Inspection·January 11, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Record review for Resident #23 consents for the use of antidepression medication, Celexa was not documented in her chart. During an interview on 01/11/24 at 11:00 a.m., LVN O said consents should be obtained for all psychoactive medication before being given. LVN O said the ADONs usually obtained consents. Residents Affected - Few During an observation and interview on 01/11/24 at 4:28 p.m., the DON said the ADONs were responsible for monitoring to ensure consent forms were completed. The DON looked throughout Resident #23's medical records via point click care (facility electronic system) and did not see where her consent was located in the chart. The DON stated she was unsure why Resident #23 had no consent form for Celexa. The DON stated it was important to ensure consent forms were filled out so Resident #23 or her representative could make an informed decision. During an interview on 01/11/24 at 4:37 p.m., the ADON said the DON/ADON gets consents for all new psychoactive medications. She said she was not sure why Resident #23 did not have her consent for Celexa. She said it was important to ensure residents or representatives signed consent forms so they could make an informed decision about their care. During an interview on 01/11/24 at 5:44 p.m., the Administrator said nurse management was responsible for ensuring psychotropic consent forms were signed and filled out. The Administrator said it was important to ensure consent forms were signed so the residents or representative understood and were able to give informed consent. She said they had a mock survey (given by the company) and they had no issues with consent. She said they may need to look at a different process for consent. Record review of the facility's policy, Resident rights and consents to receive psychotropic medication, revised date 02/0I/07, indicated, The purpose of the policy and procedure for obtaining permission for psychotropic medications to be administered is to comply with the Department of Aging and Disability rule 19.1207 regarding informed consent for psychoactive medications. This provides residents the right to: Receive information about prescribed psychoactive medications, To have psychoactive medication prescribed and administered responsibly. OBTAINING CONSENT: Consent must be obtained before the medication may be started . Consent may be obtained by: 1. Residents or their legal representatives being given the required information on the medication and the resident or the legal representatives giving the facility consent as indicated by signing the psychotropic consent form . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 2 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 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. Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: During an observation on 1/8/24 at 11:01 a.m., strong urine smell on D hall. During an observation on 1/10/24 at 8:27 a.m., strong urine smell on D hall. During an observation on 1/11/24 at 8:05 a.m., strong urine smell on D hall. During an interview on 1/11/24 at 8:21 a.m., CNA C stated she had been a CNA for 19 years. CNA C stated the urine smell was always strong on D hall all the time especially in the morning. CNA C stated Resident #41 slept in a recliner and was a heavy wetter. CNA C stated Resident #41 was not being toileted like she should be. CNA C stated D hall was the heaviest hall in the facility. CNA C stated Resident #264 was also a heavy wetter on D hall and Resident #264 was not getting her showers like she was suppose too. CNA C stated it was only one CNA C worker per hall and the facility needed more CNA's. During an interview on 1/11/24 at 9:21 a.m., housekeeping aide K stated he has been employed here for almost 2 months. Housekeeping aide K stated he worked 8:00 a.m. to 4:30 p.m. shift. Housekeeping aide K stated he was responsible for cleaning the resident rooms. Housekeeping aide K stated the rooms were to be cleaned every day and the orange tag rooms on the D hall were to be cleaned 3 times a day. Housekeeping aide K stated the orange tag rooms were for the residents who had hoarding issues. Housekeeping aide K stated the nurse's aide or laundry aide were to change the resident linens on their beds. Housekeeping aide K stated the resident nurse aides or nurses were responsible for cleaning the top of the resident mattresses. Housekeeping aide K stated the housekeeping supervisor oversaw him. Housekeeping aide K stated deep cleaning was to be done when a resident was discharging a room and before admission to the facility. Housekeeping aide K stated, The resident rooms were probably deep cleaned once a month. Housekeeping aide K stated deep cleaning considered cleaning under the resident's furniture, doors, dressers, sink, bathroom, floors, walls and lights. Housekeeping aide K stated the Housekeeping supervisor did spot checks, and he did not know how often the Housekeeping supervisor conducted spot checks in the resident's rooms. Housekeeping aide K stated the facility did not have a housekeeping checklist that housekeeping were to follow. Housekeeping aide K stated, He just did what the housekeeping supervisor told him to do when he came to work. Housekeeping aide K stated he was not aware of the urine smell on D hall. Housekeeping aide K stated he cleaned mostly on the B hall and sometimes cleaned D hall. Housekeeping aide K stated he worked Monday 1/8/24 and Thursday 1/11/24. Housekeeping aide K stated he did believe that the facility had enough cleaning supplies. Housekeeping aide K stated the nurse aids was responsible for cleaning urine or fecal matter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 3 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some off the floors and housekeeping was responsible for sanitizing the area after the nurses. Housekeeping aide K stated he completed cleaning and deep cleaning in-services last month. Housekeeping aide K stated, It was important to keep the facility clean and sanitized for basic human rights and if he had a family member in a facility that he would want their room cleaned. During an interview at 1/11/24 at 9:35 a.m., The Housekeeping supervisor stated he has been employed at the facility for a year. The Housekeeping supervisor stated housekeeping was responsible for cleaning the resident's room. The Housekeeping supervisor stated the orange tag room were to be cleaned 3 times a day and the regular rooms were to be cleaned once a day. The Housekeeping supervisor stated he was aware of the strong urine smell on D hall. The Housekeeping supervisor stated housekeeping used a solution called Enzyme to get rid of the urine smell in the facility. The Housekeeping supervisor stated the nurse's aide were responsible for changing the resident linens. The Housekeeping supervisor stated deep cleaning were done for discharge, room changed, orange tag room or a death of a resident. The Housekeeping supervisor stated the Administrator oversaw him. The Housekeeping supervisor stated white glove came every 6 months to conduct follow up visit and reports are giving after inspections. The Housekeeping supervisor stated he did spot checks daily and also did champion rounds (checked his assigned rooms daily). The Housekeeping supervisor stated the facility had a cart checklist and the facility did not have a room cleaning checklist. The Housekeeping supervisor stated the facility did have enough cleaning supplies. The Housekeeping supervisor stated he ordered the cleaning supplies every month before the 24th of each month. The Housekeeping supervisor stated the last in-service on cleaning a deep cleaning was completed a few months ago. The Housekeeping supervisor stated he did expect housekeeping aids to clean and deep clean the rooms according to the facility policy. The Housekeeping supervisor stated it was important for residents because, The residents live here and for the public, we want to have a nice facility for someone to bring their families here and make sure the facility is in tip top shape. During an interview on 1/11/24 at 10:07 a.m., the DON stated she did not oversee the Housekeeping department. During an interview on 1/11/24 at 11:28 a.m., The Administrator stated Resident #18 did not want to sleep in a bed and Resident #18 preferred to sleep in a recliner chair. The Administrator stated housekeeping was responsible for cleaning the residents rooms. The Administrator stated the floor tech was responsible for cleaning the floors. The Administrator stated she was not aware of housekeeping completing any in-services on cleaning and deep cleaning. The Administrator stated a lot of housekeeping issues was the continuation of staff and having to constantly train new staff. The Administrator stated it was hard to find staff to work longer than a few months. The Administrator stated Housekeeping did not have a housekeeping checklist, but housekeeping were to follow the facility housekeeping policy. The Administrator stated she did expect housekeeping to ensure they were deep cleaning and cleaning the residents rooms. The Administrator stated she did champion rounds and if she saw an area of concern would address it in stand up meeting in the morning with the department heads. The Administrator stated the champion round had a checklist that staff were to complete. The Administrator stated she would then review the checklist and follow up after. The Administrator stated it was important for staff to follow the policy and procedures for housekeeping so the resident could have a clean homelike environment. Record Review of the facility housekeeping policy for Cleaning and Disinfecting, dated 2022 indicated It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. The following cleaning tasks should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 4 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0584 completed daily. (1) common area: dinning rooms, shower room(s), bathroom(s), lobby(s), sitting/tv room(s), hallway(s), door/entryway(s), beauty shop, therapy gym (2) resident room(s) including closets. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 5 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 residents (Resident #12) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #12's black pants with a bow in the front when it was not returned from the laundry. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #12 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included other secondary Parkinsonism (a condition that causes tremor, muscle movement issues) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #12 was understood and understood others. The MDS assessment indicated Resident #12 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #12 was independent for eating, oral, toileting, personal and dental hygiene, dressing and required setup or clean up assistance for shower/bathe. Record review of the grievances for the month of December 2023 and January 2024 did not indicate a grievance for Resident #12's black pants with a bow in the front. During an interview on 01/09/2024 at 10:29 a.m., Resident #12 said within the last 2 months she had sent a pair of black pants with a bow on the front to the laundry and it was never returned. Resident #12 said she had notified the Housekeeping Supervisor and the Administrator. During an interview on 01/09/2024 at 11:19 a.m., the Housekeeping Supervisor said he was over the laundry as well. The Housekeeping Supervisor said if a resident reported clothes missing, he would go look for the clothes in the laundry room and go through other residents' closets to see if the missing item was located. The Housekeeping Supervisor said if he was not able to locate the missing item, he would let the Administrator know and the laundry aides so they could look for the missing item. The Housekeeping Supervisor said he was aware Resident #12 was missing black pants with a bow on the front, and he had been aware of it since about a week ago. The Housekeeping Supervisor said he had not been able to locate Resident #12's black pants. The Housekeeping Supervisor said he had not let the Administrator know. The Housekeeping Supervisor said it was important for the residents' personal items to be returned to them because he would be pretty upset if he was missing something of his, and it was their belongings and personal items. During an interview on 01/11/2024 at 4:30 p.m., ADON F said if a resident reported a lost clothing item, she would check the residents' rooms and the laundry, and if she did not find it that day, she would let the resident know. ADON F said the next day she would look for it again and once she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 6 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not able to find it, she would let the Administrator know. ADON F said she was not aware Resident #12's black pants were missing. ADON F said it was important for the residents' clothes to be returned to them because it was their personal belongings, and the facility was their home. During an interview on 01/11/2024 at 5:26 p.m., the Administrator said if a resident reported missing clothes, they would ask the resident if they put their name on it, get a description of the item, search for the items in the laundry, check with other residents, and call the family if they were unable to find it. The Administrator said normally if clothes was missing, she did a grievance and if not found replaced the items. The Administrator said if the Housekeeping Supervisor had not found Resident #12's black pants he should have let her know so she could do a grievance. The Administrator said she was not aware Resident #12 was missing a pair of black pants. The Administrator said it was important for residents clothing and personal items to be returned to them because she wanted them to feel safe in the nursing home. Record review of the facility's policy titled, Grievances, from the Social Services Manual 2003, indicated, .Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regard mg their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have . 3. The grievance official will: Oversee the grievance process oReceive and track grievances to their conclusion oLead any necessary investigations by the facility .6. All written grievances decisions will include: oThe date the grievance was received oA summary statement of the residents grievance oThe steps taken to investigate the grievance oA summary of the pertinent findings or conclusions regarding the resident's concern(s) oA statement as to whether the grievance was confirmed or not confirmed oAny corrective action taken or to be taken by the facility as a result of the grievance oThe date the written decision was issued . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 7 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident status for 1 of 20 residents (Resident #56) reviewed for MDS assessment accuracy. Residents Affected - Few The facility did not ensure Resident #56's MDS assessment was accurately coded to reflect his limitation in range of motion related to his contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both upper extremities. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had no impairment in functional limitation in range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. The MDS assessment indicated Resident #56 had an active diagnosis of other reduced mobility. Record review of a facility provided document titled Residents with contractures dated 01/08/2024 indicated Resident #56 was on the list as having contractures. Record review of an Occupational Therapy Discharge Summary with dates of service 05/17/2023-06/13/2023 indicated Resident #56 had contractures to bilateral upper extremities limiting range of motion. During an observation on 01/08/2024 at 9:39 a.m., Resident #56 was lying in bed, contractures were noted to both of his hands. During an interview on 01/11/2024 at 4:19 p.m., LVN D said she was aware Resident #56 had contractures to both of his hands. During an interview on 01/11/2024 at 5:18 p.m., the Administrator said she expected for the coding on the MDS assessments to be accurate. The Administrator said the MDS Coordinator was responsible for completing the MDS assessments. The Administrator said it was important for the MDS assessments to be coded accurately for billing purposes, for care and so the claim shows an adequate picture of the residents. During an interview on 01/11/2024 at 6:29 p.m., the MDS Coordinator said she had not coded Resident #56's contractures to both of his upper extremities because she had not noticed them, and she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 8 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not seen it in his documentation. The MDS Coordinator said she was responsible for completing the MDS assessments. The MDS Coordinator said it was important for the MDS assessments to be accurately coded to make sure they could provide the residents the care they needed. During an interview on 01/11/2024 at 6:17 p.m., the Regional Compliance Nurse said the facility did not have a policy for MDS accuracy that they followed the RAI (Resident Assessment Instrument) Manual. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, indicated, GG0115 Definition Functional Limitation in Range of Motion Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 9 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 3 residents (Resident #45) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #45's use of a blood thinner. This failure could place residents at risk of bleeding, excessive bruising, and not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #45 was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #45 did not exhibit rejection of care. The MDS assessment indicated Resident #45 required partial/moderate assistance with personal, oral, and toileting hygiene, and dependent for shower/bathe. The MDS assessment indicated Resident #45 received an anticoagulant. Record review of the Order Summary Report dated 01/09/2024 indicated Resident #45 had an order for Lovenox Injection Solution (also known as Enoxaparin Sodium a medication used to thin the blood to prevent blood clots) Inject 76 mg subcutaneously (beneath the skin) one time a day to prevent blood clots with a start date of 12/23/2023. Record review of the January MAR indicated Resident #45 received Lovenox injections 01/01/2023-01/08/2023. Record review of Resident #27's baseline care plan last reviewed 01/09/2024 did not indicate Resident #45 received Lovenox injections or received a blood thinner. During an interview on 01/11/2024 at 5:22 p.m., the Administrator said baseline care plans were started by the nurses and then the MDS Coordinator completed the baseline care plan. The Administrator said the baseline care plan should include if a resident received a blood thinner like Lovenox. The Administrator said it was important for the baseline care plan to include blood thinners for continuity of care and so the staff knew how to take care of the residents. During an interview on 01/11/2024 at 6:11 p.m., the DON said the baseline care plan was completed by the nurse managers upon admission. The DON said use of blood thinners like Lovenox should be included in the baseline care plan. The DON said the MDS Coordinator was responsible for ensuring the use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 10 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of a blood thinner was included in Resident #45's baseline care plan. The DON said the nurse managers reviewed the orders and diagnosis daily to ensure they correlated with the care plans. The DON said it was important for this to be included in the baseline care plan to ensure they were providing the best care for the resident. During an interview on 01/11/2024 at 6:30 PM, the MDS Coordinator said Resident #45's use of an anticoagulant (blood thinner) should have been included in his baseline care plan. The MDS Coordinator said if it was put on Resident #45's admission assessment it should have triggered to be included in his baseline care plan. The MDS Coordinator said Resident #45's comprehensive care plan had not been completed yet, the care plan in Resident #45's electronic health record was his baseline care plan. The MDS Coordinator said the nurses initiated the baseline care plan, and then in the morning meetings she went behind the nurses to update and add to the baseline care plans. The MDS Coordinator said Resident #45's use of an anticoagulant was not added to his care plan because it must not have been on his admission assessment, but it should have been added during the morning meeting. The MDS Coordinator said it was important for medications like an anticoagulant to be added to the baseline care plan so they can ensure they were providing person centered care. Record review of the facility's undated policy titled, Base Line Care Plans, indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- o Be developed within 48 hours of a resident's admission. o Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders. Physician orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 11 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 20 residents (Resident #16, Resident # 37, and Resident #56) reviewed for comprehensive person-centered care plans. 1. The facility failed to care plan Resident #16's CPAP machine (machine used to deliver constant and steady air pressure to help you breathe while you sleep). 2. The facility failed to care plan Resident #56's contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both hands. 3. The facility failed to ensure Resident # 37 had a fall mat at bedside. These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand. Resident #16 said he had the CPAP machine since he admitted to the facility, and he used it. During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 12 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had no impairment in functional limitation in range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. Record review of the Order Summary Report dated 01/17/2024, did not indicate any orders for Resident #56's contractures. Record review of a facility provided document titled Residents with contractures dated 01/08/2024 indicated Resident #56 was on the list as having contractures. Record review of the care plan last revised 11/15/2023 did not indicate Resident #56's contractures to both of his hands were included in his care plan. Record review of an Occupational Therapy Discharge Summary with dates of service 05/17/2023-06/13/2023 indicated Resident #56 had contractures to bilateral upper extremities. During an observation on 01/08/2024 at 9:39 a.m., Resident #56 was lying in bed, contractures were noted to both of his hands. During an interview on 01/11/2024 at 4:19 p.m., LVN D said she did not think the nurses completed the care plans, and she did not know who was responsible for the care plans. LVN D said she was aware Resident #56 had contractures to both of his hands. During an interview on 01/11/2024 at 5:03 p.m., the Administrator said contractures and the use of a CPAP machine should be included in the residents' care plans. The Administrator said the IDT was responsible for completing the care plans. The Administrator said the IDT ensured the care plans included what was required for the residents in the daily clinical morning meetings. The Administrator said it was important for the residents' care plans to include contractures and the use of a CPAP machine for continuity of care and for staff to know how to care for the residents. During an interview on 01/11/2024 at 5:50 p.m., the DON said comprehensive care plans were completed by the IDT. The DON said the MDS Coordinator was responsible for overseeing the care plans. The DON said the use of a CPAP machine and contractures should be included in the care plan. The DON said she was not aware Resident #56's contractures were not included in his care plan. The DON said Resident #16's CPAP was taken out of his care plan because they were working on getting him a new one. The DON said it was important for these to be included in his care plans because the care plan gave a detail of how they were supposed to care for the resident. During an interview on 01/11/2024 at 6:23 p.m., the MDS Coordinator said she completed the comprehensive care plans. The MDS Coordinator said the IDT reviewed the care plans as a team quarterly to ensure everything was included in the residents' care plans. The MDS Coordinator said she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 13 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm aware Resident #56 had contractures because she had not seen any documentation, and she had not noticed it when doing his assessment. The MDS Coordinator said Resident #16 did not have an order for his CPAP, and that was why it was not included in his care plan. The MDS Coordinator said it was important for the use of a CPAP machine and contractures to be included in the care plan for the residents to get the care they needed and so the care plan was focused on them. Residents Affected - Some 3. Record review of Resident # 37's face sheet dated 1/11/2024, revealed Resident # 37 was an [AGE] year old male with diagnoses of secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder, or another illness), Hypertension (blood pressure that is higher than normal), Iron Deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells), muscle weakness (commonly due to lack of exercise, ageing, or muscle injury), history of falling (A history of falls has been previously reported to be a factor associated with falls). Record review of Resident # 37's Quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #37 had a BIMS score of 8 which indicated her cognition was severely impaired. Record review of Resident # 37's care plan dated 10/31/2023, indicated interventions for fall mat at bedside, facility fall protocol. Record review of Resident # 37's order summary dated 1/11/2024, indicated fall mat to bedside. During an observation on 01/08/2024 at 2:42 P.M., revealed Resident # 37 in bed a sleep with no fall mat in place. During an observation on 01/09/2024 at 3:00 p.m., revealed Resident # 37 in bed a sleep with no fall mat in place. During an interview on 01/11/2024 at 9:45 a.m., CNA N stated she had been employed with the facility for 90 days. CNA N stated she had no knowledge of Resident #37 needing a fall mat. CNA N stated the only way she would have known if Resident # 37 needed a fall mat was if it was posted or the nurses tell her. CNA N stated it was important for Resident # 37 to have a fall mat to prevent injury. CNA N stated the failure would be he could fall and hurt himself. During an interview on 01/11/2024 at 9:52 a.m., LVN O stated it was her responsibility and the resident representative responsibility to ensure Resident #37 had a fall mat at bedside while sleeping. LVN O stated it was important for Resident # 37 to have a fall mat at bedside because he had previous falls. LVN O stated she had no idea why the fall mat was not at the bedside when Resident #37 was sleeping. LVN O stated the failure was Resident # 37 could fall and get hurt. During an interview on 01/11/2024 at 4:48 p.m., the ADON G stated she had been employed with the facility since September 2023. The ADON G stated she did not really know who was responsible for ensuring Resident #37 had a fall mat at bedside while sleeping. The ADON G state it was important to have the fall mat at bedside as a form of protection. The ADON G stated the failure could be a possible head injury or broken bones. During an interview on 01/11/2024 at 5:30 p.m., the DON stated Resident #37 should have a fall mat at bedside when in bed. The DON stated it was one of the ADON's responsibility for ensuring Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 14 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #37's fall mat was at bedside. The DON stated the importance for a fall mat at bedside was in case Resident# 37 rolls out of bed and does not hit the hard floor. The DON stated she would reeducate the CNA's on place the fall mat at bedside while resident was in bed. The DON stated the failure was not providing safety. During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated it was the DON's responsibility for ensuring Resident #37's fall mat was at bedside. The Administrator stated It was important for Resident # 37 fall mat to be at bedside because it was a fall intervention. The Administrator stated she would monitor by doing rounds in the morning and evening to ensure interventions are done. The Administrator stated the failure was he could fall and hurt himself. Record review of the facility's undated policy titled, Comprehensive Care Planning, indicated, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A request for the facility policy regarding fall mat was submitted to the Regional Nurse Consultant on 1/11/2024 at 6:17 p.m. A policy was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 15 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 - Minimal harm or potential for actual harm 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 the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. This failure could place residents at risk for burns and injuries. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar) and legal blindness, as defined in USA. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. Record review of Resident #16's care plan last reviewed 11/21/2023 indicated Resident #16 had diabetes mellitus to avoid exposure to extreme heat or cold. During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had an electric heating blanket laid out along with all his other blankets and sheets on a chair. Resident #16 said he had gotten it for Christmas because at times it got cold in his room. Resident #16 said he would use it when it got cold. During an interview on 01/09/2024 at 9:05 a.m., LVN H said she had not been working at the facility very long and she was not sure if it was ok for Resident #16 to have an electric heating blanket in his room. During an interview on 01/11/2024 at 4:28 p.m., ADON F said she had told Resident #16 not to use the electric heating blanket. ADON F said Resident #16 said he received the electric heating blanket as a gift for Christmas. ADON F said any of the staff going into his room should be checking for items not allowed in the residents' rooms. ADON F said it was important not to keep electric heating blankets in the residents' rooms because they were a fire hazard, and he could get severely burned. During an interview on 01/11/2024 at 5:25 p.m., the Administrator said she was not aware Resident #16 had an electric heating blanket in his room. The Administrator said the CNAs usually told her if the residents had items in their room that were not allowed. The Administrator said the facility had champion rounds (where dedicated staff go to the residents' rooms to check on them) to check the residents' rooms. The Administrator said it was important for the residents not to keep electric heating blankets in their rooms because it could cause a fire and it could burn them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 16 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 - Minimal harm or potential for actual harm During an interview on 01/11/2024 at 6:14 p.m., the DON said the residents should not keep electric heating blankets in their rooms. The DON said she was not aware Resident #16 had an electric heating blanket in his room. The DON said all the staff should be making sure the residents did not have them in their rooms. The DON said it was important for the residents not to keep electric heating blankets in their rooms for their safety and to prevent any burns. Residents Affected - Few Record review of a facility provided document dated May 6, 2005, titled, Nursing Home List of Items Not Allowed in Resident Room (This list is not all inclusive), indicated, . Safety Hazards . electric blankets . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 17 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #56) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #56's urinary (foley) catheter was properly secured to his leg. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1) and neuromuscular dysfunction of bladder (a type of bladder dysfunction caused by nerve, brain, or spinal cord damage). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had an indwelling catheter. Record review of the Order Summary Report dated 01/17/2024 indicated Resident #56 had an order to ensure catheter strap in place and holding every shift change as needed with an order start date of 11/21/2023. Record review of the care plan last reviewed 11/15/2023 indicated Resident #56 had a chronic foley catheter with a goal for the resident will be/remain free from catheter related trauma through review date, and interventions to ensure the tubing was anchored to the resident's leg or linens so that tubing was not pulling on the urethra. Record review of Resident #56's TAR for January 2024 indicated ensure catheter strap in place and holding every shift change as needed and was documented as completed by LVN D on 01/10/2024. During an observation on 01/10/2024 at 9:10 a.m., Resident #56 did not have a catheter strap in place. Resident #56's catheter tubing was not anchored to his leg or the linens. Resident #56 was non-interviewable. During an observation and interview with LVN D on 01/10/2024 at 9:19 a.m., Resident #56's catheter tubing was not anchored to his leg or the linens, and there was no catheter strap in place. LVN D said she was not aware Resident #56 should have a catheter strap in place to secure his catheter. LVN D said she had documented on the MAR for his catheter strap to be in place, but she did not realize that's what it meant. LVN D said she thought that referred to ensuring the catheter was still in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 18 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few place, not regarding the catheter being secured to his leg. LVN D said the nurses were responsible for ensuring the residents catheters were properly secured. LVN D said it was important for the catheter to be secured so it did not get pulled. LVN D said if the catheter was not properly secured it could cause damage to his penis. During an interview on 01/11/2024 at 4:34 p.m., ADON F said the nurses and CNAs were responsible for ensuring the foley catheters were secured. ADON F said she monitored to ensure the foley catheters were secured by checking the MARs and tasks to ensure the nurses were documenting this was done. ADON F said it was important for foley catheters to be secured properly so they would not be dislodged. ADON F said if the foley catheters were not secured properly it could get lodged in the penis or cause blood in the urine. During an interview on 01/11/2024 at 5:08 p.m., the Administrator said she expected for the nurses to ensure the foley catheters were secured properly. The Administrator said the nurses and nurse management were responsible for ensuring foley catheters were secured properly. The Administrator said it was important for the foley catheters to be secured properly so they did not pull them out or get hung on something. During an interview on 01/11/2024 at 5:56 p.m., the DON said the Infection Control Preventionist was responsible for ensuring the catheters were secured properly. The DON said Resident #56 should have had a leg strap in place to secure his foley catheter, and she did not know why he did not. The DON said it was important for the catheters to be secured to ensure it did not get pulled out or cause irritation. Record review of the facility's policy titled, Catheter Insertion, Male/Female, from the Nursing Policy & Procedure Manual 2003 did not address securement of a foley catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 19 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that residents requiring respiratory care are provided care, consistent with professional standards of practices for 5 of 63 residents reviewed for respiratory care (Residents #23, #18, #41, #11 and #16). Residents Affected - Some 1. The facility failed to ensure Resident #23's oxygen was in a bag when not in use. 2. The facility failed to ensure Resident #18 and Resident #41 oxygen concentrator filter was cleaned weekly. 3. The facility failed to ensure Resident #41 nebulizer tubing was placed inside a bag after her breathing treatment was administered. 4. The facility failed to ensure Resident #11's handheld nebulizer was stored in a bag. 5. The facility failed to ensure Resident #16 had an order for his CPAP machine (a machine used to deliver constant and steady air pressure to help you breathe while you sleep) and the facility failed to ensure Resident #16's CPAP mask was stored in a bag. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings included: 1.Record review of Resident #23's face sheet, dated 01/16/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE] with the diagnoses which included Congestive Heart Failure {CHF} (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), high blood pressure, depression (persistent feeling of sadness and loss of interest), and dementia(impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #23's quarterly MDS assessment, dated 12/21/23, indicated Resident #23 was usually understood and usually understood by others. Resident #23's BIMs score was 01, which indicated she was cognitively severely impaired. The MDS indicated Resident #23 required total assistance with bathing and toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and supervision with eating. The MDS indicated Resident #23 was receiving oxygen during the look-back period. Record review of Resident #23's physician's orders, dated 06/13/23, for Oxygen via NC at 2lpm as needed as needed related to acute respiratory failure. Record review for Resident #23's comprehensive care plan, dated 06/09/23 indicated Resident #23 required Oxygen Therapy. The interventions were for staff to monitor for signs and symptoms of respiratory distress and report to the physician as needed and to wear Oxygen at 2 liters per nasal cannula as needed. During an observation on 01/08/24 at 10:22 a.m., Resident #23 was being wheeled out of her room by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 20 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 a staff member. O2 tubing was noted sitting on the concentrator, not in a bag or dated. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 01/10/24 at 4:38 p.m., Resident #23 was sitting in her room and noted oxygen concentration was running at 2 liters. Oxygen tubing was noted as not bagged. LVN O came into the room and saw the O2 tubing sitting on the concentration and said Resident #23 does wear her oxygen periodically but it should be bagged when not used for infection control issues. Residents Affected - Some During an interview on 01/11/24 at 4:28 p.m., the DON said O2 tubing should be changed weekly on Sunday nights and as needed. She said O2 tubing should be dated and bagged when changed or not in use. She said the ADONs should be doing a spot check daily and failure to place in bags when not in use could cause infection control issues. During an interview on 01/11/24 at 4:37 p.m., ADON G said O2 tubing should be bagged when not in use. She said the charge nurses were responsible but the ADONs looked periodically to ensure they were bagged. She said if O2 tubing was not bagged it could cause some infection control issues. During an interview on 01/11/24 at 5:44 p.m., the Administrator said oxygen tubing should be stored in a bag when not in use. The Administrator said the nurses were responsible for ensuring they were stored in a bag. She said they did champion rounds with department heads as well and nurse managers should be making rounds to ensure oxygen tubing was stored in a bag when not in use. The Administrator said it was important for oxygen to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put into the resident's respiratory systems. Tubing should be bagged to prevent infection. 2. Record Review of Resident #18 face sheet, dated on 1/10/24, indicated Resident #18 was a [AGE] year-old female, admitted to the facility on the administration date of 3/30/18 with a diagnosis of Hemiplegia (part of the brain controlling movement is damaged) affecting right dominant side, Hemiparesis (a condition that causes weakness or paralysis on one side of the body, affecting daily activities and mobility), Dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life, limitations of activities due to disability and essential hypertension (high blood pressure). Record review of the most recent MDS dated [DATE] indicated Resident #18 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #18's BIMS Score was 08, which indicated moderate impairment. The MDS indicated Resident #18 required extensive assistance with bed mobility with a two-person physical assist, and extensive assistance with toileting and transfer with two-person physical assist. The MDS indicated Resident #18 received oxygen therapy. Record review of the care plan updated dated on 2/09/21 indicated Resident #18 received oxygen therapy as needed. The comprehensive care plan indicated to give medications as ordered by the physician; observe/document side effects and effectiveness. The care plan did not address the oxygen concentrator filter. Record Review of Resident #18's Oxygen and Respiratory orders on 1/9/24 at 1:16 p.m., indicated to clean or change the filter every night shift every Sunday. During an observation on 1/10/24 at 8:30 a.m., Resident #18 oxygen concentrator filter was not cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 21 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 During observation on 1/11/24 at 8:05 a.m., Resident #18 oxygen concentrator filter was not cleaned. Level of Harm - Minimal harm or potential for actual harm 3.Record Review of Resident #41 face sheet, dated on 1/10/24, indicated Resident #41 was a [AGE] year-old female, admitted to the facility on the administration date of 12/12/23 with a diagnosis of emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness, chronic obstructive pulmonary disease, pneumonia, insomnia and limitation of activities due to disability. Residents Affected - Some Record review of the most recent MDS dated [DATE] indicated Resident #41 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #41 BIMS score was 08 which indicated moderate impairment. The MDS did not indicate Resident #41 assistance with bed mobility, toileting, and dressing. The MDS indicated Resident #41 received oxygen therapy. Record review of the care plan updated dated on 12/14/23 indicated Resident #41 received oxygen therapy. The comprehensive care plan indicated to monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed; notify the nurse if oxygen is off the resident; oxygen set at 2 to 3 liters per minute. The care plan did not address the oxygen concentrator filter for Resident #41. The Care plan did not address the nebulizer for Resident #41. Record Review of Resident #41 Oxygen and Respiratory orders on 1/9/24 at 12:56 p.m., indicated to clean or change the filter of nebulizer machine every night shift every Sunday. During observation on 1/10/24 at 8:33 a.m., Resident #41 nebulizer tubing was not placed inside bag after use. During observation on 1/11/24 at 8:08 a.m., Resident #41 nebulizer tubing was not placed inside bag after use. During an interview on 1/10/24 at 6:01 p.m., LVN E stated she had been employed since November 2023 and has been working night shift since December 2023. LVN E stated she worked PRN on the night shift at the facility. LVN E stated she did not know how often filters were to be changed. LVN E stated she did not know how the filters were to be cleaned because she came from a hospital and did not have to clean the o2 filter. LVN E stated she changed the tubing for the oxygen concentrator as needed. LVN E stated she was not aware of the oxygen concentrator filter orders for Resident #41 and Resident #18. LVN E stated she did not complete in-services on nebulizer or o2 filter changing. LVN E stated she did not sign off on oxygen filter at night because she was not aware of the filters needing to be changed on Sunday by the night shift nurse. LVN E stated the DON oversaw what she did at the facility. LVN E stated it was important to follow doctor's orders for oxygen contractor for cleanliness and healthiness and to prevent residents from getting sick. During an interview on 1/11/24 at 8:08 a.m., Resident #41 stated she used her nebulizer every day. Resident #41 stated the nurses never put her nebulizer in a bag after use. During an interview on 1/11/24 at 10:07 the DON stated she had been the DON since Feb of 2023. The DON stated the ADON was responsible for monitoring the oxygen filter changes. The DON stated the ADON was responsible for monitoring the nebulizer was placed in a bag after use. The DON stated she did not know why the nebulizer was not place in a bag after use. The DON stated she was not aware that the oxygen filters were not being changed on Resident #18 and Resident #41. The DON stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 22 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some aware of the oxygen concentrator orders for Resident #18 and Resident #41. The DON stated she did expect staff to follow physician orders as prescribed. The DON stated she monitors the oxygen orders during SOC meeting daily. The DON stated during SOC meetings she would ask the ADON for updated reported what needed to be done and the changing the resident oxygen filers was never brought to her attention. The DON stated she conducted daily rounds in the morning. The DON stated each morning the, ADON, treatment nurse and MDS coordinator were assigned to halls to conduct daily rounds every day. The DON stated it was important to ensure staff were following physician orders to ensure resident were getting the best care. During an interview on 1/11/24 at 11:00 a.m., ADON F stated she had been the ADON since March of 2023. ADON F stated ADON G was in charge of the Oxygen filter changes and nebulizer. ADON F stated she did not know why the nebulizer tubing had not been placed in bag, but nurses' staff were aware of the nebulizer tubing being placed in bag after use. ADON F stated she was aware oxygen order for Resident #41 and Resident #18, but she did not check filter but will check oxygen filters for now on a daily base. ADON F stated she expected staff to ensure they were following the physician orders. ADON F stated her assigned hallway was the B hall and she monitored B hall only. ADON F stated ADON G was assigned to the C hall. ADON F stated the wound care nurse was assigned to D hall. ADON F stated in-service was last completed a few months ago on oxygen filter changes and nebulizer. ADON F stated she was not aware of LVN not being trained on how to clean oxygen filters. ADON F stated the DON oversaw her. ADON F stated, It was important for staff to follow physician orders because the orders were there for a reason, and it will help provide the best care for the resident. During an interview on 1/11/24 at 11:36 a.m., The Administrator stated the nursing staff was responsible for changing the oxygen concentrator filters. The Administrator stated the nursing staff were responsible for ensuring the nebulizers were placed in bag. The Administrator stated she did expect staff to ensure they were changing the oxygen concentrator as prescribed by the doctor. The Administrator stated she was not aware that the oxygen concentrator filter were not being changed. The Administrator stated she was not aware of the nebulizer tubing not being placed in bags. The Administrator stated she monitored the filter changes by asking clinical staff in the morning meeting. The Administrator stated staff did completed nebulizer in-services training back in October 2023. The Administrator stated she did not recall the training in-services on filters changes. The Administrator stated it was important for staff to follow physician orders for the wellbeing of the resident. During an interview on 1/11/24 at 11:44 a.m., Treatment Nurse L stated she was responsible for the monitoring the D hall. Treatment Nurse L stated she conducted rounds every day on the D Hall where Resident #18 and Resident #41 resided. Treatment Nurse L stated she would watch breakfast trays go out in the morning and then conduct rounds in the resident rooms on her assigned hall (D hall). Treatment Nurse L stated she never noticed that Resident #18 nebulizer tubing was not placed in bag after bag after Resident #18 breathing treatments were administered. Treatment Nurse L stated she the charge nurse and the ADON G were responsible for monitoring the nebulizer tubing was placed in bag after use. Treatment Nurse L stated her last round on D Hall was conducted on 1/11/24 7:40 a.m. Treatment Nurse L stated Resident #18 had one orders for the nebulizer and she was aware of Resident #18 nebulizer orders from the physician. Treatment Nurse L stated she stated resident #18 received a breathing treatment 3 times a day. Treatment Nurse L stated Resident #18 breathing treatment on her nebulizer were given at 9 a.m., 4 p.m., and 9p.m. Treatment Nurse L stated Resident #18 last used her nebulizer at 9 a.m. on 1/11/24. During an interview on 1/11/24 at 12:19 p.m., ADON G stated she had been the ADON since sept of 2023. ADON G stated she was responsible for monitoring the oxygen filter changes and making sure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 23 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nebulizer tubing were placed in bag. ADON G stated she was not aware of the oxygen order for the filter changes for Resident #18 and Resident #41. ADON G stated she did expect staff to ensure they were following physician orders. ADON G stated she monitored staff by conducting follow-up after staff to ensure staff were putting the nebulizer in bags and changing the filters according to the physician orders. ADON G stated in the past she addressed concerns with staff upon finding issues with the oxygen concentrators and nebulizer. ADON G stated she was not aware of staff completing any in-service training for nebulizer or oxygen filter changing. ADON G stated she was not aware of staff not changing the oxygen filters. ADON G stated she had no idea that the night nurse LVN did not know how to change/clean the oxygen concentrator filters. ADON G stated she the DON oversaw her. ADON G stated it was important to ensure staff were following physician orders because the physician knows what's best for the residents. 4. Record review of a face sheet dated 01/11/2024 indicated Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that stops and starts) and asthma (lung disorder characterized by narrowing of the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #11 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 required setup/clean-up assistance with eating, personal and oral hygiene, dependent for toilet hygiene, dressing, and substantial/maximal assistance with shower/bath. The MDS assessment indicated Resident #11 used oxygen therapy. Record review of the Order Summary Report dated 01/10/2024 indicated Resident #11 had an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083% (Albuterol Sulfate- medication used to treat wheezing and shortness of breath) 1 inhalation inhale orally via nebulizer four times a day with a start date of 11/29/2023. Record review of the care plan last reviewed 12/12/2023 did not address Resident #11's use of a handheld nebulizer. During an observation on 01/08/2024 at 9:50 a.m., Resident #11's handheld nebulizer was on her nightstand and was not stored in a bag. During an observation on 01/09/2024 at 8:14 a.m., Resident #11's handheld nebulizer was in her drawer and was not stored in a bag. During an interview on 01/11/2024 at 4:07 p.m., LVN D said handheld nebulizers and oxygen masks should be stored in a sack dated and initialed. LVN D said she did not know why Resident #11's handheld nebulizer was not stored in a bag because she had not worked the previous two days. LVN D said the nurses were responsible for ensuring the handheld nebulizers and oxygen masks were stored properly. LVN D said it was important for handheld nebulizers and oxygen masks be stored in a bag for infection control. 5. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 24 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. During an observation on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand with the mask laying on the nightstand not stored in a bag. During an observation on 01/10/2024 at 2:13 p.m., Resident #16 had his CPAP mask on top of his nightstand not stored in a bag. During an interview on 01/10/2024 at 2:21 p.m., LVN D said she was not aware Resident #16 had a CPAP. LVN D said she had not seen his CPAP machine in his room. LVN D said Resident #16 should have an order for his CPAP and she did not know why he did not have one. LVN D said she did not know why his CPAP mask was not stored in a bag because the night nurse was the one that put it on him. During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said she had not looked at Resident #16's orders to see if he had an order for his CPAP. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. LVN E said she was not sure why Resident #16's CPAP mask was not stored in a bag because when she worked it was stored in a bag. LVN E said it was important for CPAP masks to be stored in a bag for cleanliness and because she would not want it to touch the floor and then put it in the resident's airway. During an interview on 01/11/2024 5:05 p.m., the Administrator said residents should have an order for a CPAP machine The Administrator said nursing was responsible for putting in the order for the CPAP. The Administrator said it was important to have an order for a CPAP machine to ensure the physician orders were being followed. The Administrator said her expectations were for the oxygen/CPAP masks, handheld nebulizers to be clean and always stored if not in use. The Administrator said these items should be stored in a bag. The Administrator said the nurses were responsible for ensuring they were stored in a bag. The Administrator said it was important for oxygen/CPAP masks and handheld nebulizers to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put in the residents' respiratory systems. During an interview on 01/11/2024 at 5:53 p.m., the DON said Resident #16 should have an order for his CPAP. The DON said Resident #16 did not have an order because they were in the process of getting him a new one. The DON said ADON F was responsible for monitoring the orders. The DON said it was important to have an order for a CPAP because without an order the nurses would not know how he needed to wear it. The DON said handheld nebulizers/oxygen masks should be stored in a bag. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 25 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADON G was responsible for ensuring the nurses were storing the handheld nebulizers and oxygen masks properly. The DON said it was important to ensure the handheld nebulizers and oxygen masks were stored in a bag for infection control. Record review of the facility's policy titled, Respiratory Policies and Procedures, revision date 06/01/2007, indicated, Bi-level Positive Airway Pressure (BiP AP) and/or Continuous Positive Airway Pressure (CPAP) is set up and monitored by a licensed nurse or respiratory therapist with a physician's order. Orders must include pressure and hours of use and may include supplemental oxygen and mask size. For BiPAP, orders must also include EPAP and TPAP and may include mode of delivery and respiratory rate . Record review of the facility's policy titled, Aerosolized Hand-Held Nebulizer, from the Nursing Policy & Procedure Manual 2003, indicated, . Rinse the nebulizer and mouthpiece shake and store in a plastic bag the is labeled with the patient' s name and room number. 14. Chart to include medication, diluents, and dose on medication record. 15. Change nebulizer set-up every 7 days and more often if necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 26 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' who used anticoagulant medications were adequately monitored and free from unnecessary drugs for 2 of 5 residents (Resident #11 and Resident #58) reviewed for unnecessary medications. Residents Affected - Few 1. The facility failed to monitor Resident #11 for side effects of Eliquis (an anticoagulant medication-blood thinner). 2. The facility did not monitor Resident #58 for side effects/adverse reactions for the use of anticoagulant (blood-thinning) medications. This failure could place residents at risk of bruising and bleeding. Findings included: 1. Record review of Resident #11's face sheet dated 01/11/2024 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing (fracture at the end of the left leg bone), unsteadiness of feet, and paroxysmal atrial fibrillation (irregular heartbeat that stops and starts). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #11 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 required setup/clean-up assistance with eating, personal and oral hygiene, dependent for toilet hygiene, dressing, and substantial/maximal assistance with shower/bath. The MDS assessment indicated Resident #11 was taking an anticoagulant. Record review of the Order Summary Report dated 01/10/2024 indicated Resident #11 had an order for Eliquis 5 mg give 1 tablet by mouth two times a day with a start date of 11/29/2023. Resident #11's Order Summary Report did not indicate to monitor for side effects of anticoagulant medication. Record review of the care plan last reviewed 12/12/2023 indicated Resident #11 was on anticoagulant therapy to monitor/document/report to medical director as needed for signs and symptoms of anticoagulant complications. Record review Resident #11's MAR for January 2024 indicated Resident #11 received Eliquis 5 mg every day from 01/01/2024 to 01/11/2024 with no monitoring for side effects for an anticoagulant medication indicated. Record review Resident #11's TAR for January 2024 did not indicate to monitor for side effects of an anticoagulant medication. Record review of Resident #11's Tasks in her electronic health record indicated no documentation of monitoring for side effects of Eliquis. During an interview on 01/11/2024 at 4:12 p.m., LVN D said if she received an order for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 27 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0757 Level of Harm - Minimal harm or potential for actual harm anticoagulant medication she would put in an order for anticoagulant monitoring. LVN D said she was not aware if Resident #11 required anticoagulant monitoring. LVN D said if a resident was on anticoagulant medications, she would monitor them for bleeding and excessive bruising. LVN D said it was important to monitor when residents were taking anticoagulants to ensure they did not bleed excessively or having increased bruising. Residents Affected - Few During an interview on 01/11/2024 at 4:22 p.m., ADON F said she did not know who was responsible for ensuring the residents on anticoagulant medications were being monitored appropriately. ADON F said to her knowledge there was no process in place to ensure the residents receiving anticoagulant medications were being monitored appropriately. ADON F said it was important for residents receiving anticoagulant medications to be monitored because there was a potential for bleeding. During an interview on 01/11/2024 at 5:13 p.m., the Administrator said the DON was responsible for ensuring the anticoagulant monitoring was being done. The Administrator said she expected for residents to be monitored appropriately when taking anticoagulant medications. The Administrator said this was important for their health. During an interview on 01/11/2024 at 6:03 p.m., the DON said upon a resident's admission anticoagulant monitoring was put in the Tasks in the resident's electronic health record for the CNAs to document. The DON said she was not aware Resident #11 did not have anticoagulant monitoring in her electronic health record. The DON said ADON G was responsible for overseeing that anticoagulant monitoring was being done. The DON said it was important for anticoagulant monitoring to be done to ensure the risk for bleeding is assessed. During an interview on 01/11/2024 at 6:21 p.m., ADON G said she did not oversee the anticoagulant monitoring. ADON G said she was not sure who was responsible for putting in the Tasks for anticoagulant monitoring or who was overseeing it. ADON G said it was important for anticoagulant monitoring to be in place because it could be a life-or-death situation for the residents. 2. Record review of Resident # 58's face sheet dated 01/11/2024, revealed Resident # 58 was an [AGE] year-old male with diagnoses of Alzheimer's disease (the most common type of Dementia), Hypertension (high blood pressure). Atrial Fibrillation (fast, irregular heartbeat), Chronic Systolic Congestive Heart Failure (a specific type of heart failure that occurs in the heart's left ventricle). Record review of Resident # 58's order summary dated 01/11/2024, indicated Resident #58 received Apixaban (anticoagulant) 5mg 1 tablet by mouth two times a day ordered on 07/27/2023. Record review of Resident # 58's care plan dated 01/2/2024, indicated Resident # 58 was taking anticoagulant with interventions to monitor, document, and report signs and symptoms of anticoagulant complications. Record review of Resident # 58's Comprehensive MDS dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #58 had a BIMS score of 8 which indicated his cognition was moderately impaired. Record review of Resident # 58's Task List dated 01/11/2024, indicated no documentation of monitoring for side effects of Apixaban an anticoagulant. During an interview on 01/11/2024 at 4:30 p.m., LVN O stated when a resident was on Apixaban they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 28 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few are monitored for bleeding. LVN O stated it was supposed to be documented on the Task list so they can monitor for bleeding. LVN O stated she had no idea why it was not on the Task list. LVN O stated the failure was it not being documented on the task list you would have to do more digging to know what the resident was taking and could prolong the issue. During an interview on 01/11/2024 at 4:48 p.m., the ADON G stated she has been employed with the facility since September2023. ADON G stated she did not know anticoagulant monitoring was supposed to be documented on the Task list. ADON G stated any of the nurse managers are responsible for monitoring documentation on the Task list. ADON G stated was important to document anticoagulant monitoring on the Task list because if the resident fell or had any type of injury that breaks the skin it could be life or death. ADON G stated the failure was a potential for harm. During an interview on 01/11/2024 at 5:30 p.m., the DON stated anticoagulant monitoring should be added to the Task list immediately. The DON stated the ADON's are responsible for adding to the Task list. The DON stated it was important for anticoagulant monitoring to be on the Task list to monitor for bruising and bleeding. The DON stated it was an oversight that the anticoagulant monitoring was not added to the task list. The DON stated the failure was not assessing for bleeding. During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated anticoagulant monitoring should be added to the Task list upon order. The Administrator stated it was nurse managements responsibility for ensuring anticoagulant monitoring was added to the Task list. The Administrator stated it was important for anticoagulant monitoring to be added to the Task list so the staff taking care of Resident # 58 would know what medication he was on and to report any bruising or bleeding to the physician. The Administrator stated the failure would be Resident # 58 could have bruising and the staff would not know the reason. Record review of an untitled undated document provided by the Regional Compliance Nurse on 01/11/2024 at 11:38 a.m., indicated, Adding the Anticoagulant Monitoring Task to the Kiosk 1. Go to the resident's chart 2. Click the Tasks Tab 3. Click New Task. A new box appears 4. Scroll ¾ of the way down and place a check mark in 5. Click Save This is complete, and it will now show up on the kiosk. See below When the staff touches this task it will ask the following: 1. Did you observe any of the following: Bruising, Nosebleeds, Bleeding gums, Prolonged bleeding from wound, IV, or surgical sites, Blood in urine/feces/vomit, coughing up blood? If so, immediately report to the charge nurse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 29 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 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, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67 %, based on 2 errors out of 30 opportunities, which involved 2 of 7 residents (Resident #60 and #30) reviewed for medication administration. Residents Affected - Few 1.The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2.The facility failed to ensure LVN O administered insulin correctly for Resident #30. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1.Record review of Resident #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #60's quarterly MDS assessment dated [DATE], indicated he understood and was understood by others. Resident #60's BIMs score was 08, which indicated his cognition was moderately impaired. The MDS indicated Resident #60 required limited assistance with toileting, dressing, personal hygiene, transfers, bathing, and supervision with eating and bed mobility. The MDS indicated he received insulin injections during the look-back period. Record review of Resident #60's comprehensive care plan dated 10/06/23, indicated he had Diabetes Mellitus placing him at increased risk of infection and skin breakdown. The goal was for him not to have any complications related to diabetes. Record review of Resident #60's order summary report dated 09/21/23, indicated he had an insulin order for Humalog (Lispro): Inject as per sliding scale: if 0 - 174 = 0; 175 -999 = 0-15u use formula: Fingerstick reading -150/25= number of units to administer, subcutaneously (under the skin) before meals related to Diabetes Mellitus. During an observation on 01/08/24 at 3:57 p.m., LVN Q checked Resident #60's blood sugar and revealed 195. LVN Q used the formula (195-150/25) to calculate the amount of insulin to give. She calculated 1.8. LVN Q said she was going to give Resident #60 1 unit of Humalog insulin. LVN Q went to the cart and drew up Humalog insulin of 1 unit. LVN Q administered Resident #60 1 unit of Humalog insulin to his left lower abdomen. During an interview on 01/08/24 at 4:45 p.m., LVN K said she gave Resident #60 1 unit of insulin because she calculated 1.8. She said she had never rounded when giving his insulin based on the formula. She said she had never thought about calling the doctor to clarify the order because she thought she was calculating correctly. She said she realized after being questioned by the surveyor that she should have rounded up to 2. She said if Resident #60 does not receive the correct amount of insulin it could cause his blood sugar levels to increase and could affect his overall health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 30 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a phone interview on 01/09/24 at 1:20 p.m., The facility physician said if a nurse got a blood sugar of 195 then according to his orders, the nurse would subtract 195-150/25 =1.8. He said he would expect the nurse to give 2 units. He said if they were rounding appropriately, they were supposed to round up to 2 that was what he would expect the nurses to do. He said If they got 1.5 round to 1 but if they got 1.5 and higher round up to 2. He said they could always call him and ask him if they had any questions about an order. He said if Resident #60 received 1 unit of insulin it was incorrect, he should have received 2 units. During an interview on 01/11/24 at 11:00 a.m., LVN O said before the DON told her about the new insulin orders for rounding, she never rounded. She said if she had gotten 1.8 as the calculated dosage, on Resident #60 as Nurse LVN Q did, she would have given 1 unit. She said in nursing school, she was taught not to round up. She said she now knows she should have called the physician because the resident was not receiving the prescribed dose. During an interview on 01/11/24 at 4:28 p.m., the DON said she expected nurses to give insulin correctly. She said LVN Q should have called the physician to clarify the reading of 1.8 after using the calculated formula. She said she called the physician and got the order clarified on 01/08/24 after LVN Q gave Resident #60 1 unit of Humalog. She said LVN Q should have given Resident #60 2 units of Humalog. She said Resident #30 did not receive the correct amount of insulin and it could affect her overall well-being such as hyperglycemia (high blood sugar levels). During an interview on 01/11/24 at 4:37 p.m., the ADON G said she expected the nurses to give the insulin correctly. She said if she received 1.8 after using the calculated formula, she would have given 2 units of insulin. She said failure to give the correct amount of insulin could lead to hyperglycemia. 2.Record review of Resident #30's face sheet, dated 01/16/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes mellites (diabetic), cerebral infarction (stroke), and essential hypertension (high blood pressure). Record review of Resident #30's quarterly MDS assessment, dated 11/21/23, indicated Resident #30 understood and was understood by others. Resident #30's BIMs score was 08, which indicated she was cognitively moderately impaired. The MDS indicated Resident #30 required total assistance with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and bathing, and supervision with eating. The MDS indicated she received insulin injections during the look-back period. Record review of Resident #30's physician's orders, dated 09/26/23, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 175 = units if blood sugar less than 60-80 and not symptomatic administer glucose gel and recheck in 1 hour; 176 - 500 = 999 inject per sliding scale fingerstick result -150/25=number of units, subcutaneously before meals and at bedtime for elevated glucose. Record review of Resident #30's comprehensive care plan, dated 01/31/23 indicated Resident #30 had Diabetes Mellitus placing her at risk for infection and skin issues. The intervention of the care plan indicated staff would give medication as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 31 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0759 Level of Harm - Minimal harm or potential for actual harm During an observation on 01/11/24 at 10:48 a.m., LVN O took Resident #30's blood sugar. She received a reading of 352. LVN O went to the cart and drew up 8 units of Humalog as ordered. LVN O went into Resident #30's room and gave insulin to her left abdomen. LVN O did not wipe the end of the insulin pen off before connecting the cap, prime the insulin pen, or hold the insulin pen in the skin for 10 seconds to allow insulin to penetrate the skin therefore insulin was leaking out of the injection site. Residents Affected - Few During an interview on 01/11/24 at 11:00 a.m., LVN O said she saw the insulin dripping out of Resident #30's injection site. She said she did not know why the insulin was leaking from Resident #30's injection site. LVN O said she was not aware she was supposed to hold the insulin pen at the injection site for 10 seconds. She said she was not aware she needed to clean the insulin pen before connecting the cap or prime the insulin pen before setting the dial to the required insulin dosage. LVN O said she had not had competency training on giving insulin with an insulin pen from this facility. She said since an unknown amount of the insulin dripped out of Resident #30's injection site it would not have had the same effect as giving the ordered amount. She said it could affect her blood sugar levels and lead to higher levels. LVN O said as the nurse she was responsible for ensuring the medication was given as ordered. During an interview on 01/11/24 at 4:28 p.m., the DON said nurses needed to give insulin correctly. She said nursing staff were supposed to prime the insulin pen, set the dial to the ordered insulin, and make sure they held it at the injection site for 10 seconds to allow the medication to enter the subcutaneous tissues. She said if insulin were not given correctly, it could cause them to have an adverse reaction such as hyper/hypoglycemia (high or low blood sugars). She said she could not recall if LVN Q or LVN O had been checked off on competency of insulin. During an interview on 01/11/24 at 4:37 p.m., ADON G said she expected the nurses to give the insulin correctly. She said nurses were supposed to set the amount on the insulin pen, put on the needle, clean the skin of the resident, press to the skin, and hold to the skin to allow insulin to penetrate the skin. She said she was not aware of any training on insulin pens as she was new to the ADON position. She said failure to deliver the ordered amount of insulin could affect the resident's blood sugars negatively. During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the nurses to give medication and insulin as ordered by the physician. She said the DON was the overseer of nursing. She said she could see not giving insulin correctly could affect a resident's blood sugars. Record review of facility policy titled, Medication Administration Procedures, indicated 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to be poured, administered, and charted by the same licensed person. 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.14.A specific order must be obtained from the Physician to change the dosage form of a resident's medication (e.g., tablet to liquid form).15.Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 32 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's policy titled, Physician Orders revised 2015, indicated The purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner. 1. The Nurse will review the order and if needed contact the prescriber for any clarifications. Record review of facility's policy titled, Insulin Pen Use by Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, indicated Important information for the use of an insulin pen: o Always attach a new needle before each use. o Always perform the safety test before each injection. o Do not select a dose or press the injection button without a needle attached. o This pen is only for one resident's use Step 1. Check the insulin. A. Check the label on the pen to make sure you have the correct insulin. B. Take off the pen cap. Step 2. Attach the needle. Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks. A. Wipe the Rubber Seal with alcohol. Step 3. Perform a Safety test A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise towards the needle. D. Press the injection button in. Check if insulin comes out of the needle tip. Step 4. Select the dose. A. Check that the dose window shows 0 following the safety test. Step 5. Inject the dose. A. Insert the needle into the skin at a 90-degree angle. B. Deliver the dose by pressing the injection button all the way. The number in the dose window will return to 0 as you inject. C. Keep the injection button pressed all the way in and slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 33 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0760 Ensure that residents are free from significant medication errors. 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 that residents were free of significant medication errors for 2 of 6 residents reviewed for medication pass. (Resident #60 and Resident #30) Residents Affected - Few 1. The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2. The facility failed to ensure LVN O administered insulin correctly for Resident #30 These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1.Record review of Resident #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #60's quarterly MDS assessment dated [DATE], indicated he understood and was understood by others. Resident #60's BIMs score was 08, which indicated his cognition was moderately impaired. The MDS indicated Resident #60 required limited assistance with toileting, dressing, personal hygiene, transfers, bathing, and supervision with eating and bed mobility. The MDS indicated he received insulin injections during the look-back period. Record review of Resident #60's comprehensive care plan dated 10/06/23, indicated he had Diabetes Mellitus placing him at increased risk of infection and skin breakdown. The goal was for him not to have any complications related to diabetes. Record review of Resident #60's order summary report dated 09/21/23, indicated he had an insulin order for Humalog (Lispro): Inject as per sliding scale: if 0 - 174 = 0; 175 -999 = 0-15u use formula: Fingerstick reading -150/25= number of units to administer, subcutaneously (under the skin) before meals related to Diabetes Mellitus. During an observation on 01/08/24 at 3:57 p.m., LVN Q checked Resident #60's blood sugar and revealed 195. LVN Q used the formula (195-150/25) to calculate the amount of insulin to give. She calculated 1.8. LVN Q said she was going to give Resident #60 1 unit of Humalog insulin. LVN Q went to the cart and drew up Humalog insulin of 1 unit. LVN Q administered Resident #60 1 unit of Humalog insulin to his left lower abdomen. During an interview on 01/08/24 at 4:45 p.m., LVN Q said she gave Resident #60 1 unit of insulin because she calculated 1.8. She said she had never rounded when giving his insulin based on the formula. She said she had never thought about calling the doctor to clarify the order because she thought she was calculating correctly. She said she realized after being questioned by the surveyor that she should have rounded up to 2. She said if Resident #60 does not receive the correct amount of insulin it could cause his blood sugar levels to increase and could affect his overall health. During a phone interview on 01/09/24 at 1:20 p.m., The facility physician said if a nurse got a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 34 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood sugar of 195 then according to his orders, the nurse would subtract 195-150/25 =1.8. He said he would expect the nurse to give 2 units. He said if they were rounding appropriately, they were supposed to round up to 2; that was what he would expect the nurses to do. He said If they got 1.5 round to 1 but if they got 1.5 and higher round up to 2. He said they could always call him and ask him if they had any questions about an order. He said if Resident #60 received 1 unit of insulin it was incorrect, he should have received 2 units. During an interview on 01/09/24 at 1:34 p.m., the Regional Nurse Consultant (RNC) said she would have to clarify with the physician related to how Resident #60's insulin orders were. She said if she got results of 1.8 after using the calculated formula, she would not know whether to give 1 unit or 2 units of insulin. During an interview on 01/11/24 at 11:00 a.m., LVN O said before the DON told her about the new insulin orders for rounding, she never rounded when giving insulin using the calculated formula. She said if she had gotten 1.8 as the calculated dosage, for Resident #60 she would have given 1 unit. She said in nursing school, she was taught not to round up. She said she now knows she should have called the physician because the resident was not receiving the prescribed dose. During an interview on 01/11/24 at 4:28 p.m., the DON said she expected nurses to give insulin correctly. She said LVN Q should have called the physician to clarify the reading of 1.8 after using the calculated formula. She said she called the physician and got the order clarified on 01/09/24. She said LVN Q should have given Resident #60 2 units of Humalog. She said Resident #30 did not receive the correct amount of insulin and it could affect his overall well-being such as hyperglycemia (high blood sugar levels). During an interview on 01/11/24 at 4:37 p.m., the ADON said she expected the nurses to give the insulin correctly. She said if she received 1.8 after using the calculated formula, she would have given 2 units of insulin. She said failure to give the correct amount of insulin could lead to hyperglycemia. 2.Record review of Resident #30's face sheet, dated 01/16/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes mellites (diabetic), cerebral infarction (stroke), and essential hypertension (high blood pressure). Record review of Resident #30's quarterly MDS assessment, dated 11/21/23, indicated Resident #30 understood and was understood by others. Resident #30's BIMs score was 08, which indicated she was cognitively moderately impaired. The MDS indicated Resident #30 required total assistance with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and bathing, and supervision with eating. The MDS indicated she received insulin injections during the look-back period. Record review of Resident #30's physician's orders, dated 09/26/23, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 175 = units if blood sugar less than 60-80 and not symptomatic administer glucose gel and recheck in 1 hour; 176 - 500 = 999 inject per sliding scale fingerstick result -150/25=number of units, subcutaneously before meals and at bedtime for elevated glucose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 35 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #30's comprehensive care plan dated 01/31/23 indicated Resident #30 had Diabetes Mellitus placing her at risk for infection and skin issues. The intervention of the care plan indicated staff would give medication as ordered by the physician. During an observation on 01/11/24 at 10:48 a.m., LVN O took Resident #30's blood sugar. She received a reading of 352. LVN O went to the cart and drew up 8 units of Humalog as ordered. LVN O went into Resident #30's room and gave insulin to her left abdomen. LVN O did not wipe the end of the insulin pen off before connecting the cap, prime the insulin pen, or hold the insulin pen in the skin for 10 seconds to allow insulin to penetrate the skin therefore insulin was leaking out of the injection site. During an interview on 01/11/24 at 11:00 a.m., LVN O said she saw the insulin dripping out of Resident #30's injection site. She said she did not know why the insulin was leaking from Resident #30's injection site. LVN O said she was not aware she was supposed to hold the insulin pen at the injection site for 10 seconds. She said she was not aware she needed to clean the insulin pen before connecting the cap or prime the insulin pen before setting the dial to the required insulin dosage. LVN O said she had not had competency training on giving insulin with an insulin pen from this facility. She said since an unknown amount of the insulin dripped out of Resident #30's injection site it would not have had the same effect as giving the ordered amount. She said it could affect her blood sugar levels and lead to higher levels. LVN O said as the nurse she was responsible for ensuring the medication was given as ordered. During an interview on 01/11/24 at 3:44 p.m., the HR Supervisor looked through LVN O's file and said LVN O was hired on 10/23 and she did not have her skills competencies done. During an interview on 01/11/24 at 4:28 p.m., the DON said nurses needed to give insulin correctly. She said nursing staff were supposed to prime the insulin pen, set the dial to the ordered insulin, and make sure they held it at the injection site for 10 seconds to allow the medication to enter the subcutaneous (SQ) tissues. She said if insulin were not given correctly, it could cause them to have an adverse reaction such as hyper/hypoglycemia (high or low blood sugars). She said she could not recall if LVN Q or LVN O had been checked off on competency of insulin. During an interview on 01/11/24 at 4:37 p.m., ADON G said she expected the nurses to give the insulin correctly. She said nurses were supposed to set the amount on the insulin pen, put on the needle, clean the skin of the resident, press to the skin, and hold to the skin to allow insulin to penetrate the skin. She said she was not aware of any training on insulin pens as she was new to the ADON position. She said failure to deliver the ordered amount of insulin could affect the resident's blood sugars negatively. During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the nurses to give insulin as ordered by the physician. She said the DON was the overseer of nursing. She said she could see not giving insulin correctly could affect a resident's blood sugars. Record review of LVN Q's proficiency audit did reveal she had been checked off on SQ medication and glucometer use on 07/23/23. Record review of LVN O's competency did not reveal skill check-off on insulin administration. Record review of the facility's policy Physician Orders revised 2015, indicated The purpose was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 36 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0760 Level of Harm - Minimal harm or potential for actual harm monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner. 1. The Nurse will review the order and if needed contact the prescriber for any clarifications. Residents Affected - Few Record review of facility's policy on Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, Insulin Pen Use indicated Important information for the use of an insulin pen: o Always attach a new needle before each use. o Always perform the safety test before each injection. o Do not select a dose or press the injection button without a needle attached. o This pen is only for one resident's use Step 1. Check the insulin. A. Check the label on the pen to make sure you have the correct insulin. B. Take off the pen cap. Step 2. Attach the needle. Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks. A. Wipe the Rubber Seal with alcohol. Step 3. Perform a Safety test A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise towards the needle. D. Press the injection button in. Check if insulin comes out of the needle tip. Step 4. Select the dose. A. Check that the dose window shows 0 following the safety test. Step 5. Inject the dose. A. Insert the needle into the skin at a 90-degree angle. B. Deliver the dose by pressing the injection button all the way. The number in the dose window (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 37 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0760 will return to 0 as you inject. Level of Harm - Minimal harm or potential for actual harm C. Keep the injection button pressed all the way in and slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 38 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Hall C) The facility failed to ensure Resident #5 and Resident #52's Humalog (fast-acting insulin to control high blood sugar) insulin were taken off the cart after the opening date had expired on Hall C's nurse cart. The facility failed to ensure Resident # 17 Breo Ellipta inhaler (medication used to prevent and decrease symptoms of wheezing and trouble breathing), was dated when opened on Hall C's nurse cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion. Findings included: During an observation on 01/11/24 at 3:12 p.m., Hall C's nurse's cart revealed Resident #5's Humalog insulin was open and dated 12/09/23 and Resident #52's Humalog insulin pen was open and dated 11/17/23. Resident #17 Breo Ellipta inhaler manufacture label was 10/09/23 was opened but had no opened date. During an interview on 01/11/24 at 3:24 p.m., LVN D said she was not aware of how long insulin was good for. She said she went by the expiration date on the label. She said inhalers should be dated when opened to ensure they were getting an effective dose. LVN D said after the DON explained how long insulin was good for she was aware that Humalog insulin expired after 28 days therefore the insulin was not as effective as it should have been. During an interview on 01/11/24 at 4:28 p.m., the DON said she expected the nurses and medication aides to audit their carts at least weekly to check for expired medications. The DON said the pharmacy consultant was at the facility monthly and checked for expired medications as well. She said it was the ADON's responsibility to oversee that the carts were being audited. The DON said she expected the insulin to be removed from the cart after being opened for 28 days and the inhaler to be dated when opened. She said whoever opened the inhaler should have been responsible for dating it. The DON said the residents were at risk for medications to be ineffective. During an interview on 01/11/24 at 4:37 p.m., the ADON said she expected the medication aides and nurses to check their carts daily. She said the insulin should be dated when opened and discarded when expired. The ADON said the medication aide or nurse who opened the inhaler was responsible for dating it. The ADON said by not dating the inhalers when opened the staff would be unaware of when the inhalers expired. She said since the insulin had expired from the opening date, it could have been ineffective. During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the medication carts to not have any expired medications. The Administrator said she expected the insulin pens to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 39 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated when opened and discarded after expiration days. She said she expected the inhalers to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Administrator said the resident was at risk of receiving expired medication that could be ineffective. Record review of the facility's policy titled, Insulin Pen Use by Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, indicated, To take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time, it can be safely kept at room temperature. Do not use it after this time. Record review of the facility's policy titled, Recommended Medication Storage, Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened: (fluticasone) -Expires 6 weeks (50mcg strength) or 2 months (100 and 250 mcg strengths) after initial use. INSULINS (Vials, Cartridge, Pens) Humalog and Humalog Mix, Humalog Flex Pen 75/25 and 50/50 pens expire 10 days after opening. Novolog and Novolog Mix oExpires 28 days after initial use regardless of product storage (refrigerated or room temperature). Record review https://www.mybreo.com revealed, BREO ELLIPTA (fluticasone furoate and vilanterol) to store BREO in the unopened foil tray and only open when ready for use. Safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 40 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 20 residents (Resident #45) reviewed for laboratory services. Residents Affected - Few The facility failed to ensure Resident #45's CBC (complete blood count blood test that measures the number of different types of red blood cells, white blood cells, and platelets), CMP (comprehensive metabolic panel blood test that is used to get a broad assessment of your overall physical health it can check several body functions and processes), ESR (Erythrocyte Sedimentation Rate- blood test that can show if you have inflammation in your body), and CRP (C-reactive protein- blood test that measures the level of a protein called C-reactive protein in the blood which increases when there is inflammation in the body) were drawn on 01/01/2024 and 01/08/2024. This failure could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings included: Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #45 was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #45 did not exhibit rejection of care. The MDS assessment indicated Resident #45 required partial/moderate assistance with personal, oral, and toileting hygiene, and was dependent for showering/bathing. Record review of the Order Summary Report dated 01/09/2024 indicated Resident #45 had an order for the following labs CBC, CMP, ESR, CRP every Monday and fax to the infectious disease doctor with a start date of 11/09/2023 and no end date. Record review of the care plan last reviewed 01/09/2024 indicated Resident #45 had a potential risk for malnutrition to notify the physician for any negative findings, abnormal labs, or resident non-compliance. Resident #45's care plan indicated he had hypothyroidism (low thyroid) to obtain and monitor lab/diagnostic work as ordered. Resident #45's care plan indicated he had renal insufficiency related to acute kidney failure to monitor/document/report increased BUN and Creatinine (lab tests used to monitor kidney function and are included in the CMP). Record review of Resident #45's electronic health record did not indicate a CBC, CMP, ESR, or CRP for 01/01/2024 and 01/08/2024. During an interview on 01/09/2024 at 3:25 p.m., the DON said she did not have any labs for the month of January 2024 for Resident #45. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 41 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/11/2024 at 4:08 p.m., LVN D said the TAR instructed her to which labs needed to be drawn daily. LVN D said she was not aware Resident #45 required labs every Monday. LVN D said she was not aware because the order was not put on the TAR. LVN D said when a lab order was received and put in the electronic health record the nurse that put the order in should ensure it was going to the TAR. LVN D said the nurses were responsible for ensuring the labs were being drawn. LVN D said it was important to draw labs as ordered so they would know if there were any changes in the resident's condition. During an interview on 01/11/2024 at 4:38 p.m., ADON F said when lab orders were received it would be put in their lab book for the lab technician to know what lab to draw for the week ADON F said the nurses were responsible for filling out the lab sheet and putting it in the lab book. ADON F said the nurses should have been passing on in report that Resident #45 required weekly labs. ADON F said she was not aware Resident #45 required weekly labs to be drawn. ADON F said she was not sure who was responsible for overseeing that the labs were getting drawn as ordered. ADON F said it was important for Resident #45 to have labs drawn weekly per his orders because the doctor was monitoring how well the antibiotic was working. ADON F said not getting labs as ordered for Resident #45 could result in him being septic (infection in the blood stream) or having kidney complications. During an interview on 01/11/2024 at 5:10 p.m., the Administrator said the labs were overseen by ADON F and the DON. The Administrator said she expected for the labs to be drawn as ordered. The Administrator said it was important to draw labs as ordered for the health of the resident. During an interview on 01/11/2024 at 5:58 p.m., the DON said for a lab to be drawn the nurses would fill out a sheet and put it in the lab book and put in the order to draw the labs. The DON said ADON F was responsible for printing the labs and faxing them wherever they needed to go. The DON said ADON F was responsible for overseeing that labs were being drawn as ordered and follow-up was done as necessary. The DON was unable to provide an explanation as to why Resident #45's labs were not drawn. The DON said it was important for the labs to be drawn as ordered to ensure they were checking lab values. The DON said not drawing Resident #45's labs weekly, as ordered, could result in him becoming septic. Record review of the facility's policy titled, Physician's Orders, from the Medical Records Manual 2015, indicated, . 3. The nurse will enter the order into PCC (point click care an electronic health record system) for the resident and select either verbal or telephone, depending on how the nurse received the order. 4. If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed. 5. The receiving nurse will contact any other department or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 42 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. Residents Affected - Some The facility failed to provide food that was palatable at the lunch meal on 1/9/24. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the facility week 1 menu dated on 1/9/24, indicated the lunch meal items included Mississippi Pot roast, roasted baked potatoes halves, baby carrots, Honey kissed roll, sticky peach cake, and iced tea. During an interview on 1/8/24 at 10:14 a.m., Resident #14 stated the food was terrible and the food was better with the old company. During an interview on 1/8/24 at 10:49 a.m., Resident #42 stated food was terrible and he had hair in his spaghetti. During an interview on 1/8/24 at 10:50 a.m., Resident #1 stated the food was horrible. During an interview on 1/8/24 at 11:01 a.m., Resident #18 stated she did not like the food, the rice was dry, and the chicken dressing did not taste like dressings. Resident #18 stated the food tasted like it did not have salt in the food and no sugar was added in the sweet tea. During an interview on 1/8/24 at 11:07 a.m., Resident #12 stated sometimes the food was warm and sometimes was cold; food did not get seasoning with salt. During an interview on 1/8/24 at 3:12 p.m., Resident #46 stated she was on a mechanical soft diet and the food was no good. During observation and interview on 1/9/24 at 12:25 p.m., pot roast was bland tasting to surveyors and the Dietary Manager stated the pot roast needed more seasoning. The carrots were bland tasting to surveyors and the Dietary Manager stated the carrots were okay. The cubed potatoes were bland tasting to surveyors and the Dietary Manager stated the cubed potatoes needed more seasoning. During an attempted phone interview on 1/10/24 at 3:30 p.m., the Dietary Manager was called, and voice message left for a return phone call; call was not returned prior to exit on 1/11/24. During an attempted interview on 1/10/24 at 3:38 p.m., the Dietician was called, voice message was left for a return call; phone call not returned prior to exit on 1/11/24 During an interview on 1/10/24 at 3:42 p.m., the DON stated she did not oversea the kitchen. During an interview on 1/10/24 at 3:58 p.m., the Administrator stated she had been employed at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 43 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility for 6 years. The Administrator stated she did have food complaints from the residents about food seasoning and biscuits being too hard in the morning. The Administrator stated she talked to the Dietary Manager and made sure food was good for the residents that complained. The Administrator stated she had some residents at the facility that she cannot please. The Administrator stated she had tried everything she could think of to please those residents. The Administrator stated the facility would make a special meal of the resident's favorite food for those that complain about food. The Administrator stated she was not getting food stuck in her door with a note from the residents. The Administrator said she used to get food struck in her underneath door with a complaint note from the residents, but she had not received any food complaint notes from residents recently. The Administrator stated she did get test trays once a month from the kitchen and if she got a lot of food complaints that she would get test trays weekly. The Administrator stated she did expect food to be palliative, attractive and at the right temperature. The Administrator stated it was important to ensure the food was palatable, attractive and at the right temperature because, Food was all the residents had to live for and food prevents the resident from losing weight; Residents not eating the food could cause skin breakdown because food give the residents joy. During an interview on 1/11/24 at 8:31 a.m., CNA C stated she was hired in September of 2023. CNA C stated she had been a CNA for 19 years. CNA C stated she had taken food everyday back to the kitchen to be warmed up because by the time the food gets to the end of the hall the food was cold. Record Review of the facility Resident Rights policy dated 2003, indicated (5) Each resident is encouraged and assisted, throughout the period of stay, to exercise his/her rights as a resident and as a citizen, and to this end, may voice grievances and recommend changes in policies and services to facility staff and / or to outside representatives of his/her choice, free from restraint, interference, coercion, discrimination or reprisal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 44 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 4 residents (Resident #27) reviewed for preference. The facility failed to honor Resident #27's preference for no toast. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #27 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, mild, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with other behaviors) and dysphagia, oral phase (difficulty swallowing). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #27 was understood and understood others. The MDS assessment indicated Resident #27 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #27 required setup or clean-up assistance for eating. The MDS assessment indicated Resident #27 received a mechanically altered diet. Record review of the care plan last reviewed 01/02/2024 indicated Resident #27 had potential nutritional problems related to a therapeutic regular mechanical soft diet to observe/document/report as needed any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. Resident #27's care plan indicated she was edentulous (toothless) to give diet as ordered and consult with dietician and change if any chewing/swallowing problems were noted. Record review of an Order Summary Report dated 01/11/2024 indicated Resident #27 had an order for regular diet mechanical soft texture with an order start date of 12/27/2022. During an observation and interview on 01/08/2024 at 10:51 a.m., Resident #27 said her only complaint was that every morning she had been getting toast and she had told the staff she wanted regular bread because she could not chew the toast. Resident #27 showed surveyor she had no teeth and repeated she was unable to chew the toast because she had no teeth. During an observation, interview, and record review on 01/10/2024 at 7:38 a.m., Resident #27 was eating in her room. Resident #27 said they gave her toast again and she was not able to chew it. Resident #27 had 2 half slices of toast on her tray. Resident #27's breakfast meal ticket dated 01/10/2024 indicated Special Notes: Prefers regular bread no toast all soft foods no fried. During an interview on 01/10/2023 at 7:43 a.m., CNA B said she gave Resident #27 her breakfast tray and helped her set it up. CNA B said when passing out trays she should check the meal ticket to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 45 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm ensure the residents were receiving their food according to what was on the meal ticket. CNA B said she did not check Resident #27's meal ticket when she gave her breakfast tray. CNA B said she did not check it because Resident #27 received the same meal every day. CNA B said she did not know Resident #27 was not supposed to receive toast on her tray. CNA B said it was important for the residents to receive meals according to the ticket to ensure they could eat the food and so they would not lose weight. Residents Affected - Few During an interview on 01/10/2024 at 7:47 AM, [NAME] A said she did not look at the resident's meal tickets when serving because she knew what all the residents were supposed to get. [NAME] A said after she served the food, the dietary aide checked the meals with the tickets. [NAME] A said Resident #27 requested to receive toast on her tray. Surveyor informed [NAME] A Resident #27 requested regular bread. [NAME] A and Surveyor went to Resident #27 to give her the regular bread. Resident #27 told [NAME] A she could not chew the toast because she had no teeth. [NAME] A said she did not know Resident #27 did not want toast because she was not the one who took the residents preferences. [NAME] A said the Dietary Manager took the resident preferences. [NAME] A said it was important for the residents to receive meals according to their tickets so they would eat and not lose weight. During an interview on 01/11/2023 at 5:19 p.m., the Administrator said she expected for the meal tickets and for food preferences to be followed. The Administrator said the staff should be checking the meal tickets when serving. The Administrator said the Dietary Manager was responsible for ensuring the residents were served according to their meal tickets and preferences. The Administrator said it was important for their food preferences and meal tickets to be followed because it was their right and she did not want them to have weight loss and for the overall health of the resident. During an attempted interview on 01/11/2024 at 6:45 p.m., the Dietary Manager did not answer the phone. Record review of the facility's policy from the Dietary Services Policy & Procedure Manual 2012, revised 2016, titled, Menu approval and honoring resident special requests, and food brought to the facility from unapproved sources, indicated, .Every attempt will be made to honor resident food preferences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 46 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to seal, label and date refrigerator and freezer food items. 2) Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. 3) Dietary Staff failed to test the dishwasher to ensure dishwasher chemical levels was at 50 PPM or above. 4) Dietary Staff failed to ensure the chemical strips for the 3 compartment sink were not expired. 5) Dietary Staff failed to ensure the ice machine was cleaned. 6) Dietary Staff failed to clean the juice nozzle. 7) Dietary Staff failed to clean the fryer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During observation of Refrigerator #1 on 1/8/24 at 10:00 a.m., -(1) 2 quart container of Tomato sauce prepared 12/28/23, expired on 1/4/24. -(1) 1/2 quart container of Ketchup prepared 12/28/23 expired on 1/4/24. - (1) 5 pound bag of lettuce best by date of 1/4/24, bag not sealed and no open date. -(1) 5 pound bag of lettuce unopened had a best by date of 1/4/24 and a received date of 12/23/23. -(1) ½ quart of container of Italian dressing opened on 12/31/23, received on 12/23/23 and expired on 1/7/24. During observation of Freezer#1 on 1/8/24 at 10:00a.m., -(1) 6 pound container of sliced strawberries with sugar received on 12/27/23, had no open date and no expiration date. During observation and interview on 1/8/24 at 10:02 a.m., the ice machine was dirty with red substance in the inside. [NAME] A stated she did not know why the ice machine was dirty. [NAME] A stated housekeeping was responsible for cleaning the ice machine. [NAME] A stated she did not know how often the ice machine was supposed to be cleaned. [NAME] A stated she agreed the ice machine was dirty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 47 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 and needed to be cleaned. Level of Harm - Minimal harm or potential for actual harm During observation on 1/8/24 at 10:08 a.m., -(1) 24 ounce of Rotisserie chicken seasoning had no open date, no expiration date and no received date. Residents Affected - Many -(1) 12 ounce of Poultry seasoning, had no open date, no expiration date and no received date. -(1) 14 ounce of Ground cumin had no open date and no received date, expired on 11/29/25. -(1) 18 ounce of Ground cinnamon had no open date, no received date, expired on 1/21/26. -(1) 16 ounce of Ground Gloves had no open date, received on 1/18/19, and no expiration date. -(1) 12.5 Ground Ginger had no open date, received on 7/22/22, and no expiration date. -(1) 16 ounce of Ground Nut [NAME] had no open date, no received date and expired on 2/11/25. -(1) 5 pound black pepper had no open date, no received date and no expiration date. During observation and interview on 1/8/24 at 10:17 a.m., the juice machine nasal nozzle had a red gooey substance inside and outside the nozzle. [NAME] A stated the juice machine nasal nozzle was dirty and needed to be cleaned. [NAME] A stated the juice machine was to be cleaned every day by the dietary staff. [NAME] A stated the juice did not appear to be cleaned the day prior by the dietary staff. During observation and interview on 1/8/24 at 10:18 a.m., the fryer was not cleaned. The fryer was black in color with brown crumbs floating at the top. [NAME] A stated the fryer was last cleaned on 12/28/23. [NAME] A stated the fryer was supposed to have been cleaned on 1/4/24. [NAME] A stated she did not know why the fryer was not cleaned on 1/4/24. During observation and interview on 1/8/23 at 10:15 a.m., the 3 compartments sink chemical test strips were expired. The chemical test strips expired June 1, 2023. [NAME] A stated she only tested the 3rd sink water temperature with a thermometer and she never tested the chemical level using the test strips for the 3-compartment sink. During observation and interview on 1/8/24 at 10:25 a.m., [NAME] M stated she did not know how to test the chemical levels in the dish washer. [NAME] M stated she was not aware that she should be testing the chemical levels for the dish washer. [NAME] M did not know how often she was supposed to test the chemicals in the dishwasher. [NAME] M stated she did not remember if she completed in-services on how to operate the dishwasher. [NAME] M stated she was not the dishwasher person. [NAME] M stated she was just filling in for the dishwasher since the dishwasher person was off work. During observation of [NAME] M, the dishwasher tested at 10 ppm (parts per million). [NAME] M did not know that the chemical levels were to be at 50 ppm or above. During observation and interview on 1/8/24 at 12:00 p.m., the dietary staff served the lunch meal on paper plates. [NAME] A stated she informed the Administrator that the dishwasher chemical levels were low. [NAME] A stated the Administrator told her to serve the lunch meal on 1/8/23 on paper until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 48 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 the dishwasher was fixed. Level of Harm - Minimal harm or potential for actual harm During an attempted phone interview on 1/10/24 at 3:30 p.m., the Dietary Manager was called, and voice message left for a return phone call; call was not returned prior to exit on 1/11/24. Residents Affected - Many During an attempted phone interview on 1/10/24 at 3:38 p.m., the Dietician was called, voice message was left for a return call; phone call not returned prior to exit on 1/11/24. During an interview on 1/10/24 at 3:42 p.m., the DON stated she did not oversea the kitchen. During an interview on 1/10/24 at 3:48 p.m., the Administrator stated she had been employed at the facility for 6 years. The Administrator stated the dietary manager was over the kitchen and she oversaw the Dietary Manager. The Administrator stated Maintenance was responsible for cleaning the ice machine once a month. The Administrator stated she was not aware of the expired test strips for the 3 compartment sink. The Administrator stated she was not aware of staff not testing the chemical levels in the 3rd compartment dish sink. The Administrator stated she was not aware of the red substance found in the ice machine. The Administrator stated she was not aware of the dish washer chemicals were empty. The Administrator stated she was not aware of the dietary staff not knowing how to operate the dishwasher because all dietary staff should have been aware of how to operate the dishwasher. The Administrator stated she was not aware of the Coffee tempting at 136 degrees and not 140 degrees. The Administrator stated the cook should have tempted the coffee prior to the coffee going out to the residents. The Administrator stated she believed the coffee sat for a while. The Administrator stated she tried to be in the kitchen daily. The Administrator stated she went through the kitchen and threw away a lot of seasoning prior to survey and she did not know why the seasonings got missed. The Administrator stated she walked through the kitchen 2-3 times a week. The Administrator stated on 1/8/23 the dietary staff completed in-services on the dishwasher temps and how to operate the dishwasher. The Administrator stated she expected staff to ensure they were following policies and procedures of the facility kitchen policy. The administrator stated it was important for dietary staff to follow facility policies and procedures to protect residents and to deliver good care. Record Review of the facility Food safety policy dated 2012, indicated (2) food is to be wrapped or sealed and coved in clean container. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 49 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 staff (CNA B, CNA C, Treatment Nurse) and 2 of 4 Halls (Hall D and Hall A) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while providing wound care to Resident #44. 2. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #165. 3. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident # 60 4. The facility failed to ensure the linen carts on Hall D and Hall A were covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation of wound care on Resident #44 with the Treatment Nurse on 01/08/2024 beginning at 2:53 p.m., the Treatment Nurse removed Resident #44's dirty dressing and disposed of it. The Treatment Nurse then grabbed the wound cleanser, cleansed the wound, and patted it dry with gauze. The Treatment Nurse did not change gloves or perform hand hygiene prior to cleaning the wound and patting it dry. The Treatment Nurse then changed gloves and performed hand hygiene and patted the wound dry again with gauze. The Treatment Nurse then applied collagen fibers, the oil emulsion dressing, black foam and completed the wound care. During an interview on 01/08/24 at 4:20 p.m., the Treatment Nurse, also the Infection Control Preventionist, said when performing wound care, she should perform hand hygiene put on gloves take off the old dressing, get the wound cleanser, clean the wound, throw it away, then take gloves off and hand sanitize. The Treatment Nurse said then she should put new gloves on and continue the wound care. The Treatment Nurse said she had not changed her gloves after removing the dirty dressing and before cleaning the wound because the wound was a dirty wound, but she should have because she touched the bottle of the wound cleanser with her dirty gloves. The Treatment Nurse said it was important not to touch clean items with her dirty gloves because it could result in the spread of germs and for infection control. The Treatment Nurse said it was important to change gloves and perform hand hygiene during wound care to ensure the wound stayed clean. The Treatment Nurse said the last time she had a competency check off for wound care was 2 years ago. 2. During an observation of incontinent care with CNA C and CNA B on 01/10/2024 beginning at 9:24 AM, CNA C put on gloves, unfastened Resident #165's soiled brief and wiped her front peri area. CNA C then turned Resident #165 on her side with the assistance of CNA B. CNA C said Resident #165's wound care dressing was also soiled with stool, and she needed the wound care nurse to change it. CNA C using the dirty gloves laid Resident #165 on her back and covered her up. CNA C then removed her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 50 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gloves and left the room. CNA C did not perform hand hygiene after removing her gloves. The Treatment Nurse came into the room and removed the soiled dressing, dirty brief, and put a clean brief underneath her. CNA C put on gloves and wiped Resident #165's buttocks, then stepped aside for the Treatment Nurse to do the wound care. CNA C did not remove her dirty gloves and stood at the foot of the bed grabbing on to Resident #165's foot of the bed with her dirty gloves. The Treatment Nurse provided wound care, and then CNA C using her dirty gloves straightened up Resident #165's clean brief and fastened it. CNA C repositioned Resident #165 in the bed, covered her up and touched her pillows, still using the dirty gloves. After this, CNA C removed her gloves and performed hand hygiene. During an interview on 01/10/2024 at 9:55 a.m., CNA C said hand hygiene should be performed before and after providing incontinent care. CNA C said gloves should only be changed when visibly soiled. CNA C said hand hygiene should be performed after glove removal. CNA C said she did not change her gloves while providing incontinent care because they were not visibly soiled. CNA C said she did not realize she had not performed hand hygiene after removing her gloves. CNA C said it was important to perform hand hygiene and change gloves for infection control. CNA C said it was important to provide proper incontinent care to keep urinary tract infections down. During an interview on 01/11/2024 at 4:14 p.m., LVN D said the charge nurses were responsible for ensuring the CNAs were providing proper incontinent care. LVN D said the CNAs were trained so she hoped they were doing correctly. LVN D said she checked after the CNAs performed incontinent care to make sure they were doing it properly, and she had not noticed any issues. LVN D said she would not know if the CNAs were changing gloves and performing hand hygiene appropriately during incontinent care because she was checking after. LVN D said she had not noticed any issues with incontinent care. LVN D said if hand hygiene and glove changes were not done adequately during incontinent care this could result in the residents getting urinary tract infections. During an interview on 01/11/2024 at 4:43 p.m., ADON F said she did not know if anybody was overseeing that the CNAs were providing proper incontinent care. ADON F said the DON and herself had done an in-service on incontinent care maybe 4-5 months ago. ADON F said she was not doing random checks to ensure the CNAs were providing proper incontinent care. ADON F said hand hygiene should be performed before and after providing care, and if gloves were contaminated gloves should be removed and hand hygiene performed. ADON F said hand hygiene should be performed in between glove changes. ADON F said gloves should be changed when putting on a clean brief, and if they were removing a dirty brief they should remove the dirty gloves, perform hand hygiene, and put on new gloves. ADON F said gloves should be changed when in contact with urine or feces, even if the gloves were not visibly soiled. ADON F said it was important to change gloves and perform hand hygiene when providing incontinent care, so the residents did not end up with urinary tract infections. ADON F said not performing proper hand hygiene and glove changes could result in cross contamination and skin breakdown. During an interview on 01/11/2024 at 4:52 p.m., the Infection Control Preventionist said nurse management was responsible for ensuring the CNAs were providing proper incontinent care. The Infection Control Preventionist said they were monitoring the CNAs by having them provide care on the dummy every 6 months. The Infection Control Preventionist said they had not been monitoring the CNAs providing incontinent care on the floor. The Infection Control Preventionist said the CNAs should wash their hands before and after incontinent care, if their gloves were visibly soiled, they should change gloves and perform hand hygiene. The Infection Control Preventionist said the CNAs should perform hand hygiene in between glove changes and they should change gloves and perform hand hygiene after removing a dirty brief. The Infection Control Preventionist said if the CNAs were cleaning urine or poop, they should change their gloves before touching anything clean. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 51 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Infection Control Preventionist said it was important for the CNAs to change gloves and perform hand hygiene appropriately when providing incontinent care, so they did not have increased infections, to decrease the spread of disease and not pass bacteria throughout the facility. During an interview on 01/11/2024 at 5:15 p.m., the Administrator said she expected wound care to be provided according to infection control practices, for glove changes and hand hygiene to be performed adequately. The Administrator said the DON was responsible for overseeing the Treatment Nurse. The Administrator said she expected for incontinent care to be done according to the skill as far as hand hygiene and infection control policies. The Administrator said the DON was responsible for monitoring that incontinent care was performed adequately. The Administrator said it was important for wound care and incontinent care to be provided properly for the health of the residents. During an interview on 01/11/2024 at 6:05 p.m., the DON said she was responsible for ensuring the Treatment Nurse performed wound care properly. The DON said she monitored the wound care by going three times a week with the Treatment Nurse to perform wound care. The DON said she had not noticed any issues with the wound care provided by the Treatment Nurse. The DON said hand hygiene should be performed before and after providing wound care. The DON said gloves should be changed and hand hygiene performed after removing the soiled dressing. The DON said it was important to change gloves and perform hand hygiene while providing wound care for infection control. The DON said the nurse managers were responsible for ensuring incontinent care was provided properly. The DON said while providing incontinent care hand hygiene should be performed before and after and in between glove changes. The DON said gloves should be changed if they were visibly dirty and hand hygiene performed. The DON said if the CNA cleaned stool or urine, they would need to change their gloves and perform hand hygiene. The DON said she observed the CNAs providing incontinent care about four times a day, and she had not noticed any issues. The DON said it was important to properly change gloves and perform hand hygiene while providing incontinent care for infection control. 3. During an observation on 01/10/24 at 3:51 p.m., CNA B and CNA R were providing incontinent care to Resident #60. He had a Foley catheter. They explained what they were going to do, washed their hands, and applied gloves. CNA B cleaned the Foley catheter tubing and changed her gloves but did not do hand hygiene, she then cleaned his peri-area, reached into her pocket, took out a pair of gloves, and changed her gloves but did not perform hand hygiene. She then turned him on his side and wiped his buttocks back to front and front to back in several areas using the same wipe and then changed her gloves without hand hygiene. She pulled up his covers, made him comfortable, washed her hands, and exited the room. During an interview on 01/10/24 at 4:17 p.m., CNA B said she did an excellent job on incontinent care. After being questioned by the surveyor CNA B said she did not realize she took gloves out of her pocket during care or that she used 1 wipe in several different areas on his buttock. She said she should have performed hand hygiene between dirty to clean, used 1 wipe and then discarded, and wiped front to back only to prevent cross-contamination. She said she knew all of this but was nervous and forgot. During an interview on 01/11/24 at 11:19 a.m., ADON G said she expected proper cleaning during incontinent care. She said she expected them to change their gloves if they were soiled and when going from dirty to clean. She said staff should do this to prevent infection and cross-contamination. During an interview on 01/11/24 at 3:44 p.m., the HR supervisor said CNA B should have had her competency training on 04/23 but it was missed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 52 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/11/24 at 4:28 p.m., the DON said she expected staff to perform incontinent care correctly. The DON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. She said she did not expect staff to get gloves out of their pockets while providing care. She said they should have incontinence care checkoffs on hire, yearly, and as needed. The DON said not performing incontinent care correctly could lead to infection control issues. During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected staff to perform incontinent care properly. The Administrator said she expected the CNAs to perform hand hygiene before and after incontinent care and change their gloves after going from dirty to clean. She said the nurse managers/DON were responsible for ensuring staff performed incontinent care and hand hygiene correctly. The Administrator said if improper incontinent care or hand hygiene were performed it could lead to infection control and contamination issues. She said they had been using online training as part of their training on incontinent care and handwashing but they would start a skills fair. 4. During an observation on 01/08/2024 at 10:09 a.m., CNA B collected clean linens from the Hall A linen care, placed them in a bag, and went into a resident's room. CNA B did not cover the linen cart prior to going into the resident's room. During an observation on 01/10/2024 at 7:26 a.m., the clean linen cart on Hall D was not covered. During an interview on 01/11/2024 at 8:41 a.m., CNA B said the linen carts should be covered. CNA B said it was the staff's responsibility to ensure they always remained covered. CNA B said it was important for the linen carts to be covered for infection control. CNA B said sometimes she forgot to cover the linen carts because she was in a hurry. During an interview on 01/11/2024 at 7:50 p.m., the Administrator said the linen carts should always be covered. The Administrators said the CNAs should make sure the linen carts were covered, and the staff when doing rounds should also make sure they were covered. The Administrator said the linen carts should be covered for infection control purposes. During an interview on 01/11/2024 at 7:51 p.m., the DON said the linen carts should always be covered. The DON said all the staff were responsible for ensuring the linen carts were covered. The DON said it was important for the linen carts to be covered for infection control. Record review of the facility's policy titled, Perineal Care, with an effective date of 05/11/2022, indicated, 10) Perform hand hygiene 11) Don gloves and all other PPE per standard precautions . remove an adequate number of pre-moistened cleansing wipes . Gently perform perineal care . Gently perform care to the buttocks and anal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding . 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Record review of the facility's policy titled, Linens, from the Infection Control Policy and Procedure Manual 2018, indicated, . 12. All clean linen will be stored in a secured area. The linen cart will be covered . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 53 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy titled, Handwashing/Hand Hygiene, indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. Record review of the facility's policy titled, Infection Control Policy & Procedure Manual, dated 2019, indicated, Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Preventing Spread of Infection:(3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Linens: Personnel will handle, store, process, and transport linens to prevent the spread of infection. Event ID: Facility ID: 455532 If continuation sheet Page 54 of 55 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 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for existing staff, consistent with their expected roles for 2 of 21 employees (Dietician and LVN P) reviewed for required annual trainings. Residents Affected - Few The facility failed to ensure the Dietician and LVN P received required restraint and HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no required annual restraint training completed for the following staff: *Dietician hired on 11/01/2022 Record review of the employee files revealed there was no required annual HIV training completed for the following staff: *LVN P hired on 12/01/2022 During an interview on 01/11/2024 at 12:09 PM, the Human Resource Specialist stated she expected all staff to have the required trainings. The Human Resource Specialist stated by not having the annual required training on HIV and restraints, the staff would not have the proper education to properly care for those residents. The Human Resource Specialist stated she was responsible for ensuring the required trainings were completed along with the nurse managers. During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated she expected the staff to receive HIV and restraint training upon hire and annually on their anniversary date. The Administrator stated it was the Human Resource Specialist's responsibility for ensuring training was done. The Administrator stated the training was important because it updated the staff on how to protect themselves and others on the spread of HIV. The Administrator stated restraint training was important so staff would be able identify if someone had a restraint or not to restraint a resident. The Administrator stated by not having the proper training the staff would not be able to properly care for those residents. The Administrator stated she would use a check list to monitor annual training assessments. A request for the facility policy regarding Required Training was submitted to the Regional Nurse Consultant on 1/11/2024 at 6:17p.m. A policy was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455532 If continuation sheet Page 55 of 55