Health inspection·March 13, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior of three (Residents #32, #37, #48) of five residents reviewed for safe, clean, homelike environment. 1.The facility failed to ensure the ceiling A/C vent for Resident #32's room was clean and not dusty on 03/11/25. The facility failed to ensure the leaking pipe underneath Resident #32's sink was repaired on 03/11/25 instead of the resident using a trash can to catch the water. The facility failed to ensure that the dark gray container underneath Resident #32's sink was empty on 03/11/25 that was full of water from a leaking pipe. 2. The facility failed to ensure Resident #37's fluorescent lights had a cover, exposing metal fixtures and 2 light bulbs on 03/11/2025 that was located over his bed. 3. The facility failed to ensure the hole on the bathroom wall near the toilet in Resident # 48's bathroom was sealed on 03/11/25. These failures could affect residents and place them at risk for a diminished quality of life and a diminished clean, homelike environment. Findings included: 1. Record review of Resident #32's Face Sheet, dated 03/13/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included dementia, polyneuropathy, unspecified, a condition where multiple peripheral nerves (nerves outside the brain and spinal cord) are damaged, but the specific cause is unknown, spinal stenosis is a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed, malignant neoplasm of the prostate (a prostate cancer, a type of cancer that starts in the prostate gland, a small gland in the male reproductive system), joint pain, and abnormalities with gait and mobility. Record review of Resident #32's Quarterly MDS assessment, dated 02/07/25, revealed the resident had a BIMS score of 15 indicating his cognition was intact. Page 1 of 22 455486 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 Record review of Resident #32's Care Plan, dated 02/21/25, revealed the following: Level of Harm - Minimal harm or potential for actual harm Focus: Resident #32 has an ADL Self Care Performance Deficit r/t Dementia, Pain . Residents Affected - Some Resident #32 is at risk for falls related to: History of falls, muscle wasting/atrophy, lack of coordination, spinal stenosis, wedge compression fracture of vertebra. Date Initiated: 02/16/2024 Revision on: 02/16/2024 Goal: Resident #32 will have no fall related injuries through the review date. Date Initiated: 02/16/2024 Revision on: 02/29/2024 Target Date: 02/26/2025 Resident #32 will have a reduced number of falls through the review date. Date Initiated: 02/16/2024 Revision on: 02/29/2024 Target Date: 02/26/2025 Resident #32 is at risk for falls related to: History of falls, Muscle Wasting/Atrophy, Lack of Coordination, Spinal Stenosis, Wedge Compression Fracture of Vertebra . During an observation and interview on 03/11/25 at 10:40 AM with Resident #32 in his room revealed the resident was alert and standing up looking at television. The A/C vent in Resident#32's bed was dusty and uncleaned. Resident #32 stated that he did not remember the last time the A/C vent in his room was cleaned by staff. He stated that he was not aware that the A/C vent in his room was dusty and not cleaned. He stated that he has been at the facility for one year. During the observation of Resident #32's room, he stated that there was a water leak in the sink in his room. He opened the 2 cabinet doors underneath the sink and pointed to a dark gray plastic container that was filled to the top with water. He stated that the white pipe underneath his sink was leaking and causing water to drip, and he decided to place the dark gray plastic container underneath his sink to hold the water from the leaking pipe. Resident #32 stated when the dark gray plastic container was filled with water, he would bend down and retrieve the container and dump the water into the toilet in his bathroom. Resident #32 stated that he has told staff and maintenance about the leaking pipe underneath his sink, but no one has repaired the leaking pipe since he has been at the facility. 2. Record review of Resident #37's Face Sheet, dated 03/13/25 revealed the resident was a [AGE] 455486 Page 2 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident's diagnoses included Parkinson's disease (a chronic and progressive neurodegenerative disorder that affects movement and other functions), history of repeated falls, unsteadiness on feet, polyneuropathy unspecified (a condition where multiple peripheral nerves (nerves outside the brain and spinal cord) are damaged, but the specific cause is unknown), heart disease, heart failure, and paranoid schizophrenia (a mental health condition characterized by persistent delusions and hallucinations). Record review of Resident #37's Quarterly MDS assessment, dated 02/18/25, revealed the resident had a BIMS score of 15 indicating his cognition was intact. During an observation and interview on 03/11/25 at 11:10 AM with Resident #37 in his room revealed the resident was alert and laying on his bed. Resident #37 stated that he's been at the facility for several years. Resident #37 stated that he was unaware how long he had been in his current room. During the observation of Resident #37's room, there was no cover for the fluorescent lights above his bed. Resident #37 stated that he was he did not notice that the cover for the fluorescent lights above his head was not covering the light fixture. Resident #37 stated that no staff have mentioned to him that the light cover was missing. He stated that there have not been any repairs made to the light fixture above his bed. 3. Review of Resident #48's face sheet, dated 03/13/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #48's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and borderline personality disorder (a mental health condition characterized by intense and unstable emotions, impulsive behaviors, and difficulties in relationships), osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones within a joint, leading to pain, stiffness, and reduced movement), and Type 2 diabetes mellitus with hyperglycemia (means a person with type 2 diabetes has persistently high blood sugar levels (hyperglycemia) due to insulin resistance and/or insufficient insulin production). Record review of Resident #48's Quarterly MDS assessment, dated 02/12/25, revealed the resident had a BIMS score of 13 indicating her cognition was intact. During an observation and interview and on 03/11/25 at 11:47 AM with Resident #48 in her room revealed that she was alert and sitting in her wheelchair and was looking at television. Resident #48 stated that she had been at the facility for 1 year. During the observation of Resident #48's bathroom, the bathroom was a shared bathroom with Resident #48, her roommate and 2 residents in the room beside Resident #48 shared the same bathroom . The bathroom observation revealed there was a large sized hole in the bathroom wall behind the toilet. During interviews with Resident #48 and the other residents that share the same bathroom revealed they were unaware that there was a whole in the bathroom wall behind the toilet. All parties revealed that maintenance or staff have mentioned to them the presence of a large sized hole on the wall behind the toilet. Record Review of the facility's Maintenance Request Log at the 100 Hall's Nurses Station, revealed there was no entries regarding repairs for the rooms or bathrooms of Resident #32, Resident #37 and Resident #48. In an interview with Maintenance Supervisor on 03/13/25 at 11:07 AM, he stated that he had been employed at the facility for 1 month. He stated that he remembers an unknown staff member informing him 455486 Page 3 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the pipe underneath the sink in Resident #32's room was leaking. He stated that he gave the work order for the repair for the leaking pipe in Resident #32's room to his worker, Maintenance Staff B. He stated that he assumed that Maintenance Staff B completed the work order in Resident #32's room. He stated that he did not hear anything else regarding the leaking pipe underneath Resident #32's sink, and no one has complained about the anything, therefore he assumed that the work order was done, and the repair was completed and closed. He stated that he did not follow-up on work orders that were given to Maintenance Staff B. He stated that he was unaware that the A/C vent in Resident #37's room was dusty and uncleaned. The Maintenance Supervisor stated that he was unaware that there was a hole in the wall behind the toilet in Resident #48's bathroom. He stated that it is his responsibility for ensure that the repairs are done in the facility including the exterior and interior areas within the facility, such as the residents' rooms and bathrooms including the A/C vents, and light fixtures. He stated that the risk of there being a large size hole in the wall behind the toilet in Resident #48's bathroom are that critters, such as snakes and rodents can enter from the exterior of the building into any openings or holes such as the hole in Resident's 48's bathroom wall. He stated that that residents that use that bathroom can get their foot caught in the hole, which could harm them and cause some serious injuries because of the contained area in the bathroom. He said that risk walls. The Maintenance Director stated that the risk of the leaking pipe under Resident #32's sink can cause there being stagnant water in the dark gray container underneath the sink in the resident's room which can cause some harm if the resident has any allergy issues. He stated that he has drank water from a [AGE] year old water well and he has not become sick. He stated that the light cover not being over the fluorescent lights above Resident #37's bed can become hot and can explode or pop, which can lead to the resident being harmed by being cut by the shard glass from the broken florescent lights above his head. In an interview with Maintenance Staff B on 03/13/25 at 12:25 PM, who stated that he had been employed as the Maintenance Assistant at the facility for almost 13 years. He stated that staff are required to complete any Maintenance Requests in the Maintenance Log in the facility's software program, such as any issues such as dusty A/C vents, repairs such as walls, leaking pipes, and light fixtures. He stated that he has not seen any requests in the Maintenance Log regarding the A/C vents, wall repair or leaking pipes, and light fixture repairs on the 100 Hallway for Resident #32, Resident #37, and Resident #48. He stated that it is the responsibility of the Nursing Staff to notify the Maintenance Departments if there is something like dust on the A/C vents, repairs such as walls and leaking pipes, wall repairs and light fixture issues/concerns in a resident's room. He stated that staff are required to complete any Maintenance Requests in the Maintenance Log in the facility's software program, such as any issues such as dusty A/C vents, repairs such as walls, leaking pipes, and light fixtures. He stated that he was unaware that the A/C vent in Resident #32's room was dusty and unclean until it was brought to his attention. He reported that the Maintenance Supervisor will give him a sheet with the open Work Orders, and he will complete the Work Orders as they are completed. Maintenance Staff B stated that the Maintenance Supervisor has never given him a Work Order for repairs for Resident #32's room. He stated the risk of the ceiling vents being unclean is that if the dust blew onto residents they could be affected and have issues breathing. He stated that he was unaware that Resident #32 had a leaking pipe underneath his sink and there was a dark gray plastic container underneath the sink to hold the water from the leaking pipe. He stated that he did not know that Resident #32 was emptying the dark gray plastic container underneath the sink for approximately 1 year according to the resident. He stated that Resident #32 can be at risk for falling trying to bend down to pick up the heavy dark gray plastic container of water and 455486 Page 4 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he could hurt his back and spill the water in the container and slip and fall and harm himself and be seriously injured. Maintenance Staff B stated that he was unaware that the 2 fluorescent light bulbs above Resident #37's bed did not have a halogen cover. He stated that if the fluorescent lights were to get hot and bust, it can harm Resident #37 by him being cut by broken class, which can cause injuries to different areas of the body. Maintenance Staff B stated that he was unaware that there was a large sized hole in the wall behind the toilet in Resident #48's bathroom. He stated that if there is a large hole in the wall near the toilet, it can cause rodents, snakes and other animals to enter the facility through the hole in the wall, which is nasty. He stated that the large sized hole in the wall in Resident #48's bathroom could cause harm if a snake enters the hole and anyone in the facility can be bitten by the snake. In an interview with the Operations Manager on 03/13/25 at 1:31 PM revealed that he had been employed at the facility since November 2024. He stated that he was unaware that the A/C vent cover in Resident #32's room was not dusty and unclean. Log at the Nurses Station on the 100 Hallway would be used for something such as dusty A/C vents. He stated that the responsibility of the A/C vents being cleaned falls upon the Maintenance and Housekeeping departments, not his nursing staff. DON stated that the A/C vents in a resident's room were not a risk for infection and everyone's vents in their homes, including new build homes and the State Surveyors homes were probably not dusty and clean. He stated that there was a potential for harm due to the A/C vents being harmful, but dust was in everyone's vents any place you go. He stated that going forward, he would have his staff put in any work orders regarding the cleaning or the A/C vents. He stated, he will relay to his staff, if it doesn't seem right, fix it. He stated that his expectation was that staff notify himself, management or maintenance if they observe something like the A/C vent covers needing to be cleaned or any repairs, such as repairs to pipes and walls that need to be done. He stated that the Maintenance Department uses a software system to report repairs. The Operations Manager stated that he visits with Resident #32 in his room at least once a week and he has never mentioned to him anything about having a leaking pipe underneath his sink and there being a dark gray plastic container underneath the sink that contains water that was being dumped by Resident #32 on a regular basis. He was advised that on 03/12/25 during the Resident Council Meeting, Resident #32 mentioned the issue with the leaking pipe to another State Surveyor. He stated that if Resident #32 were to spill water from the dark gray plastic container, he could slip and have falls. He stated that he did not feel that there could be any harm to a resident if there is water on the floor. He stated that he was unaware of the dusty and uncleaned A/C vent in Resident #32's room. He stated that the Maintenance Department is responsible for ensuring that the A/C vents in the residents' room are cleaned a regular basis. He stated that he felt that the dusty and unclean are vent can cause respiratory and breathing issues to anyone who is exposed to the allergens from the A/C vents. He stated that he was unaware that the halogen cover was not on the light fixture above Resident #37's bed in his room. He stated that if a light bulb gets too hot, it will burst and can hurt anyone who has access to the broken glass shards. In an interview with CNA A on 03/13/25 at 2:39 PM revealed that she stated that he had been employed at the facility for 3 years. She stated that her primary assignment was the 100 Hallway. She reported that she has not noticed that the A/C vent cover in Resident #32's room were dusty and not clean. She stated that if she was to observe the A/C vents in a resident's room not clean, she would notify Maintenance and her Charge Nurse so that the need for repair could be documented. She stated that if the A/C vents in resident's room are not cleaned on a regular basis, residents can be at risk for respiratory issues from the dust being on the A/C vent. She stated that dusty and unclean A/C vents can cause harm to anyone who has access to them breath properly. 455486 Page 5 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated that she was unaware that Resident #32 had a leaking pipe underneath his sink and there was a dark gray plastic container full of water underneath the sink. She stated that she was unaware that Resident #32 stated that he had emptied the dark gray plastic container of water out on a regular basis. She stated that Resident #32 should use his Call Light to request assistance from staff with emptying the dark gray plastic container of water. CNA A stated that Resident #32 has unsteadiness of his feet and the risk of him bending down to remove the full dark gray plastic container of water in the sink could cause harm, which can include Resident #32 slipping, and falling on any water spilled on the floor. She stated that if Resident #32 drank the stagnant water in the dark gray plastic container he can risk drinking contaminated water, which is not safe. She stated that the water in the dark gray plastic container may be brown, which is not good and can cause some health issues or concerns for the resident. CNA A stated that she was unaware that the fluorescent lights above Resident #37's bed did not have a cover over the light. She stated that without there being a halogen light cover over the fluorescent lights above Resident #37's bed, there is a risk that the fluorescent lights can get too hot and explode. She stated that without the prescience of a halogen light cover over the fluorescent lights above Resident #37's bed, he can be harms by broken glass, step on the broken glass, touch the broken glass and receive cuts. CNA A stated that she was unaware of the large sized hole in the bathroom wall behind Resident #48's toilet. She stated that the risk of there being a large sized hole in any wall could lead to any rodents or insects entering the building through the hole in the wall. She stated that harm can be cause by there being a large sized home can include rodents biting anyone in the building, which can lead to infections and illnesses. Record review of the facility's Maintenance Service policy dated 2001, revised December 2009 revealed, Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards . d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. e. Maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order. f. Establishing priorities in providing repair service . h. Maintaining the grounds, sidewalks, parking lots, etc., in good order. 455486 Page 6 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0584 i. Providing routinely scheduled maintenance service to all areas. Level of Harm - Minimal harm or potential for actual harm j. Others that may become necessary or appropriate. Residents Affected - Some 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . 7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments. 8. The Maintenance Director is responsible for maintaining the following records/ reports. k. Inspection of building; l. Work order requests; m. Maintenance schedules; . o. Warranties and guarantees. 9. Records shall be maintained in the Maintenance Director's office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. 455486 Page 7 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for one (Resident #29) of three residents reviewed for abuse and neglect. The facility failed to protect Resident #29 from abuse on 01/05/2025 when CNA E was witnessed calling Resident #29 an asshole. The noncompliance was identified as Past non-compliance. The noncompliance began on 1/5/25 and ended on 1/7/25. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm. Findings included: Review of Resident #29's Face Sheet, dated 03/12/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and a subsequent admission date following a hospital stay on 09/30/2024, with diagnoses including: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (is a mental health condition that can develop after exposure to a traumatic event. It is characterized by symptoms such as: distressing memories or flashbacks of the trauma, feelings of hopelessness or negative thoughts about oneself or others). Review of Resident #29 ' s MDS reflects a BIM ' s (Brief Interview of Mental Status) score of 10. A score of 10 indicates moderate cognitive impairment. Review of Resident #29 ' s Comprehensive Care Plan dated 07/05/2024 reflected he had an ADL (Activities of Daily Living) self-care performance deficit due to dementia and limited mobility. The plan also reflected Resident #29 was at risk of falls, and elopement. The plan does not indicate any areas of concerns for behavioral issues or concerns. Review of Resident #29 ' s nurses notes reflect RN F entered a note on 01/05/2025 that stated resident had an altercation with staff; resident verbally abused staff and attempted to assault staff member. Resident was redirected and is now calm. Administration notified. Review of Resident #29 ' s nurses note reflect a note entered on 01/06/2025 that stated Don alerted that CNA E asked resident to stop being an a##hole due to resident attempting to hit CNA E as well as cursing and yelling at CNA E. Director of Operations made aware of event. DON to contact physician and make medical doctor aware as well as psychiatry. DON to ask that resident been seen my provider at next visit. Psychiatrist states that she saw resident yesterday and thought resident was doing better. DON to inform of resident behaviors. Psychiatrist states she will see resident at next visit. DON to ask that charge nurse alert Reporting Party of concern. Facility social worker also made aware of everything. Resident was asked about the event and resident did not recall this happened. At current time no concerns noted with resident nor voiced by resident. Review of Resident #29 ' s nurses note reflect a note entered on 1/6/2025 that stated Reporting Party notified of incident involving a CNA E over the weekend of 1/4 - 1/5. RP was informed of the 455486 Page 8 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disciplinary action taken to ensure this type of incident would not happen again. Reporting Party was in agreement of action taken and had no further complaints at this time. Review of Resident #29 ' s nurses note reflected a note entered on 1/6/2025 that stated Director of operations to call and speak with charge nurse as well as CNA E in 2 separate calls regarding occurrence with resident over the weekend. CNA E as well as charge nurse both state that resident was being very aggressive with male CNA D and was accusing male CNA D of abusing other residents. Both CNA E as well as charge nurse state that this never occurred and that no one was abused, and that resident was having a moment of paranoia/confusion/and possibly sundowning. Per charge nurse resident was hitting CNA E with clip board cursing CNA E out and had stood up and was very aggressive with CNA E to where charge nurse had to intervene. Charge nurse states that CNA E did slip up and tell resident to please stop being an as*hole but states that CNA E was also being hit. Per charge nurse resident was eventually redirected from nurse station with no further occurrence. Charge nurse states that when CNA E checked on resident shortly thereafter that resident didn ' t even seem to know anything had even occurred. Observation of Resident #29 on 03/11/25 at 1:35PM revealed he was clean, well-groomed, and appropriately dressed. He was free from any odors. There were no visible marks or bruises noted on his person. Resident #29 was alert and oriented; he was resting in his bed. During an interview with Resident #29 on 03/11/25 at 1:35PM, he stated facility staff treated him well and he felt safe at the facility. He had no concerns regarding the facility, or the care received; he reported he just returned from his mother ' s funeral today and was feeling sad. Resident #29 could not recall the specific incident between him and CNA E but said that CNA E talks to people rudely. During an interview with CNA E on 3/11/25 at 11:45AM he revealed he was gathering people to have coffee and snacks before dinner. He stated there was one resident that was combative during care, and she was amped up already. He stated hours at a time she will sit there crying. He stated he brought her to dining and Resident #29 went over to try to console her. CNA E stated Resident #29 then rolled down the hall to the nurse ' s station accusing CNA E of hurting the female resident. He stated Resident #29 stood up and started coming toward him while he was in med room (behind nurse station). CNA E stated he closed the door and Resident #29 was trying to get in the room and then Resident #29 put his weight on the door so CNA E could not get out and this lasted a few seconds. CNA E said he asked RN F for help and to make sure other residents are not around for their safety. CNA E said this happened for about an hour that Resident #29 was following him around and saying he would call the cops. CNA E stated Resident #29 was cussing at him, and CNA E said he told Resident #29 to stop acting like an asshole. CNA E said it was very heated in the moment he said that to Resident #29. CNA E said he realized he should not have said that and could have used another word or term. CNA E said Resident #29 came back and apologized about the incident. During an interview with RN F on 3/12/25 at 5:46 PM she revealed she was at the nurse desk during the incident. She stated CNA E was prepping snacks for residents and Resident #29 rolled up to the desk and was upset. She stated Resident #29 thought CNA E was abusing the residents. RN F stated Resident #29 stood up and he and CNA E were yelling at each other, and CNA E told Resident #29 to stop being an asshole. She stated they were arguing back and forth. She stated Resident #29 lunged forward pushing the door shut locking CNA E in the med room. RN F stated CNA E and Resident #29 continued going back and forth and she tried to deescalate the situation. RN F stated Resident #29 tried to hit CNA E with a clipboard. RN F stated Resident #29 tried hitting CNA E again and CNA E grabbed 455486 Page 9 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #29 ' s hand and pushed it away. She stated Resident #29 left the nurse station and later came back and tried to call 911 to report CNA E and they took the phone away from him. RN F stated prior to this incident she had not seen signs of aggression in Resident #29 before, possibly just depression. RN F stated she immediately reported the incident to the ADON. During an interview with the social worker 01/13/25 at 10:30 AM, she revealed she completed Safe Surveys after the incident. She reported she spoke to Resident #29 who told her Oh that is the way he (CNA E) talks. She stated Resident #29 said he did not like the tone that CNA E used toward him. She said she did not know what CNA E said to the resident exactly. She said after the incident she ensured the resident was on psych services. During an interview with LVN G on 3/12/25 at 11:00 AM, she reported she had worked at the facility for 7 days and had worked with CNA E twice. She reported she had heard CNA E cussing in general conversation and to where residents were able to hear him swearing. During an interview with the Operations Manager on 1/13/25 at 2:00 PM, he stated he was informed by RN F about the incident involving Resident #29. He stated the results of his investigation were confirmed. He stated there were consistent stories given by individuals interviewed. He stated CNA E was suspended and required to take assigned trainings regarding abuse/neglect prevention, etc. prior to returning to work. The Operations Manager stated he had a one-on-one staffing with CNA E who was given a written warning. The Operations Manager reported there have been no complaints since about CNA E prior to the incident that he is aware of. The Operations Manager stated he sees CNA E often in the hallways and people have said good things about him. He stated Safe Surveys were completed throughout the entire facility. He stated Resident #29 was back to himself after the incident. The Operations Manager did not have any concerns for CNA E to continue to provide care to Resident #29 or other Residents in the facility. Review of Facility Provider Investigation Report dated 01/06/2025 reflected the following: Incident date occurred on 01/05/2025 at 3:45 p.m. At approximately 3:30 p.m. RN [NAME] witnessed CNA [NAME] using inappropriate language towards resident [NAME]. Resident [NAME] is routinely seen by psych services. Facility immediately launched investigation into the matter. Residents MD, RP, and VA notified. Alleged Perpetrator suspended pending investigation. Safe Surveys initiated. Staff in service on abuse and neglect initiated. Should be noted that the alleged victim has a diagnosis of cognitive communication deficit, altered mental status, unspecified, depressive disorder, recurrent, mild, dementia in other diseases classified elsewhere, mild, with other 07/02/2024 other diagnosis behavioral disturbance, bipolar disorder, unspecified, major depressive disorder, single episode, unspecified mild cognitive impairment of uncertain or unknown etiology. It should also be noted that alleged victim resides on the facility ' s memory care unit. In an interview with Operations Manager [NAME] and Director of Nursing [NAME] on 1/7/25, witness [NAME] (RN) was able to provide the same details of the event that the alleged perpetrator [NAME] (CNA) provided. Resident safe surveys brought forth no further concerns. (surveys attached). It is my reasonable conclusion that the allegation was confirmed. The alleged perpetrator has been consistent with his story on what happened, and the witness as well. As a result, the alleged perpetrator was suspended and assigned several healthcare academy modules (E-learning) (Certs are attached). Staff in-service completed on abuse and neglect. Alleged perpetrator was educated on appropriate topics and issued final written warning from supervisor before returning to work. Review of the following E-learning courses completed by CNA E: 455486 Page 10 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of In-Service Training Report dated 01/07/2025, of all staff and departments, topic of Abuse Neglect Resident Rights. The report indicates 5 types of abuse, the abuse coordinator, and reporting abuse protocols. Review of 5 Safe Survey ' s indicated one resident responded to question #4 Have you ever heard a staff member yell at another resident? The resident responded No not really, just correction. Not abusive. Everything is being addressed the right way. Resident #29 ' s response to question #4 on the safe survey stated, just me, me and CNA E had a couple of words, but it was a misunderstanding. Review of the facilities Abuse and Neglect - Clinical Protocol, Revised March 2018, reflected Abuse is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 455486 Page 11 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 3 residents (Resident #29) reviewed for Preadmission Screening and Resident Review Level I screenings. Residents Affected - Few The facility failed to ensure Resident #29's Preadmission Screening and Resident Review Level One screening completed 07/02/24 and 02/11/25 on accurately reflected his diagnosis of mental illness. There was no evidence that Resident #29 was referred to a Level Two Preadmission Screening and Resident Review Screening. This failure could affect residents by placing them at risk for not receiving needed treatments and services. Findings included: Review of Resident #29's Face Sheet, dated 03/12/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and a subsequent admission date following a hospital stay on 09/30/2024, with diagnoses including: unspecified head injury, depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (is a mental health condition that can develop after exposure to a traumatic event. It is characterized by symptoms such as: distressing memories or flashbacks of the trauma, feelings of hopelessness or negative thoughts about oneself or others). Review of Resident #29's MDS Assessment, dated 02/21/24, also reflected he had diagnoses including anxiety disorder, depression, bipolar disorder, and post traumatic stress disorder. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 07/02/24, reflected there was no evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 11/20/24, reflected there was evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 02/11/25, reflected there was no evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Behavioral health diagnostic assessment dated [DATE], reflected Resident #29 had a long history of post-traumatic stress disorder secondary to the service in the Coast Guard. The assessment also reflects that Resident #29 had a long history of depression and alcohol abuse. The report also reflects that Resident #29 reported despite past treatments including inpatient care, he continues to have difficulties with nightmares and depression. The report reflects that Resident #29 was diagnosed with Major depressive disorder and Post-traumatic stress disorder. Review of Resident #29's New admission Worksheet dated 07/02/24 with attached hospital medical 455486 Page 12 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few records dated 06/28/24 reflect Medical Problems list include: major depressive disorder, bipolar disorder, post-traumatic stress disorder and anxiety. Review of Resident #29's Diagnosis Report reflected he was diagnosed with Dementia on 7/2/24. Review of Resident #29's Mental/Illness/Dementia Review, Form 1012, reflected that resident does not have any mental illness. Observation of Resident #29 on 03/11/25 at 1:35PM revealed he was clean, well-groomed, and appropriately dressed. He was free from any odors. There were no visible marks or bruises noted on his person. Resident #29 was alert and oriented; he was resting in his bed. During an interview with Resident #29 on 03/11/25 at 1:35PM, he stated facility staff treated him well and he felt safe at the facility. He had no concerns regarding the facility, or the care received; he reported he just returned from his mother's funeral today and was feeling sad. He reported his wife is also at the facility and often sees her. During an interview with the MDS Coordinator on 03/12/25 at 2:03PM, she stated Resident #29's Preadmission Screening and Resident Review Level I was completed and does not indicate a mental illness because his primary diagnosis is Dementia. She reported that if a resident has a diagnosis of dementia, then they do not qualify for a level 2. She reported that Resident #29's physician signed a paper stating Resident has a primary diagnosis of Dementia (see record review of Form 1012, Mental Illness/Dementia Review) Review of the Facilities admission Policies and Procedures, Revised March 2019, states 9. a. The facility conducts a Level I Preadmission Screening and Resident Review screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID, or RD. b. if the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state Preadmission Screening and Resident Review representitive for the Level II (evaluation and determination) screening process. 455486 Page 13 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #11) of 3 residents reviewed for care plans. The facility failed to develop interventions to address the goal on Resident #11's care plan to maintain nephrostomy tube care through the next review date. This failure could affect the facility's residents who were occasionally or frequently incontinent of bladder and/or with catheter or nephrostomy tube placement by placing them at risk of not receiving the necessary care and services to meet their needs. Findings included: 1.) Review of Resident #11's Face Sheet, dated 3/13/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, unspecified hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), urinary tract infection, other mechanical complication of other urinary catheter, initial encounter, type II diabetes, and dementia. Review of Resident #11's Care Plan, completed on 08/11/2023, reflected she had the potential for or presence of altered nutrition and hydration due to protein calorie malnutrition, history of infections: UTI. She requires a therapeutic diet low of concentrated sweets, diet, minced and moist texture, thin (regular) 1 consistency. The goal stated Resident #1 nutrition needs will be met thru next review date. The plan also reflected a focus area station Alteration in elimination of bowel and bladder due to incontinence. Resident #11 will be free of UTI daily through next review. The plan also reflected another focus area stating, Resident #11 has potential for complications due to incontinence, frequently incontinent. Review of Resident #11's Physician Progress Note dated 03/11/2025 reflected the following: History of present illness: [AGE] year-old lady admitted to facility [NAME] on 08/08/2022 as status post admission she tried to walk a little and fell and hit her left hip. She sustained a closed displaced fracture of the femoral neck and subsequently underwent a left hip hemiarthroplasty. The patient has a past medical history significant for dementia and diabetes mellitus 2. 09/26/2023 patient returned from the ER after due to abnormal outpatient x-ray result. Patient noted to have a new left sacral fracture nondisplaced. Patient was prescribed with acetaminophen 500 mg 2 tablets twice daily and can have a dose in between as well as every 6 hours. Patient was ordered to ambulate as tolerated, follow-up with clinic or Orthopedic as needed. On October 29 (unknown year) patient was treated with Macrobid 100 mg twice daily for 10 days for ESBL E. Coli. S/P hospitalization 1/12/24 to 1/15/24 for pneumonia 455486 Page 14 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few S/P hospitalization from 10/29/24 to 11/3/24 due to pneumonia and urinary tract infection. Imaging showed kidney stones with placement of left nephrostomy tube. Returned to facility with IV Invanz to be completed on 11/19/24. 12/27/2024 - patient readmitted after being treated at hospital [NAME] - status post left nephrostomy tube exchange, acute metabolic encephalopathy secondary to urinary tract infection, acute complicated urinary tract infection-ESBL E coli. readmission from hospital [NAME] for blocked nephrostomy tube and discovered infection and stayed for IV antibiotics. During an observation and interview on 3/13/25 at 9:26 AM, Resident #11 was observed outside her room in her wheelchair. She was clean and well groomed. The MDS Coordinator washed her hands, donned a gown and assisted Resident #11 to bed using a gait belt. MDS Coordinator stated Resident #11 understood some English but mostly spoke Spanish. The MDS Coordinator communicated to Resident #11 using Spanish and was able to translate. LVN G washed her hands, gathered supplies and donned a gown and gloves. She stated Resident #11 had pulled the dressing off her nephrostomy tube and she was there to replace it. Resident #11's nephrostomy tube was intact and capped. It was light pink at the insertion site with no drainage or swelling. LVN G cleaned the site and replaced the dressing using sterile technique. The MDS Coordinator stated Resident #11 had a history of urinary tract infections and was found to have kidney stones, so the nephrostomy tube had been placed. She stated the resident was seen by a specialist and was expecting to have the tube removed sometime soon. During an interview with the Director of Nursing (DON) on 3/13/2025 at 1:25 p.m., she reported resident #11 has a nephrostomy tube and cannot recall the exact date she received it. She reported she checked and it is not included in Resident #11's care of plan and was not sure why. She stated she added it today after becoming aware that it was not included. After checking her notes, she reported Resident #11 went to the hospital on [DATE] and came back on 11/2/2024 with the tube. She reported Resident care plans are updated anytime they go to the hospital and come back so she was not sure how that happened. The DON stated there is no risk to the residents because the orders are still there, this was just missed. The DON stated the only people that see the care plan or reference it is management nurses. She stated the orders are there to treat the resident, the care plan was just missed. 455486 Page 15 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 9 errors out of 25 opportunities which resulted in a 36% percent medication error rate for 1 (Resident #28) of 4 residents reviewed for medication errors. Residents Affected - Few On 3/12/25, RN C administered 9 individual medications via Gtube (surgically placed tube used to administer nutrition, fluids, and medications) to Resident #28 by pushing the medications through a syringe without an order rather than by gravity as noted in their policy. This failure placed the resident at risk of Gtube complications, aspiration pneumonia, and not receiving the therapeutic effects of medications. Findings included: Record review of Resident #28's admission Record dated 3/12/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE]. Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected he was rarely understood and rarely understood others and had severely impaired cognitive skills for daily decision making. His diagnoses included stroke; aphasia (impaired ability to communicate verbally); hemiplegia (weakness or paralysis on one side of the body); dysphagia (inability to swallow safely); non-Alzheimer's dementia; and seizure disorder. He received his calories and hydration from a feeding tube. Record review of Resident #28's Care Plan reflected the following: [Resident #28] requires tube feeding for complete nutritional needs r/t Dysphagia NPO Status. Relies solely on licensed nurse to administer all medications, nutrition and hydration needs via peg tube. Date initiated 5/18/23, Revision on 7/26/23. Interventions included: .Flush Gtube with 30 ml tap water before and after each med .Licensed nurse to crush medications and administer via Gtube; medications per order; Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration . Record review of Resident #28's Order Summary Report dated 3/12/25 at 10:51 AM reflected the following: Enteral: if enteral feeding tube becomes dislodged, clogged or unusable for any reason and the tube is the primary source of nutrition and/or hydration contact the physician immediately to determine if iv fluids are needed every shift for dislodged clogged feeding tube. Order date 2/27/24. Flush g-tube with 30 ml tap water between each med. Order date 1/31/25. Medication orders included the following: Tricor oral tablet 124 mg give 1 tablet via G-tube one time a day 455486 Page 16 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0759 Eliquis oral tablet 5 mg give 1 tablet via G-tube every 12 hours Level of Harm - Minimal harm or potential for actual harm Aspirin tablet 81 mg give 1 tablet via G-tube one time a day Simethicone tablet 80 mg give 1 tablet via G-tube two times a day Residents Affected - Few Furosemide solution 10 mg/ml give 4 mls via G-tube one time a day Multivitamin liquid give 15 mls via G-tube one time a day Potassium Chloride oral solution 20 mEq/15 ml give 15 mls via G-tube one time a day Keppra solution 500mg/5 mls give 5 mls via G-tube one time a day Hyoscyamine Sulfate elixir 0.125 mg/5 mls give 5 mls via G-tube one time a day Record review of Resident #28's Order Summary Report dated 3/12/25 at 3:52 PM reflected the following order had been added: Nurse may gently or slowly push the plunger into the barrel of syringe to administer medicines via G-tube. Order date 3/12/25. During an observation and interview on 3/12/25 at 7:52 AM, Resident #28 was observed in his bed. The head of his bed was elevated 30 degrees, he was awake and nodded in response to greeting and request to observe care. RN C washed her hands, put on gloves and prepared the following medications and placing them in individual medication cups: Tricor oral tablet 124 mg-crushed; Eliquis oral tablet 5 mg-crushed; Aspirin tablet 81 mg-crushed; Simethicone tablet 80 mg-crushed; Furosemide solution 10 mg/ml 4 mls poured; Multivitamin liquid 15 mls poured; Potassium Chloride oral solution 20 mEq/15 ml 15 ml poured; Keppra solution 500mg/5 mls 5 mls poured; and Hyoscyamine Sulfate elixir 0.125 mg/5 mls 5 mls poured. The medications were mixed with water to dissolve. RN C washed her hands and donned PPE. She disconnected Resident #28's tube feeding and checked for residual. Resident #28 was observed to have a large bulge in his upper right abdomen which RN C identified as a hernia (bulging of an organ or tissue through an abnormal opening). She flushed the residents Gtube with approximately 30 ml of water using the plunger of the syringe. RN C was asked about the use of a plunger and stated, they've never had us doing any by gravity here. She proceeded to slowly administer all nine medications, one at a time flushing between each medication with 30 ml of water. RN C utilized the plunger for all medications and flushes. Resident #28 was noted to cough during the medication administration. RN C stated he had a history of coughing and a large amount of secretions. She stated he was receiving medications for the secretions including the Hyoscyamine as well as a medication patch placed every three days. She elevated the head of the resident's bed higher after he began to cough. She completed the medication pass and washed her hands. During an interview on 3/12/25 at 2:53 PM, RN C stated she spoke with Resident #28's physician after the medication pass and received the order. She stated she should have gotten an order prior to using the plunger as the facility policy was to administer medications using gravity. She stated had previously spoken with the physician about Resident #28 because she had previously had difficulty passing his medications by gravity because of his hernia. She stated he would cough during the medication pass using gravity it would cause the medications to come up out of the syringe and go everywhere. She stated she had been approved to use the plunger previously but had failed to enter the order. 455486 Page 17 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated the risks of using a plunger included rupturing the tube or causing problems at the stoma (surgically created opening) site and she always went very slow when administering the medication. During an interview on 3/12/25 at 3:18 PM, the DON stated RN C had told her that morning she had used aa plunger on Resident #28's Gtube. She stated Resident #28 had a hernia and sometimes coughed during medication administration because the tube did not always flow well. She stated RN C had called the physician and obtained the order. She stated RN C should have called the physician prior to using the plunger because it was the facility's policy to use gravity for medication administration unless the physician ordered otherwise. The DON stated resident #28 had a long history of having trouble with his gtubes and was being treated by a GI specialist. She stated none of his issues were related to the use of a plunger. The DON stated the risk for using a plunger during medication administration included damage to the tube and aspiration pneumonia (an infection that occurs when something other than air is inhaled into the lungs). In an interview on 3/13/25 at 8:00 AM, LVN D stated she occasionally cared for Resident #28 and was his Charge Nurse on 3/11/25. She stated she passed his medications using gravity and had not encountered any difficulties. She stated Resident #28 had just had his gtube replace a few weeks earlier and had an upcoming follow-up appointment with his specialist in April 2025. LVN D stated the risk of using a plunger was it could be administered too fast and too much air could be inserted into his stomach. She stated the facility's policy was to use gravity unless they had a physician order. During an interview on 3/13/25 at 1:42 PM, the Medical Director stated she had spoken with RN C regarding Resident #28's Gtube medications on 3/12/25 and approved the use of a plunger for his medication administration. She stated she believed RN C had previously discussed the issue with another physician in their group on an earlier date. The Medical Director stated medications were typically administered using gravity and there were risks involves with using a plunger such as administering the medication too quickly. She stated the risk of missing the medications due to clogging or other complications was much higher than the risk of using the plunger for administration and she had approved the use. She stated she was not aware of any issues with the use of the plunger and facility staff should call her anytime they had concerns with a Gtube. Record review of the facility's policy titled, Administering Medications through an Enteral Tube, dated, Revised September 2024 reflected: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Steps in the Procedure .9. Dilute medication: a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. Dilute crushed (powdered) medication with at least 30 mL clean water (or prescribed amount). c. Dilute liquid medication with 30 mL or more (depending on viscosity) clean water. 10. Administer each medication separately. 11. Reattach syringe (without plunger) to the end of the tubing. 12. Administer medication by gravity flow, or per physician order. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level 455486 Page 18 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0759 of insertion. Level of Harm - Minimal harm or potential for actual harm b. Open the clamp ·and deliver medication slowly. c. Begin flush before the tubing drains completely. Residents Affected - Few 13. If administering more than one medication, flush with 15 mL warm clean water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm clean water (or prescribed amount). 15. Quickly clamp the tubing when the flush is complete. Remove syringe . 455486 Page 19 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

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 observations, interviews, 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 for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines on 3/11/2025. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 3/11/2025. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed on 3/11/2025. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 03/11/2025 at 9:15 AM, revealed the following: Dry storage area *One bag of Oreo Cookie Pieces with an expiration date, 12/01/23 * One bag of opened Pistachio Instant Pudding Mix * Ziploc bag dated 11/26 with an open bag of Quaker grits with no use by date * A plastic bin of what appears to be sugar not labeled * One 28oz bag of Creamy Wheat not sealed * 2 opened packs of brown gravy mix in plastic Ziploc bag not sealed * Plastic container of what appears to be Fruit Loops cereal not labeled or sealed * Plastic bin with crackers not labeled * 5 packs of instant oatmeal in a black bowl sitting on a shelf Refrigerator area *One box labeled Homestyle Fried Eggs with Cracked Black Pepper dated 2/4/25 contained an unsealed plastic bag of what appears to be eggs had an odor and no use by date 455486 Page 20 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0812 *Jimmy Dean Turkey Sausage Patties in a plastic bag opened and not sealed Level of Harm - Minimal harm or potential for actual harm Freezer area *Plastic container with frozen ground beef and other frozen meats has dried blood on the container Residents Affected - Some * French Fries dated 2/18 with no expiration date *Once clear Ziploc bag with French fries dated 3/4 and 3/10 with no use by date In an interview with the Dietary Manager J on 3/11/2025 at 9:45 AM, manager stated all staff are scheduled to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas are not expired and unsealed. DM stated she would check everything in the kitchen to ensure there were not any unopened and expired items in the dry pantry, refrigerator and freezer areas. DM stated she would throw away all expired items and unsealed items in the kitchen. She stated her expectation was for staff to throw away any items that are expired or opened in the kitchen's dry pantry, refrigerator and freezer areas and notify herself of what they found. She stated staff have received several in-services relating to food preparation, storage, and labeling and to immediately remove any expired items. She stated staff have been trained and educated when they are restocking to place the items already on the shelf in the front and the new items behind the items that were already shelved. She stated she would throw away the expired items in the kitchen and retrain and reeducate the staff via in-service trainings. In an interview with [NAME] S on 03/11/24 at 10:20 AM, she stated that she had been employed at the facility for 3 years. She stated that she was unaware that there were expired and unsealed items in the dry storage, refrigerator, and freezer areas. She stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that she had taken in-service trainings on food preparation and storage and her last in-service training was about a year ago. She stated that if a staff member sees an item(s) that are expired, the staff member was to throw the item away in the trash can and then inform the Dietary Manager or Dietary Aide what they threw away. She stated that everything in the dry storage, freezer and refrigerator should be labeled and dated. [NAME] S stated that if someone ingested food that had been cross-contaminated, there was a risk that someone could die. She stated that with food in the dry pantry, refrigerator and freezer areas being unsealed and expired items can cause anyone who ingests the food to have an airborne illness and become sick which can cause them harm. In an interview with the Dietary Aide S on 03/11/25 at 10:28 PM, she stated that she had been employed at the facility for 1 year. She stated that she was unaware that there were expired and unsealed items in the dry storage and freezer areas. She stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that her expectations for all staff in the kitchen is to use the First In, First Out Method, which means that kitchen staff should label the food with the dates they store them, and when staff are restocking the shelves, they are to put the older foods in front or on top so they can be used first. She stated that this system allowed the kitchen staff to find the food quickly and use it more efficiently. She stated the Dietary Manager In-Services staff on food storage, labeling and dating and removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas. She stated that there are risks of airborne illness anytime someone that ingest food items from the kitchen any items that have not been label and stored properly. 455486 Page 21 of 22 455486 03/13/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0812 Record review of the facility's policy titled Food Receiving and Storage dated, November 2022 reflected, Foods shall be received and stored in a manner that complies with safe food handling practices. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Some Dry Food Storage: 1. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 2. Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Such foods are rotated using a first in -first out'' system. Refrigerated/Freezer Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by'' date, frozen, or discarded. 9. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 455486 Page 22 of 22