Health inspection·October 5, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few went to therapy or when staff told her a wheelchair needed to be fixed. The PTA stated she was also informed of wheelchairs that needed to be repaired during their routine staff meetings. The PTA stated Resident #7 was recently discharged from therapy and that was why she did not notice his chair. During interview on 10/5/22 at 1:35 p.m., the DON stated therapy was responsible for changing wheelchair arms, even when residents did not participate in therapy, they are responsible because they had a restorative program in place. The DON stated she expected staff to report wheelchair arms that needed to be replaced. The DON stated the facility had stop and watch forms available that anyone could out for repairs such as the wheelchair arms. The DON stated they did not have a process in place or keep a log of when therapy was notified of repairs, staff just informed therapy that repairs needed to be done. During an interview on 10/5/22 at 3:02 p.m. with the Corporate Adm, The Corporate Adm stated she expected torn and ripped wheelchair arms to be reported and fixed. She stated the Maintenance director was responsible for making sure wheelchair repairs were completed. During an interview on 10/5/22 at 2:37 p.m. a policy for environment and wheelchair safety was requested from the DON but was not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 2 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #50) reviewed for residents reviewed for PASRR. Residents Affected - Few The facility failed to ensure Resident #50's PASRR Level 1 screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: Record review of Resident #50's physician order summary report, dated 10/05/2022, indicated Resident #50 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included bipolar disorder (a mental illness characterized by periods of depression and periods of abnormally elevated happiness lasting days to weeks). Record review of Resident #50's admission MDS, dated [DATE], revealed Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #50 understood others and made herself understood. The assessment indicated Resident #50 was cognitively intact with a BIMS of 15. Record review of Resident #50's care plan, dated 09/22/2022, did not address Resident #50's mental illness. Record review of Resident #50's PASRR Level 1 Screening, completed on 8/17/2022, indicated, in section C0100, no evidence of this individual having mental illness. During an interview on 10/05/2022 at 9:44 a.m., the SW stated she was responsible for all the PASRR Level 1 Screenings and for coordinating the appropriate PASRR services. The SW stated she only knew how to submit a Level 1 Screening on new admits. The SW stated she informed the administrator on 8/23/2022 that she needed additional training with PASRR's. The SW stated in section C0100 of Resident #50's Level 1 Screening should had been marked yes because she had a diagnosis of mental illness. The SW stated not completing the PASRR accurately could result in residents not having the services that were offered. During an interview on 10/05/2022 at 9:58 p.m., the Regional Reimbursement Consultant stated the SW was responsible for all the PASRR Level 1 Screenings and for coordinating the appropriate PASRR services. The Regional Reimbursement Consultant stated she was trained twice by her on how to complete and certify the PASRR evaluation. The Regional Reimbursement Consultant stated when Resident #50 admitted to the facility the IDT team which consisted of the DON, MDS Coordinator, ADON, SW and the administrator should have reviewed her medical records to identify any diagnosis positive PASRR issues. The Regional Reimbursement Consultant stated after reviewing Resident #50's records and saw she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 3 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a diagnosis which included bipolar disorder a new PASRR Level 1 Screening should have been submitted. The Regional Reimbursement Consultant stated not completing the PASRR accurately could affect their ADL function. During an interview on 10/05/2022 at 3:18 p.m., the DON stated the SW was responsible for ensuring Resident #50's PASRR Level 1 Screening was completed prior to admission and updated if necessary. The DON stated the administrator was responsible for monitoring appropriate PASRR services. The DON stated not completing the PASRR accurately could result in residents missing out on services that could be provided to them. During an interview on 10/04/2022 at 9:15 a.m., the Corporate Administrator stated she was standing in for the Administrator and Interim Administrator who was out on leave. The Corporate Administrator stated she had only been in the building since 10/04/2022. Record review of the facility's Preadmission and Screening Resident Review (PASRR) policy, revised 06/03/2020, indicated, if the resident has a qualifying MI diagnosis and the NF feels the resident should be positive, they should talk to the referring entity and ask them to correct the PL1 or complete the 1012 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 4 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 18 residents (Residents #10 and #51) reviewed for comprehensive care plans. 1.The facility failed to ensure Resident #10's care plan addressed wounds to her right calf and left breast. 2. The facility failed to ensure Resident #51's care plan addressed wounds to his right buttocks and left hip. These failures could place residents at risk for unmet care needs due to lack of implementation and following orders. Findings include: 1. Record review of the physician order summary report, dated 10/05/2022, indicated Resident #10 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney failure), essential hypertension (high blood pressure), and chronic venous hypertension (increased pressure inside veins) with ulcer and inflammation of right lower extremity. Record review of the quarterly MDS, dated [DATE], indicated Resident #10 usually understood others and made herself understood. The assessment indicated Resident #10 was moderately cognitively impaired with a BIMS score of 9. The assessment indicated Resident #10 required supervision with bed mobility: limited assistance with transfers, dressing, toileting, personal hygiene, and extensive assistance with bathing. Record review of the care plan reflected a focus area, with a revision date of 10/06/2021, that indicated Resident #10 had the potential for the development of a pressure ulcer and venous ulcers. The care plan interventions included, repositioned frequently or more often as needed or requested, weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity, and report new conditions to the physician. The care plan did not reflect actual wounds or specific wound interventions or treatments for Resident #10. 2. Record review of the physician order summary report, dated 10/05/2022, indicated Resident #51 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities, essential hypertension (high blood pressure), and diabetes mellitus due to underlying condition with diabetic neuropathy (complication of diabetes mellitus (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Further record review of the physician's order summary report dated 10/05/2022, indicated Resident #51 had an order for wound care to the right buttock and left hip with a start date 09/29/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 5 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 Record review of the quarterly MDS, dated [DATE], indicated Resident #51 understood others and made himself understood. The assessment indicated Resident #51 was severely cognitively impaired with a BIMS score of 3. The assessment indicated Resident #51 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, personal hygiene: and total dependence with bathing. The MDS indicated Resident #51 did not have any wounds, ulcers, or skin problems. Residents Affected - Few Record review of the care plan reflected a focus area, with a revision date of 06/16/2022, that indicated Resident #51 had the potential for the development of a pressure ulcer. The care plan did not reflect actual wounds or specific wound interventions or treatments for Resident #51. During an interview on 10/04/2022 at 9:38 a.m., RN P stated she was the treatment nurse and had only been in the facility for two weeks. RN P stated she was not told by the DON what all her duties were. RN P was not aware she was responsible for care planning wounds and interventions for Residents #10 and #51. RN P said this failure could potentially put Resident #10 and #51 at risk for infection control and adverse reaction to wound care dressing. During an interview on 10/05/2022 at 1:39 p.m., the MDS Coordinator stated the treatment nurse was responsible for care planning wounds and acute conditions. During an interview on 10/05/2022 at 3:18 p.m., the DON stated the treatment nurse was responsible for updating the care plans to reflect wounds and interventions. The DON stated she expected Residents #10 and #51 care plans to be updated when the wounds were identified. The DON stated there was not a system in place to ensure care plans were updated to reflect wounds and interventions, due to her previous treatment nurse had been on medical leave. The DON stated the treatment nurse she had now had only been at the facility for two weeks. The DON stated a potential negative outcome of care plans not been updated to reflect wounds was worsening of the wounds and infection control. Record review of the facility's Care Plans and CAA policy, revised 05/06/2021, indicated, the purpose of this guide was to ensure that an interdisciplinary approach is utilized in addressing the care area triggers that were generated by the completion of the MDS in order to effectivity address the care area assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident . the IDT will review the care plans, annually, quarterly and as needed to ensure all goals and approaches are appropriate . as acute problems or changes to intervention or goals are identified, an appropriate care will be developed or modified by a nursing staff member . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 6 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, which included comprehensive and quarterly review assessments for 1 of 18 residents (Resident #10) reviewed for care plan timing and revision. The facility failed to revise Resident #10's care plan to reflect her code status. This failure could place residents at risk of having resident's end of life wishes dishonored. Findings include: Record review of the physician order summary report, dated [DATE], indicated Resident #10 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney failure), essential hypertension (high blood pressure), and chronic venous hypertension (increased pressure inside veins) with ulcer and inflammation of right lower extremity. The order summary report included a status of DNR. Record review of the quarterly MDS, dated [DATE], indicated Resident #10 usually understood others and made herself understood. The assessment indicated Resident #10 was moderately cognitively impaired with a BIMS score of 9. The assessment indicated Resident #10 required supervision with bed mobility: limited assistance with transfers, dressing, toileting, personal hygiene, and extensive assistance with bathing. Record review of the care plan dated [DATE] indicated Resident #10 had a physician order which included a status of full code. The care plan interventions included: ensure full code order on chart, ensure staff was aware of code status through designated systems and monitor for changes in resident's code status, update as needed, review at least quarterly, begin CPR after absence of vital signs, call 911, and notify physician and notify family/responsible party. Record review of the OOH-DNR order revealed Resident #10 signed the order on [DATE]. During an interview on [DATE] at 1:39 p.m., the MDS Coordinator stated her, and the SW were responsible for updating residents code status on the care plans. When asked specifically about Resident #10's code status not been updated, the MDS Coordinator stated she must have overlooked it by accident. The MDS Coordinator stated a potential negative outcome of an inaccurate code status would be her wishes not been honored. During an interview on [DATE] at 2:08 p.m., the SW stated she was responsible for updating the code status on the care plans. The SW stated she completed an audit on the care plans on [DATE] to ensure all code statuses were updated and correct. When asked specifically about Resident #10's code status not been updated, the SW stated she must have missed her code status changed to DNR. The SW stated the DNR should have been updated to reflect the DNR code status on [DATE]. The SW stated a potential negative outcome of an inaccurate code status would be her wishes not been honored. During an interview on [DATE] at 3:18 p.m., the DON stated the SW was responsible for updating the code status on the care plan. The DON stated she was not aware Resident #10 had changed over to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 7 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DNR. The DON stated the SW worked directly under the Administrator. The DON stated a potential negative outcome of an inaccurate code status would be her wishes not been honored. Record review of the facility's Advance Care Plan Guidelines policy, revised [DATE], indicated, . provide the opportunity for residents, and surrogates families to understand and consider wishes concerning the future health and care of the resident . the values and needs of a resident should be known and respected by those providing healthcare to that individual . the social worker will follow up and implement the resident/resident representative advanced care plan wishes. Record review of the facility's Care Plans and CAA policy, revised [DATE], indicated, the purpose of this guide was to ensure that an interdisciplinary approach is utilized in addressing the care area triggers that were generated by the completion of the MDS in order to effectivity address the care area assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident . the IDT will review the care plans, annually, quarterly and as needed to ensure all goals and approaches are appropriate . as acute problems or changes to intervention or goals are identified, an appropriate care will be developed pr modified by a nursing staff member . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 8 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 26 residents reviewed for ADL care. (Residents #53 and Resident #59). Residents Affected - Few 1.The facility failed to ensure Resident #53's fingernails were cut. 2.The facility failed to ensure Resident #59 was routinely showered. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings Include: 1.Record Review of Resident #53's face sheet (no date) indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (constriction of airway), high blood pressure and depression. Record Review of Resident #53's care plan dated 5/13/2020 indicated the focus was on ADL's. The goal included, the resident would remain a sense of dignity by being clean, dry, odor free and well groomed. Interventions indicated extensive assist x1 for personal hygiene and total assist x1 for bathing. Record Review of the quarterly MDS dated [DATE] indicated Resident #53 had a BIMS score of 7, which indicated severely impaired cognition. Section G of the MDS indicated Resident # 53 required extensive assistance with personal hygiene and total dependence with bathing. Record Review of Resident #53's shower sheets dated 9/19/22-10/4/22 indicated her last bath was on 9/30/22. During an observation and interview on 10/05/22 at 1:13 PM, Resident #53 stated she had not received a bath since 9/30/22 and her bath days were on Monday, Wednesday, and Friday. Resident #53 stated she asked for one multiple times and did not get one. Resident #53 could not recall the name of who she reported it to. Resident #53 stated not getting her showers irritated her. Resident #53 was observed to have long nails approximately 2-3 cm long and both hands were contracted. Resident #53 stated he nails were too long and she wanted them cut because they dug into her hands. Resident #53 had no visible marks on her hands but stated her hands hurt when the nails dug into them. Resident #53 stated she asked the aid for help last week with cutting her nails but she did not know which one. During an interview on 10/5/22 at 1:27 p.m., CNA A stated Resident #53's nails should be trimmed on her shower days and resident was on the 2-10 shift per her request. CNA stated if Resident #53's nails were not cut they could dig into her skin. During an interview on 10/5/22 at 10:25 a.m., LVN B stated Resident #53 refused showers because she got anxiety in the shower room. LVN B stated Resident #53's nails should have been noticed and cut on her shower days and it must had got missed. LVN B stated Resident #53 was particular about her nails and liked them long. LVN B stated long nails could cause skin tears if they were not cut. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 9 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/5/22 at 3:00 p.m., LVN C stated Resident #53 had not received her showers because the facility was short staffed. LVN C stated Resident #53 should not have long nails because it could cause a pressure sore or infection because of her contractures. During an interview with the DON on 10/5/22 at 1:35 p.m., the DON stated she expected residents to receive their showers per schedule to prevent infection and get their nails trimmed. The DON stated Resident #53 normally refused baths and wanted her nails long. The DON stated long nails could lead to infection from getting scratched. Record Review of the policy on ADL care dated 2/10/2020 indicated residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal/oral hygiene. The process indicated residents would participate in person centered care and receive bathing. 2. Record review of the consolidated Physician Orders, dated 11/10/21 revealed Resident #59 was [AGE] year-old who was admitted to the facility on [DATE] with diagnosis which include Chronic Obstructive Pulmonary Disease (breathing disorder) and Atrial Fibrillation (irregular heartbeat). Record review of the admission MDS, dated [DATE], revealed Resident #59 had a BIMS of 10, which indicated moderate impaired cognition. She preferred receiving showers, bed baths and sponge baths. The resident required total dependence one staff assistance for bathing. She participated in the completion of the assessment. Record review of the Quarterly MDS, dated [DATE], revealed Resident #59 had a BIMS 10, which indicated moderate impaired condition. She required one staff assistance with bathing due to being totally dependent. She participated in the completion of the assessment. Record review of the Comprehensive Care Plan dated 09/06/22, for Resident #59 revealed she exhibited impaired cognition. She had an ADL self-care performance deficit and was at risk for not having her needs met timely. She required the assistance of one staff member for bathing. Record review of the Nursing Progress Notes dated 8/01/11 to 10/05/22 revealed Resident #59 was totally dependent on staff for bathing, and no resident refusals of bathing were noted. Record review of the shower schedule for Resident #59 revealed she was scheduled for bathing on Monday, Wednesday and Fridays on the evening shift. Record review of the bathing documentation dated 8//1/22 to 10/3/22 revealed she missed 17 of 27 scheduled bed baths during the time period. During an observation and interview on 10/03/22 at 12:02 PM with Resident #59, she stated, I get bed baths because I cannot get up, and I would like them more often. The resident was noted to have1/4-inch chin hairs to her chin, her hair was disheveled, and she had, flaky skin on face. During an observation and interview on 10/05/22 at 10:20 AM revealed Resident #59's hair was disheveled, dirty and chin hairs were noted. The resident stated, she knew one of her bed baths was on Saturday, but I did not know exactly what her scheduled days were for bathing. Resident #59 stated she had knew she had not had a bed bath or any bathing in more than a week. During an interview on 10/05/22 at 01:10 PM with CNA D, she stated, she never bathed Resident #59 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 10 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0677 and did not know her shower days, but thought the evening shift on her shower days. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/22 at 01:11 PM with the ADON revealed Resident #59s scheduled bathing days were on the daily shower sheets. The aides on the shift's completed resident baths, and hers was on the two to ten shift in the evening. The CNAs should document if a shower was not completed, or if a resident refused, and tell the nurse for documentation purposes as well. Residents Affected - Few During an interview on 10/05/22 at 02:27 PM with CNA E revealed Resident #59 never refused a shower from her. She gave the resident a bed bath about 2 weeks ago during her shift. CNA E stated, on second shift there was 3-4 CNA's, 2 nurses and 2 medication aides, and sometimes the CNA's did not get all of the baths done. CNA E stated she always got her baths done, but she knew others did not. During the interview on 10/05/22 at 02:54 PM with the DON, she stated, there were 5 CNAs on the evening shift, 2 nurses, and 2 medication aides, but they had about 3-4 CNAs. Having less CNA's made things hard, and she did not know if everyone got things done, it could be challenging. The DON stated this can affect the residents in that bathing may not be on their scheduled days as per preference. Record review of the facilities ADL Care Guidelines policy, dated 02/11/21, revealed residents will receive essential services for ADLs to maintain grooming and personal hygiene. Residents receive the following person-centered care: bathing, which includes grooming activities such as shaving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 11 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 18 residents (Resident #10) reviewed for quality of care. Residents Affected - Few The facility failed to follow physician orders for wound care to Resident # 10's right calf and left breast. This failure could place residents at risk for decreased quality of care and injury. Findings include: Record review of the physician order summary report, dated 10/05/2022, indicated Resident #10 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney failure), essential hypertension (high blood pressure), and chronic venous hypertension (increased pressure inside veins) with ulcer and inflammation of right lower extremity. Record review of the quarterly MDS, dated [DATE], indicated Resident #10 usually understood others and made herself understood. The assessment indicated Resident #10 was moderately cognitively impaired with a BIMS score of 9. The assessment indicated Resident #10 required supervision with bed mobility: limited assistance with transfers, dressing, toileting, personal hygiene, and extensive assistance with bathing. Record review of the care plan reflected a focus area, with a revision date of 10/06/2021, that indicated Resident #10 had the potential for the development of a pressure ulcer and venous ulcers. The care plan interventions included, repositioned frequently or more often as needed or requested, weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity, and report new conditions to the physician. The care plan did not reflect actual wounds or specific wound interventions or treatments for Resident #10. Record review of a TAR dated 10/1/2022-10/31/2022, indicated Resident #10's wound care to her right calf was to cleanse with normal saline or wound cleanser, pat dry, apply hydrogel (wound care supplies), and cover with a dry dressing daily with a start date of 09/24/2022. The TAR was not signed off by a nurse on 10/01/2022 and 10/02/2022. Record review of a TAR dated 10/1/2022-10/31/2022, indicated Resident #10's wound care to her left breast was to cleanse with normal saline or wound cleanser, pat dry, apply medi-honey (wound care supplies), and cover with dry dressing daily with a start date of 09/26/2022. The TAR was not signed off by a nurse on 10/1/2022 and 10/2/2022. During an interview on 10/04/2022 at 9:24 a.m., Resident #10 stated her wounds were not changed over the weekend. Resident #10 stated she had reported it to a staff member but was unable to recall their name. During an interview on 10/04/2022 at 9:38 a.m., RN P stated she was the treatment nurse and had only been in the facility for two weeks. RN P stated she completed wound care on Resident #10 on 10/03/2022. RN P stated the date on the old dressings was 09/30/2022. RN P stated the order was for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 12 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressings to be changed daily. RN P stated the charge nurses on the weekend were responsible for providing wound care. RN P stated since she had been at the facility Resident #10 had reported to her that her wound care dressings were not changed on the weekend. RN P stated she did not report this because the nursing management was aware of this issue. RN P stated she should have still reported the issue. RN P stated she was not told by the DON what all her duties were. RN P said this failure could potentially put Resident #10 at risk for infection control and adverse reaction to wound care dressing. An attempted telephone interview on 10/05/2022 at 2:59 p.m. with LVN Q, the LVN charge nurse for the weekend of Saturday 10/01/2022 and 10/02/2022, was unsuccessful. During an interview on 10/05/2022 at 3:18 p.m., DON stated she expected residents wound care orders to be followed which included weekends. The DON said the charge nurses were responsible for ensuring wound care was done on the weekends and when the wound care nurse was off. The DON stated she was not aware wound care was not done on the weekends. The DON stated recently she had not been monitoring wound care on the weekends due to the facility merging to electronic records and training the new treatment nurse and ADON's. The DON stated not providing wound care could cause the wound to worsen leading to infection. Record review of the facility's Following Physician's Orders policy dated 9/28/2021 indicated, the policy provides guidance on receiving and following physician orders . 3. (c) carry out and implement orders . (d) documents resident response to physician order in the medical records as indicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 13 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 18 residents (Resident #212) reviewed for pressure ulcers. (Resident #212). Residents Affected - Few The facility failed to change Resident #212s wound dressings according to the physician's orders. This failure could place residents at risk of not receiving wound care services appropriately, could contribute to a decline in a wound, infection and a decline in physical, mental and psychosocial well-being. Findings included: Record review of Resident #212's Physician Orders dated 09/29/22 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #212 had diagnoses which included morbid obesity, chronic pain and osteomyelitis (infection) of the vertebra, sacral and sacrococcygeal region. Record review of Resident #212's admission MDS dated [DATE] revealed in progress. Record review of Resident #212's the Care Plan dated 09/30/22 revealed Resident #212 had a pressure ulcer that required wound care per physician's order. He was at risk for infection, pain and decline. Record review of the Admit/Readmit Evaluation dated 09/29/22 at 03:50 PM revealed Resident #212 had a stage III wound to sacrum, and he was alert and oriented. Record review of Resident #212's Nursing Progress note dated 09/30/22 at 02:27 PM completed by the Wound Care RN revealed the resident was admitted with a sacral wound. The wound was packed with gauze and covered with an adhesive bandage. He had scattered perineal wounds with wound care orders for cleansing and a dressing to perineal area and cleansing and a dressing to his sacral wound. Record review of Resident #212's Physicians Orders dated 10/01/22 revealed he required wound care to his perineal wounds. Staff should cleanse with normal saline or wound cleanser, pat-dry, and apply Bacitracin then cover with a bordered foam alginate dressing every day shift. He also had wound care to his sacral wound. Staff should cleanse with normal saline or wound cleanser, pat-dry, and then pack with iodoform 1 inch packing strip (using one strip, pack loosely). Then cover with the calcium alginate with silver securing with dry dressing every day shift. Record review of Resident #212's Treatment Administration Record dated 10/01/22 to 10/02/22 revealed the above wound care orders were not signed off by the nurse and was left blank. Record review of the Nurse Staffing schedule dated 10/01/22 and 10/02/22 revealed RN H was the nurse during the weekend on both days. Record review of Resident #212's Nursing Progress Note dated 10/03/22 completed by the Wound Care RN revealed Resident #212 was seen by the physician this morning for the initial wound assessment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 14 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0686 made changes to the wound care orders. Level of Harm - Minimal harm or potential for actual harm During an observation of Resident #212s wound care on 10/05/22 at 09:31 AM revealed the Wound Care RN and CNA G in the room to assist with the wound care. Changed daily as per the ordered wound care. Residents Affected - Few Interview with Resident #212 on 10/03/22 at 12:09 PM he said, over the weekend my wound care dressings to his butt were not changed daily like they needed to be. Interview with RN H on 10/04/22 at 11:41 AM she said she did not get a chance to measure Resident #212s wound when he was admitted on 09/29 because she had two new admits at the same time. RN H said last weekend she worked both day shifts, but did not have time to change Resident #212's complicated wound care dressings because she was too busy. RN H said not changing the dressings daily like the order said could make the wound worsen. Interview with the DON on 10/04/22 at 10:38 AM she said on the weekends, wound care dressings were completed by the nurse on duty in that resident hallway. Wound care orders should be followed per the physician orders, otherwise a wound could get worse or not heal as fast. Interview with the Wound Care RN on 10/04/22 at 11:45 AM she said the physician came to the facility on Monday, 10/03. He looked at Resident #212s wounds and changed the dressings. The wound care RN noted there was more dead tissue in the wounds that had to be debrided and also noticed the dressings they removed were the original dressing she had placed on 09/30/22. The dressings should have been changed daily. Daily changes helped with ensuring the wound improved, and if they were not changed daily as ordered, there could be a decline in the wound healing, increased risk of infection, or multiple things. Record review of the Skin Prevention and Management Guidelines, revised 2/14/22, revealed the facility is committed to the promotion of healing of existing pressure injuries. Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. Compliance with interventions will be documented in the monthly wound note summary charting. Pressure ulcer healing is documented using descriptive characteristics of the wound (i.e., depth, width, presence of granulation tissue, exudate). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 15 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain accectable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 18 residents reviewed for nutrition. (Resident #12) Residents Affected - Few The facility failed to ensure Resident #12 received his dietary supplement as physician ordered. This failure could place residents at risk of not receiving appropriate calories and contribute to further weight loss. Findings included: 1. Record review of Resident #12's Physician Orders dated 06/16/20 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses that included protein-calorie malnutrition. Record review of Resident #12's Quarterly MDS dated [DATE] revealed a BIMS of 09, which indicated moderately impaired cognition. He was independent set-up assistance only for eating and weighed 110 pounds. Record review of Resident #12's Care Plan dated 12/30/21 revealed he received a regular diet with supplements as ordered by the physician. Record review of Resident #12's monthly weights from 07/12/22 to 09/12/22 revealed on 07/12/22 he weighed 109 pounds, on 08/12/22 he weighed 107.4 pounds and then on 09/12/22 he weighed 107 pounds. Record review of the Nutritional assessment dated [DATE] revealed Resident #12 ate independently in his room. He reported the used to weigh 135 pounds 2 years ago. His supplements included Vitamin B-12, Med Pass 2.0 240 milliliters twice a day and a House shake with all meals. He was offered Med Pass and the house shake, tasted them and accepted both. Record review of Resident #12's Nursing Progress Notes dated 08/01/22 to 10/04/22 revealed no refusals of supplements noted. Record review of Resident #12's Physician Orders dated 09/07/22 revealed the resident should receive the House Supplement with meals and Med plus 2.0 twice a day, along with Vitamin B-12. Record review of Resident #12's current meal ticket dated 10/05/22 revealed it lacked the documentation of the need for a health shake/supplement at every meal. Record review of the Medication Administration Record from 09/07/22 to 10/04/22 revealed there was no documentation noting the resident received Vitamin B-12 or med plus supplements per the physician's orders. During an interview with Resident #12 on 10/03/22 at 11:02 AM he said he was put on the health shake and the med pass last month some time, but he did not start getting it regularly until this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 16 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 weekend. Resident #12 said he did not get it for his Monday meals. Level of Harm - Minimal harm or potential for actual harm During an observation of Resident #12s breakfast on 10/05/22 at 08:53 AM revealed he did not receive his health/house shake. Residents Affected - Few During the interview with the dietary manager on 10/05/22 at 09:06 AM he stated, sometimes the orders for the residents did not get communicated to the kitchen. The health shake, if the kitchen knew a resident needed it, it would be noted on the resident's meal ticket. Med pass/plus was something the nurses/medication aides took care of. The dietary manager said he was unaware the resident needed the health shake and would add it to his meal ticket. During the interview with CMA K on 10/05/22 at 01:06 PM she stated, Resident #12 should have been getting the supplements since 09/07/22. CMA K said she had not seen an order for the health shake, but the kitchen took care of that. During the interview with the ADON on 10/05/22 at 01:12 PM she stated, dietary gave the residents the health shakes, She did not know why Resident #12 had not been getting them as per the physicians orders. He had a diagnosis of malnutrition, if he didn't get his supplements as ordered, that could cause further weight loss. Requested the facility policy on nutrition/supplements from the DON on 10/05/22 at 02:54 PM, have not received as of 10/06/22 at 02:20 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 17 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen in the facility. The facility failed to provide sufficient dietary staffing during the weekend shifts. This failure could place residents at risk of diminished quality of life. Findings included: Record review of the 08/01/22 to 10/05/22 Kitchen Staffing schedules revealed: No kitchen staffing schedules found for 08/01/22 to 09/18/22 09/19/22, 09/20/22, 09/22/22, 09/25/22, 09/27/22, 09/30/22, 10/01/22- only 2 staff for the morning shift 09/20/22, 09/22/22, 09/25/22, 09/28/22- only 1 staff for the evening shift During an interview on 10/04/22 at 01:38 PM the dietary manager said the facility had agency kitchen staffing in the kitchen now, but he had worked almost every weekend the past few months. The kitchen was down by five kitchen support staff. The kitchen should have 3 employees for the morning shift and 2 employees for the afternoon shift. The least scheduled for the kitchen staff was 2 employees in the morning and 1 in the afternoon. The dietary manager said he made it work because he was there for the residents and he wanted to do a good job, staffing had been an issue with getting food out timely and ensuring appropriately cooked food and that affected the resident's quality of life negatively. Requested the facility policy on kitchen staffing requirements on 10/05/22 at 02:32 PM from the DON and on 10/06/22 at 01:00 PM from the Traveling Benchmark Regional Manager for the kitchen, but did not receive the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 18 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food and drink that was palatable, attractive and served at a safe and appetizing temperature for 2 of 24 residents (Resident #46 and #36) reviewed for palatable food. Residents Affected - Few The facility failed to provide palatable food to Residents #46 and #36. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: 1.Record Review of Resident #46 undated face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had a diagnosis of High blood pressure, type 2 diabetes (blood sugar disorder) and atherosclerotic heart disease (damage of the heart vessels). Record Review of Resident#46's orders dated 8/30/21 indicated he was on a consistent carbohydrate diet with regular texture. Thin liquid consistency and large meat portions. Record Review of Resident #46's care plan dated 9/9/21 indicated the focus was on a consistent carb diet and at nutritional and hydration risk related to diet and restrictions. Interventions indicated the dietary manager discussed food preferences with the resident upon admission and then as needed to meet the resident's dietary needs. During an interview on 10/3/22 at 3:00 p.m., Resident #46 stated the food was no good and jails had better food than the facility. 2. Record Review of Resident #36's undated face sheet indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #36 had a diagnosis of type 2 diabetes (blood sugar disorder), HTN (high blood pressure) and unspecified dementia (confusion). Record Review of Resident #36's orders dated 7/29/2020 indicated she was on a NAS (no added salt) diet. Regular texture and thin liquid consistency. Record Review of Resident #36 quarterly MDS dated [DATE] indicated she had a BIMS of 12, which indicated she was mildly impaired. Record Review of Resident #36's care plan dated 10/28/21 indicated she was on a regular diet at nutritional and hydration risk. She has frequent complaints of food. Interventions indicated the DM to discuss food preferences with resident upon admission and as needed to meet dietary needs During an interview on 10/3/22 at 2:00 p.m., Resident #36 stated, the food was greasy, bland, and cold. During an observation and interview with the DM on 10/04/22 at 12:59 PM, the state surveyors and Dietary Regional Manager sampled a test tray with fish, green beans, rice, and no dessert. The fish was not warm but had good flavor. The green beans had no flavor and was not warm. The rice was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 19 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 - Few warm. The Dietary Regional Manager stated there was no dessert available for the state surveyors to taste. The Dietary Regional Manager stated the oven did not cook properly and they had to throw away all the brownies and serve chocolate pudding instead. Stated he had already reported the oven not working and someone would look at it today. During an interview on 10/4/22 at 10:26 a.m., the Dietary Regional Manager stated they had served pepperoni pizza on 10/2/22 from a local restaurant because the water heater went out and the ice machine flooded the kitchen floor. The Dietary Regional Manager stated they had a side salad available upon request and sandwiches available for alternatives. They also had plenty of cookies and cheese puffs to give out. During an interview on 10/4/22 at 10:00 am, CNA A stated the residents were served raw chicken on several occasions in the past but could not give a time frame. CNA A stated when she served the meals on the hall and had to cut the chicken in pieces for residents, she noticed it was not cooked all the way through and the residents complained. CNA A stated she notified the kitchen and residents were offered peanut butter and jelly sandwiches or chicken noodle soup instead. CNA A denied any residents getting sick that night from raw chicken. During interview on 10/5/22 at 3:02 p.m., the Corporate Administrator stated dietary staff was responsible for cooking foods. During an interview on 10/5/22 at 2:37 p.m. a policy for palatable food tray was requested from the DON but was not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 20 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the attending physician delegated to a registered or licensed dietician the task of prescribing a resident's diet, which included a therapeutic diet, to the extent allowed by the State law for 2 of 18 residents (Residents #8 and #4) reviewed for therapeutic diets. The facility failed to ensure Residents #8 and #4's chicken was ground as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and choking. Findings include: 1. Record review of Resident #8's physician order summary report, dated 10/05/2022, indicated a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) due to thrombosis (blood clots) of unspecified artery, dysphagia (difficulty swallowing), and essential hypertension (high blood pressure). Record review of Resident #8's physician order summary report, dated 10/05/2022, indicated Resident #8's diet was mechanical soft texture, thin liquids consistently with a start date 09/12/2022. Record review of Resident #8's quarterly MDS, dated [DATE], indicated the resident sometimes understood others and sometimes made himself understood. The assessment indicated Resident #8 was severely cognitively impaired with a BIMS score of 0. The assessment indicated he required extensive assistance with eating. The assessment indicated Resident #8 required a mechanically altered diet. Record review Resident #8's care plan, dated 05/03/2021, indicated Resident #8 was on a regular texture diet with a mildly thicken fluids and at nutritional and hydration risk related to CVA. The care plan indicated Resident #8 must have supervision with meals due to dysphagia from CVA. The care plan intervention included, provide, served diet as ordered. Record review of an untitled sheet dated, 10/04/2022, indicated chicken for mechanical soft should be ground. Record review of Resident #8's meal ticket dated, 10/03/2022, indicated mechanical soft with ground baked chicken breast. During an observation on 10/03/2022 at 12:43 p.m., Resident #8 received small, cubed pieces of chicken on a flour tortilla with lettuce, pinto beans, and water by ADON L. During an interview on 10/05/2022 at 2:24 p.m., ADON L stated he was responsible for checking the diet with the meal ticket and ensuing all items required were on the tray before serving. ADON L stated he did look at the ticket and thought what was on Resident #8 tray was correct. ADON L stated now that he looked back the meat was not grounded according to what was required. ADON L stated the potential harm for Resident #8 chicken not being grounded was aspiration and possibly pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 21 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/05/2022 at 3:18 p.m., the DON stated ADON L should have verified Resident #8 diet and texture with the diet roster and tray card before serving. The DON stated she expected the residents to receive the diet as ordered. The DON stated ADON L was probably nervous due to the state surveyors being in the building and forgot to ensure Resident #8 received the correct diet. The DON stated she did random spot checks at least once a meal weekly and had not noticed any issues. The DON stated this failure could potentially cause Resident #8 to choke or aspirate. 2. Record Review of Resident #4's undated face sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #4 had a diagnosis which indicated dementia, depression, and muscle weakness. Record Review of Resident #4's Quarterly MDS dated [DATE] indicated he had a BIMS score of 6, which indicated he was moderately impaired. Section K of the MDS indicated he was on a mechanically altered diet. Record Review of Resident #4's orders, dated 8/3/2020, indicated he was on a regular diet with ground meat texture and thin liquids. During dining observation and interview on 10/03/22 at 12:10 p.m., Resident #4 was observed eating in the dining room. Resident #4 had 1 chicken fajita on a flour tortilla with lettuce, pinto beans, and water. The chicken was diced. Resident #4's meal ticket indicated regular with ground meat. During an interview on 10/5/22 at 2:00 p.m., [NAME] R stated she did not work on 10/3/22 but the chicken fajita wrap should have been served as a whole chicken strip for regular diets and diced up smaller for ground meat and mechanical. [NAME] R stated they used the robo to blend meat for mechanical and ground meals and it should have been used on the chicken. [NAME] R stated serving the wrong meat texture could be a choking hazard. [NAME] R stated it was the responsibility of the cook, DM and nursing staff to make sure the trays were correct. [NAME] R stated it was ultimately the nursing department's responsibility to monitor the trays for the right texture. [NAME] R stated flour tortillas are considered mechanical soft as long as they were not hard or grilled. During an interview on 10/5/22 at 10:25 a.m., LVN B stated the nurses were responsible for checking food trays prior to giving them out to residents. During an interview with the Dietician on 10/5/22 at 9:10 am, the Dietician stated she expected physician orders to be followed. The Dietician stated ground meat should be blended just like the mechanical soft meat using the robo. During an Interview on 10/5/22 at 3:02 p.m., the Administrator stated she expected the food trays to be checked and residents to receive the correct diet. Record Review of the undated policy on Consistency Modified Diets did not address the mechanical soft or ground meat diets. During an interview on 10/5/22 at 2:37 p.m. a policy for therapeutic diets was requested from the DON but was not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 22 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a suitable, nourishing alternative meal and snack was provided to residents who wanted to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 2 of 9 resident's (Residents #36 and #46) reviewed for snacks. The facility failed to provide an evening nourishing snack routinely to all residents. This failure could lead to residents' experiencing complications of diabetes such as low blood sugar or weight loss. Findings include: 1.Record Review of Resident #46's undated face sheet indicated he was [AGE] year-old male and admitted to the facility on [DATE]. Resident #46 had a diagnosis of High blood pressure, type 2 diabetes (blood sugar disorder) and atherosclerotic heart disease (damage of the heart vessels). Record Review of Resident#46's orders dated 8/30/21 indicated he was on a consistent carbohydrate diet with regular texture. Thin liquid consistency and large meat portions. Record Review of Resident #46's care plan dated 9/9/21 indicated the focus was on a consistent carb diet and at nutritional and hydration risk related to diet and restrictions. Interventions indicated the dietary manager discussed food preferences with the resident upon admission and then as needed to meet resident's dietary needs. During an interview on 10/3/22 at 3:00 p.m., Resident #46 stated he was not given snacks in the evenings, and he was diabetic. Resident #46 stated that he reported no snacks to the nurses on several occasions, but he still does not receive them. 2. Record Review of Resident #36's undated face sheet indicated was a [AGE] year-old female admitted on [DATE]. Resident #36 had a diagnosis of type 2 diabetes (blood sugar disorder), HTN (high blood pressure) and unspecified dementia. Record Review of Resident #36's orders dated 7/29/2020 indicated she was on a NAS (no added salt) diet. Regular texture and thin liquid consistency. Record Review of Resident #36 Quarterly MDS dated [DATE] indicated she had a BIMS of 12, which indicated she was mildly impaired. Record Review of Resident #36'scare plan dated 10/28/21 indicated she was on a regular diet at nutritional and hydration risk. She had frequent complaints of food. Interventions indicated the DM to discuss food preferences with resident upon admission and as needed to meet dietary needs. During an interview on 10/3/22 at 2:00 p.m., Resident #36 stated the residents were never given any snacks in the evenings and she was a diabetic. Resident #36 stated she had reported it to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 23 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0809 Administrator in the past and still did not receive them. Level of Harm - Minimal harm or potential for actual harm During a resident council group meeting on 10/4/22 at 3:00 p.m., all residents stated they weren't getting snacks except Residents #27, #18, #23, #55, and #43. Residents Affected - Some During an interview with CNA A on 10//4/22 at 10:00a.m., CNA A stated snacks were supposed to be out at 6:00 p.m., but they had been receiving them at 9:00 p.m. CNA A stated some days they did not get snacks at all, or they gave them rotten fruit and nursing staff would throw it away. CNA A stated when they did get snacks, it was either pimento and cheese or crackers for the last 3 months. During an interview on 10/5/22 at 2:00 p.m., [NAME] R stated she made a basket of snacks last week and they were delivered to the halls. [NAME] R stated snacks were required to meet the dietary needs of residents. During an interview with LVN C on 10/5/22 at 3:00 p.m., LVN C stated she got a basket of snacks every afternoon to pass out, but they did not have enough staff to pass them out to every resident. LVN C stated the residents must come get the snacks at the nursing station if they wanted any. LVN C stated snacks were needed because the diabetic residents had low blood sugars from receiving insulin in the afternoon or because some residents did not eat much for supper. During an interview on 10/5/22 at 1:35 p.m., the DON stated nursing staff often purchased snacks because they did not receive any from dietary. During an interview on 10/5/22 at 3:02 p.m., the Corporate Adm stated she expected snacks to be provided. The Corporate Adm stated if snacks were not provided, they would not be following the plan of care and resident needs would not be met. Record Review of the facility policy on hydration/supplement and snack distribution, dated 4/2019, indicated, there will be adequate supplements or snacks for bedtime snack pass for those residents who require a supplement or wish to have a snack. Bedtime snacks will be offered to all residents, within the individual diet restrictions. #6 the charge nurse must check the cart and assign staff to pass snacks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 24 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure food items in the kitchen refrigerators and freezers were dated, labeled, and sealed appropriately. This failure could place residents at risk for food-borne illness, and food contamination. Findings include: During an observation and interview on 10/3/22 at 10:00 a.m. with the Dietary Regional Manager the following items were revealed: 5 large bags of frozen chicken nuggets were not dated in the freezer 1 large bag of French fries were open and not dated in the freezer 1 large open bag of tortilla chips were not dated 1 large box of cookies were not sealed or dated in the freezer 2 bags of open pasta with no open date 1 plastic container of pasta was not labeled 1 large plastic container with lemons were dated 8/17/22 on the counter 1 plastic container of corn flakes were not labeled or dated 1 plastic container of raisin brand were not labeled or dated 1 plastic container of rice crispies were not labeled or dated 1 plastic container of cheerios were not labeled or dated 1 plastic container of fruit loops were not labeled or dated During an interview with the Dietary Regional Manager on 10/3/22 at 10:00 a.m., the Dietary Regional Manager stated he was filling in for the DM because the DM quit 2 weeks ago. The Dietary Regional Manager stated he expected the food items to be labeled, dated, and sealed properly and it was the DM's responsibility to check it daily. The Dietary Regional Manager stated the items should be labeled and stored properly for health and safety reasons. During an interview on 10/5/22 at 2:00 p.m., [NAME] R stated the DM was responsible for labeling and sealing all food items. [NAME] R stated if labeling, dating, and sealing was not done, it could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 25 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 cause bacteria or food borne illness. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/5/22 at 3:02 p.m., the Corporate Adm stated she expected food items to be labeled, dated, and sealed properly. The Corporate Adm stated it was the responsibility of dietary staff to make sure it got done. The Corporate Adm stated not dating, labeling, or sealing foods could result in serving food that was spoiled. Residents Affected - Some Record Review of the facility policy on dry foods and supplies storage, dated 11/2006, indicated: .#7 Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids. Each container must be labeled with the common name of the food. All storage must be properly sealed and labeled with the common name of the food . #9 All opened products must be resealed effectively and properly labeled, dated, and rotated for use. This may require storage in an approved NSF container or food grade storage bag. #10 Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record Review of the facility policy on frozen and refrigerated foods storage dated 12/5/2017 indicated: .#6 Food must be labeled with the date they were removed from the freezer and a use by date which is 7 days from the date removed from the freezer. #7 Proper labeling of cooked foods includes the date placed in the refrigerator, and an expired or use by date. Refrigerated items that are open must be labeled with an opened on date #13 On a daily basis the cooks will: check labeling and dating, use any items that are close to their use by date and discard any items that are past their use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 26 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that was accurately documented for 1 of 18 residents (Resident #49) reviewed for accuracy of medical records. The facility failed to ensure Resident #49's physician order summary report, code status was updated to indicate a DNR status. This failure could place residents at risk of having residents end of life wishes dishonored. Findings include: Record review of the physician order summary report, dated 10/05/2022, indicated Resident #49 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included neurocognitive disorder with lewy bodies (decreased mental function), essential hypertension (high blood pressure), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the physician order summary report dated 10/05/2022, revealed a status of full code. Record review of the admission MDS dated [DATE], indicated Resident #49 understood others and made herself understood. The assessment indicated Resident #49 was severely cognitively impaired with a BIMS score of 3. Section J1400 asked Does the resident have a condition or chronic disease that may result in life expectancy of less than 6 months? This section was marked 1 which meant Yes. Record review of the care plan, dated 09/13/2022, did not address Resident #49's code status. The care plan indicated Resident #49 had a terminal illness and received hospice or palliative care. The care plan interventions included, coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met and ensure advance directives were in place per resident and responsible party's request. Record review of the OOH-DNR order revealed Resident #49 signed the order on 11/13/2011 and the physician signed the order on 11/28/2011. During an attempted interview on 10/3/2022 at 10:38 a.m., indicated Resident #49 was non-interview able. During a telephone interview on 10/05/2022 at 10:45 a.m., Resident 49's family member stated Resident #49 had been a DNR for quite awhile. During an interview and record review on 10/05/2022 at 2:08 p.m., the SW stated she was not aware Resident #49 was a DNR until she looked at Resident #49 paper chart with the state surveyor and saw the OOH-DNR order. The SW stated she was responsible for verifying the code status, placing the code status in electronic records, and adding it to the care plan. The SW stated she did not know how the order got put in as a full code but whoever received Resident #49 DNR should have alerted her to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 27 of 28 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few input the code status on the care plan and update the electronic records. The SW stated a potential negative outcome of an inaccurate code status would be her wishes not been honored. During an interview on 10/05/2022 at 3:18 p.m., the DON stated the SW was responsible for verifying residents code status and obtaining OOH-DNR on admission. The DON stated the SW was responsible for inputting the code status in resident's electronic medical records. The DON stated she was aware Resident #49 was a DNR. The DON stated she did not monitor the code status in the electronic records because ultimately it was the SW responsibility to ensure the residents code status was correct. The DON stated the SW worked directly under the Administrator. The DON stated a potential outcome of a resident being marked as full code and really a DNR would be prolonging treatment to sustain life. During an interview on 10/04/2022 at 9:15 a.m., the Corporate Administrator stated she was standing in for the Administrator and Interim Administrator who was out on leave. The Corporate Administrator stated she had only been in the building since 10/04/2022. Record review of the facility's Advance Care Plan Guidelines policy, revised 05/12/2022, indicated, . provide the opportunity for residents, and surrogates families to understand and consider wishes concerning the future health and care of the resident . the values and needs of a resident should be known and respected by those providing healthcare to that individual . the social worker will follow up and implement the resident/resident representative advanced care plan wishes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 28 of 28