitary environment for 1 of 1 laundry room, and 1 of 1 resident (Resident #34) reviewed for infection control, in that: Residents Affected - Some A: failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella bacteria can grow and spread. B: failed to ensure laundry was disinfected by monitoring/maintaining a water temperature of 140 degrees. C: failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 1 resident (Resident #34) reviewed for infection control These deficient practices place facility residents at risk for airborne infections. Findings include: A: During an interview with the administrator on 8/3/2023 at 10:00 am she said no system was in place to measure testing protocols or to intervene when control limits were not met. The administrator said they looked at the drains in the showers, looked at the air conditioner for proper function, and looked at the water systems monthly but did not have a map indicating where those items were that needed to be looked at. During an observation of an air conditioner vent in the laundry room on 8/3/2023 at 11:00 pm, excess condensation was noted on the vent, and the ceiling was discolored near the vent. During an interview on 8/3/2023 at 11:00 pm with the Maintenance director he was asked if air conditioner vents that displayed excess condensation were checked for legionella, and he said he did not know how to do that. B: During an interview with the administrator on 8/3/2023 at 11:10 am she said the washing machines check the temperature of the water. The administrator said the temperature of the water should be 125 degrees. Record review of the manufacturer the temperature should be above 125 degrees to disinfect clothes. During an interview with the housekeeping supervisor on 8/3/2023 at 11:10 am she said the water should be 180 degrees to disinfect the clothes. During an interview with the housekeeping staff on 8/3/2023 at 11:10 am she said clothes were disinfected with hot water. She did not know what temperature water should be to disinfect clothes. During an interview with the Maintenance director on 8/3/2023 at 11:10 am he said he did not know what temperature water should be to disinfect clothes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 7 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the administrator on 8/3/2023 at 3:45 pm she said the temperatures of the laundry water are not recorded. This time, the Administrator said the water temperature should be at 140 degrees F. A record review of the facility Environment of Care Policy and Procedure Manual (2003) indicates: The water temperatures of the laundry and kitchen areas should be maintained at a temperature of 140 degrees F. A: A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation indicates the water management program includes the following elements: b: A detailed description and diagram of the water system in the facility, including the following: 1 receiving 2 cold water distribution 3 heating 4 hot water distribution 5 waste c: The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains and medical devices such as CPAP machines, hydrotherapy equipment etc. d: The identification of situations that can lead to Legionella growth, such as: 1 construction 2 water main breaks 3 changes in municipal water quality 4 the presence of biofilm, scale or sediments 5 water temperature fluctuations 6 water pressure changes 7 water stagnation 8 inadequate disinfection e: specific measures used to control the introduction and/or spread of legionella )e.g., temperature, disinfectants) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 8 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 0880 f: the control limits or parameters that are acceptable and that are monitored Level of Harm - Minimal harm or potential for actual harm g: a diagram of where the control measures are in place h: a system to monitor control limits and the effectiveness of control measures Residents Affected - Some I: a plan for when control limits are not met or not effective J: documentation of the program C: A record review of Resident #34's face sheet documented an [AGE] year-old male originally admitted on [DATE] and a re-admission on [DATE]. Resident #34's diagnoses included Parkinson's, Lewy Bodies (neurocognitive disorder), major depression, high blood pressure, malnutrition, a visual disorder, dementia with agitation and behavioral disturbance, hallucinations, lack of coordination, anxiety, and constipation. A record review of Resident #34's MDS dated [DATE] documented a BIMS of 10, indicating moderate cognitive impairment. Observation on 08/01/23 at 2:10 pm revealed Resident #34 was turned to his right side, facing the wall of his room, while CNA A provided peri care. CNA A did not change gloves before placing a clean brief beneath Resident #34. CNA A repeatedly pulled wipes from the package they were in with soiled gloves during peri care. CNA A touched Resident #34 while directing him to turn from his right side to his back with soiled gloves. An interview with the DON on 08/03/23 at 9:26 am revealed the process for incontinent care was to knock on the door prior to entering, explain the procedure, wash hands with soap and water, pull the curtain, and have supplies ready to go. The DON stated during incontinent care, gloves were worn, enough wipes should be pulled out, so they (staff) don't dig back into the package to avoid contamination, then use one wipe per swipe, from front to back. Gloves should be changed, and hand sanitizer should be used before putting on clean gloves unless the gloves were visibly soiled, then put on clean gloves, then place the clean brief. The DON stated the CNAs got training via annual competencies, in-services as needed, and when she found a trend of infections going up, such as UTIs. The DON stated UTIs could be prevented to an extent, but some of the residents were more susceptible and/or have comorbidities. An interview with LVN A on 08/03/23 at 02:23 am revealed the process for incontinent care was to wash hands, knock, explain the procedure, put gloves on, remove the soiled brief, change gloves, use ABHR, provide care with a wipe from the container in single wipes from top to bottom; the wipes would be taken from the container prior to starting. If more wipes were needed, remove gloves, use ABHR, put on new gloves, put the new brief on, throw away the trash, remove gloves, and sanitize hands. Interview with LVN B 08/03/23 02:29 pm revealed the process for incontinent care was to knock, announce self, wash hands, explain the procedure, close the curtain/provide privacy, get supplies: gloves, a bag for trash, barrier cream if needed, wipes. Put down a barrier, put all supplies on it, assess for pain prior to turning, and get assistance if needed. Open the soiled brief, wipe front to back, wipe the outsides of the labia one at a time until clean, roll the resident to his/her other side, wipe bottom front to back, then wipe the butt cheeks, remove gloves, wash hands, put on new gloves, apply barrier cream, take gloves off, use ABHR, put new gloves on, place the new brief under the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 9 of 10 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 676491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Ridge Rehab & Nursing Center 401 Swift Street Refugio, TX 78377 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident, remove the trash, remove gloves, wash hands. Use only 1 wipe per swipe; the wipes are out of the container, and if more are needed, either have an assistant get them, or change gloves, ABHR, and put on new gloves. An interview with LVN C on 08/03/23 at 02:36 pm revealed the process for incontinent care was to knock, announce self, explain why she's there, ask permission, provide privacy, gather linens; whatever I need, explain the procedure, don gloves, clean front to back with the proper number of cloths, one at a time, right then left then middle of labia then bottom to top for the back. Remove soiled linen, remove gloves, wash hands, put on new gloves, place the new brief under the resident, change sheets if needed, reposition the resident, and provide comfort. LVN C stated she teaches her students not to cross-contaminate. An interview with CNA B on 08/03/23 at 02:43 pm revealed the process for incontinent care was to knock on the door, announce self, wash hands, explain the procedure, put gloves on, get supplies, a new brief, and wipes. Wipe once, throw it away, wipe at least 2 more times and throw them away after use, remove gloves, use ABHR, put on new gloves, then place the new brief and adjust the resident. Put trash in the trash bag, put dirty gloves in the trash bag, tie it up and place it in the dirty barrel, wash hands, make sure the resident has their call light, and the bedside table with remote, and water, and whatever else they wanted on it within reach, then let them know to use the call light if they need anything else. Record review of the facility policy, Perineal Care effective 05/11/22 documented under Prepare: 1) Assemble supplies 2) Knock 3) Acknowledge resident 4) Introduce yourself . 6) Explain procedure 7) Provide privacy 8) Prepare work station 9) Reposition bed 10) Perform hand hygiene 11) [NAME] gloves 12) Remove an adequate number of pre-moistened cleansing wipes 13) Position resident 14) Provide privacy at all times 15) Protect mattress if needed 16) Wipe the pubis area 17) Perform perineal care, wiping from clean to dirty and avoiding contamination to the urethral area . 21) Gently perform care to the buttocks and anal area, working from front to back and avoiding contamination to the urethral area . 23) .apply moisture barrier as directed 24) Doff gloves 25) Perform hand hygiene 26) Provide comfort . 29) Return resident items on the table 30) Tie off the disposable trash bag 31) Perform hand hygiene . Always perform hand hygiene before and after glove use FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 10 of 10