Health inspection·September 11, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Date Initiated: 06/12/2024. The resident has a pressure ulcer or potential for pressure ulcer development Date Initiated: 10/06/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 10/06/2024. The resident needs assistance to turn/reposition at least every 2 hours. Date Initiated: 10/06/2024. Observation and interviews with Resident #2 and a family member on 09/09/2025 at 1:15 pm revealed he was sitting up in his recliner. He was alert and oriented x3. He had no complaints and talked about his time in the military. He said he was able to walk with assistance. A rollator walker was in front of him. The family member showed me the changing sheets staff and residents used to document Resident #2's incontinent care, and she explained that both the staff member and the resident had to sign the changing sheets. There was a sign inside his room on his wall that read Q 2-hour Checks. Resident #2 said he did not recall the incident.During a phone interview with Resident #2‘s family member on 09/09/2025 at 1:25 pm she said, pictures were taken by some of the girls, but they have left or been fired since then. She said she did not have any of the pictures and did not know who, if anyone, had them. She described the scenario as, Resident #2 had been soiled and wet all night. In the recliner where he slept, his legs and the floor around him were covered in dry, caked-on feces and dried urine. She said, That kind of treatment was negligent and cruel. She said she had discussed the situation with the DON, and the DON was very, very upset. She said there was a sign for checking Resident #2 every 2 hours on his wall. She said she was an old, retired nurse and what she saw was unbelievable. She said some of the CNAs came by every 2 hours on the dot, but others did not. She said staff had a sheet they sign when they change Resident #2 and have the resident sign it as well. She said Resident #2 burned his butt sitting on a heating pad a couple of years ago, and that was where the wounds came from and why he was admitted to the facility. She said Resident #2 was in hospice. She said Resident #2 burned his butt sitting on a heating pad a couple of years ago, and that was where the wounds came from and why he was admitted to the facility. She said the wounds on his bottom were healed now, but he was always moist down there. In an interview with the DON on 09/09/2025 at 2:25 pm she said the facility was fully staffed with 3 CNAs for day shift, 2-3 on night shift, and 2 nurses per shift. She said weekends were also 3 & 2. She said department heads made champion rounds every morning and afternoon. She said all staff were responsible Q (every) 2 hours for checking residents and walking rounds, including nights, weekends, and weekend nights. She said the nurses were responsible for making sure the q 2 hr. checks were done.In an interview with CNA J on 09/09/2025 at 5:19 pm she said she had not heard anything about anyone being covered in dried feces and/or urine in late February 26th and the morning of February 27th. Her schedule showed she was working as the driver at 7:22 am on the 27th.In an interview with LVN L on 09/10/2025 at 10:15 am, she said nurses worked 12-hour shifts, 6 am-6 pm. She said she had worked at the facility for about a year. She said Resident #2 was covered in feces and urine. She said there were photos taken because it was unbelievable. She said she did not know who had the pictures, but she had seen them. She said the DON spoke with the staff. She said she would have fired the staff responsible on the spot. She said she did not know who was working at the time of the incident. She said there was a rule for residents to be checked every 2 hours. She said, This was blatant neglect. In an interview with RN E on 09/10/2025 at 11:22 am, she said she remembered the situation because she heard about it. She said they (unknown) had found him like that, meaning there was feces and urine on and around Resident #2, and she did not remember who said that. She said she worked the night it happened, but the resident was not found until the morning. She said she had stayed over the morning of 02/27/25 to help someone across the hall from Resident #2. She said there was no smell, and his call light was not on when she was across the hall. She said she had the impression the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 2 of 11 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 09/11/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident really happened because why else would the staff be talking about it?. She said she heard staff say Resident #2 had a lot of poop, like a loooot of poop on and around him. She said Resident #2 pooped and urinated a lot when he goes. She said he was on a diuretic. She said she did not hear anything about the feces and urine being dried and stuck to him. She said residents were checked every 2-3 hours at night. She said she did not recall if he was checked every 2-3 hours that night because she was in charge of the other hall. She said staff (CNAs and/or Nurses) were supposed to check residents every 2-3 hours. She said the nurses were responsible for making sure the residents were checked every 2-3 hours. She said she was working the other side of the building that night. She said the nurses were responsible for their crews. She said she did not remember if there was an in-service because the DON was always saying make your rounds. In an interview with the DON on 09/10/2025 at 12:25 pm she said she was familiar with Resident #2. She said she was not at the facility at the time of the incident but heard about how he was covered in dried poop. She said neither the family member nor the resident used his call light. She said Resident #2 and his family would tell the DON they did not want to bother them. The DON said CNA K, who was assigned to that hall, had been terminated for poor performance after the incident. She said she saw the pictures on someone's phone, but did not know who took the photos. She said the pictures were awful. She said the resident and his family member had been spoken to by her on multiple occasions, including today, about not wanting to bother anyone when either one of them needed something to use the call light. In an interview with CNA F on 09/10/2025 at 1:24 pm she said she had worked at the facility for 25 years. She said she did not know about the incident. She said the CNAs checked on residents every 2 hours, and it was always that way. She said the last training for Q2 hr. checks, lifts, and feeding was on or about the 12th of August. She said the nurses were responsible for making sure the residents had been checked on every 2 hours. She said if a resident was found with poop on them, it would be neglect. In a phone interview with RN G on 09/10/2025 at 2:22 pm she said she saw the pictures of Resident #2. She said she did not know who took them. She said it was pretty bad. She said there was dried, crusty poop all up the back of his legs, the chair, on the floor, and mixed urine and poop had pooled and run across the floor. She said she did not know who the CNA was on the floor that night. She said it was uncalled for. She said his family member, who found him, had been crying because she was so upset. She said the state the resident was in was neglectful. In a phone interview with RN H on 09/10/2025 at 2:46 pm he said he barely recalled Resident #2 being covered in feces and urine. He said he was not sure if he was in the facility at the time. He was reminded of his time sheet at this time. He said he did not recall which aide he worked with. He said he did not notice anything out of the ordinary on the night in question. He said he made frequent rounds throughout his shifts, and his last rounds were around 5:00 am. He said Resident #2 would pee and poop himself and wouldn't ask for help because he was hardheaded and did not want to bother anyone, and would rather sit in his own stuff. He said he recalled Resident #2‘s family member being very upset, but that was a while back. He said he had many conversations with both of them about it not being good in any way for the resident to sit in soiled clothing. In an interview with CNA D on 09/10/2025 at 5:45 pm she said she was not working on that hall at the time of the incident. She said Resident #2's room was on CNA K's side and CNA K was her partner at work. She said CNA K was always lazy. She said the CNAs had certain tasks to get done when they first got to work. She said they were expected to pick up meal trays and look at the plates to make sure residents were eating, take linen and trash barrels out, lay the residents down, change the residents who were already in bed, stock briefs, gloves, etc. She said it took her about 2 hours when she first came in to get to the point where she could chart. She said she would walk the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 3 of 11 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 09/11/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few halls to peek in and/or check on her residents basically every 2 two hours, but CNA K would plop down at the nurse's station and pretend to be charting and CNA K would disappear throughout her shift, and no one would know where she was. She said CNA K was on her phone most of the time she was at work. She said CNA K would get mad if the nurses asked her to do something/anything. She said she would call in or just not show up to work, and always had some excuse. She said she was let go for that. She said CNA K probably only went in his room the first round, and that was typical. She said she would talk to whoever the nurse was about not being able to find CNA K. She said she felt like CNA K was neglecting her patients by not checking on them. She said CNA K was freaking out and told her that she forgot to check on her patients that night of the 26th. She said she didn't work with CNA K after that.Additional evidence obtained by the ADM on 09/11/25 at 6:00 pm. A verbal statement by CNA K stated she always checked on Resident #2 due to his being a fall risk. She reported that she checked on residents every 2 hours, and her last round was done around 4:00 am on 02/27/25. She reported she was busy and forgot to chart. Record review of Resident #2's progress notes for 02/27/25 revealed no mention of dried feces & urine on 02/27/25. Record review of the undated facility policy titled, Abuse and Neglect under Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio-video Recordings by Nursing Home Staff: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). This facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s). Our residents have the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care. Taking photographs or recordings of a resident and/or his/her private space without the resident's or designated representatives ' written consent is a violation of the resident's right to privacy and confidentiality. Examples include, but are not limited to, staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area. Taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (e.g., cameras, smartphones, and other electronic devices) and/or keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status, it is considered mental abuse. This would include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, toileting, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part without the resident's face whether it is the chest, limbs, or back, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position.Record review of the facility's undated policy titled, Abuse/Neglect stated, The resident has the right to be free from abuse, neglect.Residents should not be subjected to abuse by anyone.The facility will provide and ensure the promotion and protection of resident rights. It is each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 4 of 11 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 09/11/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect.and situations that may constitute abuse or neglect to any resident in the facility. Definitions: 4. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. 7. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 10. Mistreatment means inappropriate treatment or exploitation of a resident. Procedure: C. Prevention-The facility will provide the residents, families, and staff with an environment free from abuse and neglect.Record review of the facility's undated policy titled, Corporate Code of Conduct stated, As an integral member of this facility's team, you are expected to accept certain responsibilities and exhibit a high degree of personal integrity always. This not only involves sincere respect for the rights and feelings of others but also demands that both in your business and your personal life, you refrain from any behavior that might be harmful to you, your coworkers, and/or that might be viewed unfavorably by current or potential customers or by the public at large.Types of behavior and conduct that this facility considers inappropriate include, but are not limited to, the following:.Disregarding safety or security regulations, Violation of residents' rights, Failure to carry out duties and responsibilities, or performing work of substandard quality or quantity.If your performance, work habits, overall attitude, conduct, or demeanor becomes unsatisfactory in the judgment of this facility, i.e., violates any of the above or is in violation of any other Facility policies, rules, or regulations, you will be subject to disciplinary action, up to and including termination. Event ID: Facility ID: 676491 If continuation sheet Page 5 of 11 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 2 residents reviewed for accidents and hazards.The facility failed to ensure CNA A provided adequate supervision and used a 2-person assist while providing incontinent care to Resident #1. CNA A left Resident #1's bedside, while she lay on her right side. Due to her positioning, Resident #1 fell off the bed. Resident #1 sustained a rib fracture and contusions (bruising) to her right cheekbone, forehead, and back on 06/02/25.A PNC (Past Non-Compliance) Immediate Jeopardy (IJ) situation was identified on 06/02/25. The PNC IJ was removed on 06/30/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm.Findings included:Record review of Resident #1's face sheet dated 07/25/22 revealed an [AGE] year-old female with an admission date of 07/25/22 with diagnoses including dementia with agitation, heart disease, femur fracture, wrist fracture, traumatic brain bleed, muscle weakness, abnormal gait and mobility, muscle wasting and atrophy, anxiety, malnutrition, mental disorders, depression, insomnia, and herpes.Record review of Resident #1's quarterly MDS report dated 07/23/25 revealed Resident #1 had a BIMS score of 99, indicating severe cognitive impairment and was dependent on staff for all ADLs. Resident #1 required 2-person assistance for transfers via mechanical lift, bed mobility, and incontinent care. She could sit in a recliner-type wheelchair but could not self-propel due to upper and lower body impairment and contractures to her hands. She was incontinent of bladder and bowel.Record review of Resident #1's Care Plan dated 07/26/22 indicated she was dependent on staff for all ADLs and required 2-person assistance for transfers, bed mobility, and incontinent care. The following care plan updates were implemented after the incident on 06/02/25: Resident #1 has potential for pain due to contractures of the joints of both hands. She has limited use of her hands due to contractures and a recent fracture of a rib from a fall. Date Initiated: 06/02/2025 Revision on: 06/06/2025. The resident utilizes a bolster or concave mattress to prevent unintentional slipping or rolling out of bed. Date Initiated: 07/23/2025 The resident will not be injured from a fall from the bed. Date Initiated: 07/23/2025 Ensure the bolster is in place while the resident is in the bed. Date Initiated: 07/23/2025. The resident will receive assistance with all ADLs (bathing, dressing, grooming, toileting, eating, mobility) as needed, to maintain skin integrity, prevent infections, and promote comfort, while respecting their preferences and ensuring safety. Date Initiated: 06/06/2025. Revision on: 06/06/2025. The resident is at risk for falls r/t impaired cognition and poor safety awareness. The resident had a recent fall. Date Initiated: 06/02/2025. Revision on: 06/06/2025. The resident will not sustain serious injury through the review date. Date Initiated: 06/02/2025. Revision on: 06/06/2025. The resident will remain free from falls and injury by implementing safety measures, such as environmental modifications and supervision, and by increasing awareness of safety cues, with the support of staff and family, to promote a safe living environment. Date Initiated: 06/06/2025. Target Date: 10/15/2025. Mechanical lift with staff x2 to assist with transfers. Date Initiated: 06/02/2025 Resident may have a mattress with bolsters. Date Initiated: 06/11/2025 Resident to have a low bed and floor mat on both sides of the bed. Date Initiated: 06/02/2025 Revision on: 06/02/2025 Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Record review of the physician notes dated 06/05/25: EXAM: .Resident #1 is functionally impaired due to the physiological changes of an advanced age state and moderate dementia. The patient requires medication management with continued treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 6 of 11 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 is vulnerable to safety risks and requires ongoing supervision to maintain their protection from harm. Resident #1's vocabulary and fund of knowledge indicate her cognitive function is at/or below lifetime baseline, indicating a moderate state of dementia.Record review of the Facility's PIR dated 06/06/25 revealed the fall incident was on 06/02/25 at 10:40 am. There were no witnesses. Resident #1 was assessed by a nurse (LVN C), and the findings were redness to the right side of the forehead and cheekbone, and swelling of the cheekbone. Resident #1 was sent to a local hospital for evaluation. The Resident #1 returned the same day with diagnoses of contusions (bruises) to the right cheek and forehead, mid back, and a non-displaced rib fracture. CNA A was suspended on 06/02/25 pending investigation. Police Case #134533. Steps taken immediately and corrective action implemented by the facility beginning 06/02/25:Medical Director, RP, notified. Resident sent to hospital. In-service on Abuse & Neglect initiated. Staff statements obtained. Actual/alleged abuse/neglect monitoring ad hoc protocol initiated. In-servicing on checking & following Kardex/POCs including making sure second person is available before initiating care. Bed mobility/transfer for 2-person assist. One on one in- servicing with alleged perpetrator. Monitoring initiated from ad-hoc protocol for the next 30 days or as needed to ensure compliance. Weeks 1-4 monitoring of incontinent care was completed by the DON. Care plans were updated for all residents on air mattresses to be 2-person assists. Transfer training techniques discussed and demonstrated with use of proper body mechanics with 2-person transfers. Discussed bed mobility training with proper rolling technique's and scooting upward in bed safely with 2-person assist. Coaching Form for CNA A to follow P&P and refrain from leaving residents unattended while providing incontinent care. (verified)Written witness statement by CNA A dated and signed 06/02/25 revealed I was in the room changing Resident #1 when I needed to change my gloves. Resident #1 was lying on her right side on the bed. When I turned my back to get some gloves when I heard a loud noise, that's when I turn to see what happened, I saw that Resident #1 had fallen off the bed. Another co-worker was in the room before the incident had happened, but she had to step out for a few minutes.Written witness statement by CNA-B dated and signed 06/02/25 revealed .I asked CNA A if she needed help, and she said yes. I told her give me a minute I had to go to another hall. I said I'll be right back. I came back and CNA A had already started (incontinent care) with Resident#1. I was moving the mechanical lift and shower chair out the door to another room. Came back and CNA A said Resident #1 fell out of bed. I saw her (Resident #1 on the ground). I went to call nurse and DON.Written statement by the ADM (at the time) dated and signed 06/05/25 revealed During my review of Resident #1's fall on 06/02/25, I met with the DON and family member of the resident. The family member stated she saw on camera [Resident #1] fell out of bed when nurse aide left bedside to get clean gloves. Resident's family member stated she was informed of the incident and staff's (unknown) description matched what she saw on camera. Video was not shared with facility.Record review of Resident #1's fall risk assessments dated 07/25/22 was 18, 07/27/22 was 12, 07/31/22 was 13, 08/07/22 was 12, 01/06/23 was 12, and 06/02/25 was 10. All scores indicated her fall risk was high since admission. Record review of the local hospital records dated 06/02/25 at 11:25 am: Chief complaint: fell out of bed at nursing home while staff was changing brief, possibly hit right side of head on floor/dresser. History of Present Illness: Here for a fall, unsure if any injuries as she is only alert and oriented to self, and only sometimes, at her baseline. She Is bed bound, from remote traumatic SAH and right hip fracture, has been bed bound for some time, (muscle) wasting in legs, does not speak much at all. She comes in today because they were changing her on nursing home on her bed, and they accidentally walked away with the rail up, and she was still on her side, causing her to roll off the bed. She had some redness on the side of her face, right side, but no other obvious injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 7 of 11 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few They brought to ER to make sure no other injuries. She does not cooperate with history or exam, so she has no specific complaints, she Is alert, not drowsy or tired appearing, but just looks around room and will not answer questions. At 12:20 pm: concluded Resident #1 had a closed fracture of one rib of left side with routine healing. Contusion of back. Contusion of face. Contusion of head. Fall. Observation of Resident #1 on 09/10/25 at 1:00 pm revealed a well-kempt female in a recliner wheelchair with blankets on. She was awake and positioned close to a television in the common area. She had a light blanket covering her and one around her shoulders. She did not respond to her name nor look in the direction of my voice. In an interview with the DON on 09/09/2025 at 2:25 pm, she said the facility was making communication more user-friendly by providing Resident #1's family with her direct email and cell phone number. She said Resident #1 was the only resident with an in-room camera. In an interview with the DON on 09/10/25 at 8:50 am, she said CNA A was by herself, and Resident #1 could not move on her own. She said and demonstrated how CNA A turned to get gloves about 8 feet away from the bed, heard a thump, and found Resident #1 on the floor on 06/02/25. She said Resident #1 was on an air mattress, and CNA A probably did not know about the 2-person requirement for residents on air mattresses. She said, That rule was implemented that day. She said CNA A should have known Resident #1 was a 2-person assist anyway. She said she also audited all residents on air mattresses, updated their care plans, and all staff in-services were done for the new 2-person requirement when patient care was done on someone on an air mattress. She said the rule existed at the time of the incident, but she did not know about it until the day of the incident, and found it in a QAPI ad-hoc she came across while looking for a policy. She said she conducted follow-up monitoring for 4 weeks. She said a police report was also done, and a case number was provided. She said Resident #1's family member was upset after seeing the incident on the in-room camera. She said CNA A was not allowed in Resident #1's room for a period of time, but could now go in as long as someone else was with her. She said CNA A was suspended for less than 3 days due to immediate education, in-services, and corporate allowed CNA A back on the floor. She said CNA A did not have any reprimands in her personnel file. In an interview with RN E on 09/10/2025 at 11:28 am, she said she had worked at the facility for 1 year. She said she heard about a resident who had rolled off her mattress when she was being changed. She said, That resident is heavy, so she should have been a 2-person assist anyway. In an interview with CNA F on 09/10/2025 at 1:08 pm, she said she had worked at the facility for 25 years. She said Resident #1 would call out whenever anyone touched her at all. She said she heard about Resident #1 falling out of the bed. She said she heard CNA A had put Resident #1 in bed and had turned her on her side, then CNA A went to get gloves, and the resident flipped herself over and off the bed. CNA F said that since that happened, Resident #1 was a 2-person assist whenever we went in to do anything for her. She said the mechanical lift and residents on air mattresses required 2 people now. She said leaving a resident's bedside like that would be neglect.During a phone interview with RN G on 09/10/2025 at 2:30 pm she said CNA A turned Resident #1 on her side, then left the bedside to get gloves, and Resident #1 fell off the bed. She said Resident #1 was a 2-person assist at the time, but CNA A did it by herself, and this was not the first time CNA A had done something that got her in trouble. She said Resident #1's family member asked her one day why Resident #1 was still in bed. She said CNA A told her and the family member she just didn't do it. RN G said she was on duty the day of the incident and assisted LVN C with the situation. During a phone interview with RN H on 09/10/2025 at 2:48 pm he said he could not recall and did not know the details of Resident #1 falling out of bed. He said there probably should have been 2 people in there. He said he was not surprised. During a phone interview with CNA A on 09/10/2025 at 4:05 pm she said she was changing Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 8 of 11 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on 06/02/25 and needed to change her gloves because they were soiled. She said she left Resident #1 lying on her side in the middle of the bed, changed her gloves, turned around, and she was on the ground. She said the gloves were by the door, the bed was by the window (B bed). She said Resident#1 had never moved like that before, meaning she never rolled by herself. She said 2 staff members were changing Resident #1 now. She said she should have known better than to leave Resident #1. She said she did not have all her supplies ready to go for changing Resident #1, like she was taught. She said Resident #1 had always been a 2-person assist because she did not move or do anything for herself. She said, and another staff member, CNA B, put Resident #1 to bed with the mechanical lift, but CNA B left the room, and I should have waited for her to return to help, but I took it upon myself to change her. I did not want to wait. She said CNA B did not work there anymore because of attendance. [Termed 06/24/25 for NCNS] She said Resident #1's bed was waist high on her and she's 5'3, about 3 feet off the floor when she fell. She said she found out Resident #1 had a fractured rib as a result of the fall. She said Resident #1 landed on her face when she fell. She said they waited for the paramedics to move her. She said Resident #1 fell on a fall mat. She said there was a fall mat on each side of her bed. She said RN G came in when she called for help. She said Resident #1 was a 2-person assist for everything. She said she never changed her by herself, and she just wasn't thinking. She said there was a camera in her room, but she did not see the video. She said it was around 10 or 10:30 in the morning. During a phone interview with LVN C on 09/10/2025 at 4:43 pm she said, Resident #1 could not hold herself in place, so if she was on her side, gravity could easily make her fall. She said Resident #1 was not responsive to anything but pain and was non-communicative except to yell out. She said Resident #1 was not hard of hearing. She said she did not know why CNA A left the resident's side. She said Resident #1 was a mechanical lift that required 2 people. She said she assessed Resident #1 after the fall and did not move her. She said they waited for the paramedics to move her. She said she could see redness on Resident #1's face. She said RN G assisted her with the situation.In an interview with CNA D on 09/10/2025 at 6:13 pm, she said she heard Resident #1 had fallen from her bed. She said the accident could have been avoided because Resident #1 was little and stiff. She said CNA A should have made sure she had everything she needed before she got started with Resident #1, so she did not have to step away. She said Resident #1 was probably too close to the edge of the bed to start with. She said Resident #1 always had fall mats. She said Resident #1 was a 2 person everything. Interviews with current staff beginning 09/09/25 at 2:25 pm: CNA A, LVN C, CNA D, RN E, CNA F, RN G, RN H, and CNA J were all aware and correctly identified steps in the facility policies regarding transfers and 2-person assists. Record review of CNA A's personnel file included a counseling form dated 03/10/25 for Failure to check on a resident for several hours. 06/10/25 for failure to report an incident involving a resident transfer from a Geri chair to the bed. There were no other details about the incidents. Record review of an in-service dated 06/03/25-Any resident on an air mattress needs at least 2 staff to assist with bed mobility and/or incontinent care in the bed. Record review of facility In-services dated 06/03/25 included: 2. Any resident on an air mattress needs at least 2 staff to assist with bed mobility and/or incontinent care in the bed. 3. Mechanical lift-2 people assist always: No exceptions. 4. How to use the kardex (a concise summary of a patient's care plan, used as a quick reference guide) in the electronic health record 5. Ensure that you follow all care planned interventions, including how many staff are required to perform ADLs and/or if they need a mechanical lift 6. If, for any reason, the number of staff assistance is not listed for bathing, bed mobility, transferring, walking, or incontinent care, then you should contact the charge nurse, the assistant DON, and/or the DON. 7. If more assistance is required than what is on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 9 of 11 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the kardex, report to the DON or the assistant DON so it can be updated. 8. Report all change in the conditions of residents to the charge nurse, assistant DON, and/or the DON.Record review of the facility's corporate email communication with the DON dated 09/10/25 revealed there was no policy for air mattress.Record review of the facility's undated policy titled, Fall Policy stated, Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS will also assist in determining a resident who is at risk.The assessment tool should be scored, and interventions implemented as indicated. Appropriate interventions will be addressed immediately in the interdisciplinary plan of care. Reassessment will occur after each fall. Interventions will be resident-centered. See Appendix A for Fall Intervention Methods on the following pages. In instances where fall risk measures do not prevent a fall, the residents will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. The nurse will complete an event fall nurses' note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. Appropriate education will be provided to all staff members as needed on fall prevention. Appendix A.Positioning devices such as bolsters, wedges, and special mattresses can increase safety in bed/chair. Staff must be trained in safe transfer techniques and proper use of body mechanics.Record review of the facility's undated policy titled, Abuse/Neglect stated, The resident has the right to be free from abuse, neglect.Residents should not be subjected to abuse by anyone.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect.and situations that may constitute abuse or neglect to any resident in the facility. Definitions: 4. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. 7. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 10. Mistreatment means inappropriate treatment or exploitation of a resident. Procedure: C. Prevention-The facility will provide the residents, families, and staff with an environment free from abuse and neglect. Record review of the facility's undated policy titled, Turning a Resident in Bed 17. Assure the resident is placed in the center of the bed and not on the edge of the bed.Record review of the facility's undated policy titled, Corporate Code of Conduct stated, As an integral member of this facility's team, you are expected to accept certain responsibilities and exhibit a high degree of personal integrity always. This not only involves sincere respect for the rights and feelings of others but also demands that both in your business and your personal life, you refrain from any behavior that might be harmful to you, your coworkers, and/or that might be viewed unfavorably by current or potential customers or by the public at large.Types of behavior and conduct that this facility considers inappropriate include, but are not limited to, the following:.Disregarding safety or security regulations, Violation of residents' rights, Failure to carry out duties and responsibilities, or performing work of substandard quality or quantity.If your performance, work habits, overall attitude, conduct, or demeanor becomes unsatisfactory in the judgment of this facility, i.e., violates any of the above or violates any other Facility policies, rules, or regulations, you will be subject to disciplinary action, up to and including termination. The noncompliance was identified as PNC. The IJ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 10 of 11 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 09/11/2025 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 0689 began on 06/02/25 and ended on 06/30/25. The facility had corrected the noncompliance before the survey began. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676491 If continuation sheet Page 11 of 11