Inspection·August 30, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #23's electronic Comprehensive Care Plan dated 07/19/2022 revealed no evidence of any Focus initiated prior to 07/11/2022. During an interview on 08/30/2022 at 2:20 PM Resident #23 stated she never received a copy of her baseline care plan, and she was unaware of what a care plan was. Residents Affected - Some Record review of Resident #34's face sheet dated 08/30/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer's, COVID-19, urinary tract infection, and diabetes. Record review of Resident #34's Quarterly MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. Record review of Resident's #34's electronic medical record revealed no evidence of a baseline care plan. Further review revealed no evidence of the summary given to the resident. Record review of Resident #34's Baseline Care Plan Acknowledgment assessment dated [DATE] revealed: A copy of the baseline care plan was provided to the resident and a copy of the baseline care plan was provided to the resident representative on 07/07/2022 at 13:00 (1:00 PM). Further review revealed assessment was signed by the DON. During an interview on 08/30/2022 at 2:30 PM Resident #34 stated she never received a copy of her baseline care plan, and she was unaware of what a care plan was. Record review of Resident #94's electronic face sheet dated 08/29/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of stroke, malnutrition, high blood pressure, irregular heart rate, and arthritis. Record review of Resident #94's MDS revealed no evidence of MDS submitted or accepted. Record review of Resident #94's BIMS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Record review of Resident's #94's electronic medical record revealed no evidence of a baseline care plan. Further review revealed no evidence of the summary given to the resident. Record review of Resident #94's Baseline Care Plan Acknowledgment assessment dated [DATE] revealed: A copy of the baseline care plan was provided to the resident representative on 08/25/2022 at 10:00. Further review revealed assessment was signed by the DON. Record review of Resident #94's electronic Comprehensive Care Plan dated 08/24/2022 revealed: Focus: Contact Precautions. Resident is a new admit to facility unvaccinated from covid. Date Initiated: 08/24/2022. Further review or comprehensive care plan revealed no evidence of any other Focus and no interventions initiated prior to 08/28/2022. During an interview on 08/30/2022 at 11:21 AM, the MDS nurse stated the admission nursing assessment triggered care plan areas in the comprehensive care and then the facility began to initiate the care plans. She stated the nurse who did the admission printed out the nursing assessment as the baseline care plan and the comprehensive care plan with the triggered focus areas, reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 assessment and the care areas with the residents and representative, and provided the resident and representative with the printed copy. She stated all baseline care areas were addressed with the focus, goal, and interventions within 48 hours. She stated the facility was not aware of there being a failure and she felt the baseline care plans were being done correctly. She stated not having a baseline care plan within 48 hours could put the residents at risk of not receiving adequate care. Residents Affected - Some During an interview on 08/30/2022 at 11:45 AM, the DON stated comprehensive care plans are triggered when the admission nursing assessment is completed and used as the baseline care plan, which was done immediately upon admission. She stated she printed a copy of the admission assessment and the triggered care areas, reviewed it with the resident and representative, and provided a copy. She stated the facility did not keep of copy of what documentation was provided. She stated she was responsible for ensuring that the baseline care plan information was entered and reviewed within 48 hours. She stated she was unaware that there was a failure. Record review of facility policy titled Base Line Care Plans, not dated revealed: Completion and implementation of the bassline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing 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 are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan .The baseline care plan will 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, Dietary orders, Therapy services, Social services, and PASARR recommendations, if applicable .This facility will provide the resident and their representative with a summary of the baseline care plan that includes but not limited: The initial goals of the resident, A summary of the resident's medications and dietary instructions, Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and Any updated information based on the details of the comprehensive care plan, as necessary. The medical record will contain evidence that the summary was given to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (Hall C Med Cart and Hall D Med Cart) of 4 medication carts reviewed for security. The facility failed to ensure Hall C and Hall D Medication Cart with prescription medications and biologicals were not left unlocked, unsecured, and unattended. These failures could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. The findings included: Observation on 08/28/22 at 9:55 AM revealed Hall D Med Cart was left unattended and unlocked. Hall D Med Cart was sitting against the wall beside the door to room [ROOM NUMBER]. RN A was in room [ROOM NUMBER] talking with residents, her back was to the hallway. Hall D Med Cart was not in line of site of RN A. Residents were observed walking past the open Hall D Med Cart. Observation on 08/28/22 at 10:10 AM of Hall D Med Cart contained the following: eye drops, Nitro, Sertraline, Buspirone, Carbidopa-Levodopa, Hydralazine, Amlodipine, Lisinopril, Lithium, Metoprolol, Lamotrigine, Trazadone, Keppra, Wellbutrin, Duloxetine, Paroxetine, Carvedilol, Isosorbide, Clopidogrel, Losartan, Diltiazem, Milk of Magnesium, Robitussin, Pepto-Bismol, Mylanta, Nystatin, Lactulose, and Nose sprays. The following controlled medications were not under double lock: Morphine, Lorazepam, Nitrofurantoin, Norco, Lyrica, Clonazepam, Oxycodone, and Tramadol. Observation on 08/30/22 at 2:05 PM revealed Hall C Med Cart was left unattended and unlocked. Hall C Med Cart was parked on the outside wall of the nurse's station. LVN B walked away from Hall C Med Cart without locking cart and entered medication room, no other nursing staff was observed at nurse's station. Residents were observed walking down hall passing the unlocked Hall C Medication Cart. Observation on 08/28/22 at 2:10 PM of Hall C Med Cart contained the following: eye drops, Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen, Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin, Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex, and Nasal Spray. The following controlled medications were not under double lock: Alprazolam, Modafinil, Clobazam, Hydrocodone, and Tramadol. During an interview on 08/28/22 at 10:10 AM with RN A, she stated medication carts should be locked whenever unattended. RN A stated she had entered resident's room and must have forgotten to lock the cart. RN A stated if a resident were to get into and unlocked med cart it would not be good. RN A stated resident could have adverse reactions, which could lead to minimal or server harm. RN A stated she was trained on securing medication in nursing school. During an interview on 08/30/22 at 11:19 AM with the ADMN, she stated her expectation was that medication carts were to be locked at all times and never be left unattended while unlocked. The ADMN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 - Some stated the nurse assigned to cart for the shift was responsible to ensure medication cart was not left unattended when unlocked. The ADMN stated the DON, ADON and the ADMN were ultimately responsible to ensure carts were locked. The ADMN stated she monitored carts frequently when she was on the floor, by looking at carts and pulling drawers. The ADMN stated unlocked med carts could affect residents by a resident could take medications that were not theirs, which could have interfered with their medications causing side effects with a potential for minimal to severe harm. The ADMN stated what led to failure of medication carts left unattended and unlocked was the weekend RN A supervisor had to work the floor (because a nurse called in) and got distracted. During an interview on 08/30/22 at 12:58 PM with the DON, she stated medication carts were to be always locked, medication carts should not be left unattended while unlocked. The DON stated nurses should have eye contact with cart when it is unlocked. The DON stated the nurse or medication that had keys to medication cart was responsible to ensure cart not left unlocked and unattended. The DON stated she monitored medication cart when she was out on the floor, she would look to see if carts were unlocked by pulling on drawers and reeducate staff if she found an unlocked cart. The DON stated the affect to residents was a resident could take a medication that was not theirs, which could have caused a negative impact to resident, or another resident's medication could be lost. The DON stated what led to failure of carts left unlocked and unattended was staff not realizing unlocked cart needed to be in line of sight, needed reeducation for securing medication carts. During an interview on 08/30/22 at 2:18 PM with LVN B, she stated she thought she had pushed the button to lock cart, that she was always good about locking cart. LVN B stated the effect on residents could have been resident get sick or worse. LVN B stated securing medications was common nurse training. Record review of facility's policy titled, Storage of Medication, dated 2003 revealed: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medication (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access. Record review of facility's policy titled, Storage and Documentation of Schedule II Controlled Medications, dated 2003 revealed: All Schedule II controlled medications will be stored under double lock FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The Facility failed to ensure foods were sealed and/or labeled properly in dry food storage area, the kitchen refrigerators, and the freezers. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 08/28/2022 from 10:15AM to 10:40AM of the kitchen revealed: Dry Storage Area: 1. One large bag of elbow macaroni in bag not sealed and no date on bag. 2. Four jars of pickled Okra with no date 3. One box of butterscotch pudding on the floor with six other boxes containing canned goods stacked on top. Chest freezer: 1. One large bag of frozen squash round in orginal labeled or dated 2. One bag frozen of chicken wing not labeled or dated. 3. One bag frozen of chicken leg not labeled or dated 4. Three bags frozen of chicken breasts not labeled or dated Refrigerator #1 with top freezer: 1. One opened bag celery stalk not sealed or dated 2. Three opened bags celery stalks not labeled or dated 3. One bag cucumber not sealed or dated 4. One silver container with lid, double compartment with gel-like food product with no label or date. Refrigerator # 2: 1. Two bags of yellow liquid with no date and not labeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 2. One gallon container of ice cream with no date and not labeled Level of Harm - Minimal harm or potential for actual harm Freezer #2 revealed: 1. One bag of tortellini with no date or label Residents Affected - Many 2. One bag of pot pie filling with no date or label 3. One bag of Brussel sprouts with no date or label 4. One bag of mini taco with no date or label During an interview on 08/28/2022 at 10:35 AM, [NAME] A stated the boxes had been on the floor since 08/25/2022. She stated they should be stored on the racks. She stated she did not know why this happened, she stated she had been off. During an Interview on 08/28/22 at 11:30 AM, DM stated all dietary staff were responsible for labeling products the date received. She stated if the product was leftovers the date to be removed was three days after product was made. She stated in dry storage the canned goods were in boxes on the floor due to a leak in the wall area that had to be fixed and sheetrock replaced. She stated there were no other place to store the canned goods during this process. She stated all products should be stored at least 6 inches off the floor. During an interview on 08/30/2022 at 08:30 AM, DM stated she was responsible for monitoring that all products are labeled and stored properly. She stated staff was also responsible for labeling and storing products when they are delivered. She stated she did not know why the failure occurred. She stated the dietary staff was trained on storage and labeling upon hire and as needed. She stated the effect on the residents could be if the food product was out of date and not good it could cause the resident to get a food born illness. During an interview on 08/30/2022 at 10:29 AM, ADMIN stated her expectations was that all items were dated and labeled as they come into the kitchen. She stated she did not know why the failure occurred. She stated she made rounds in kitchen for monitoring of storage of products and labeling. She stated the canned goods stored on the floor had only been there for two days due to a pipe bursting and needing to replace sheetrock in dry storage area. She stated the failure to properly label could place residents at risk for food borne illness. She stated that all dietary staff were trained on how to label and store all products for the kitchen. Review of DM employee file revealed training on storage and labeling on 05/01/2022 Review of facility policy titled: Dry Storage and Supplies dated 2012 All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 Storerooms are to be well lighted, ventilated and temperature controlled. Level of Harm - Minimal harm or potential for actual harm b. All food and supplies and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning. Residents Affected - Many 4. Open packages of food are stored in closed containers with tight l covers and dated as to when opened. Review of facility policy titled: Storage Refrigerators dated 2012 All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage. 5. Food must be covered when stored with a date label identifying what is in the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program to prevent the development and transmission of communicable diseases and infections for 3 of 3 (Resident #94,6, #14) residents on the warm unit with unknown Covid status/hot unit Covid positive, reviewed for infection control. Residents Affected - Some CNA-A was passing lunch meal trays on the warm/hot resident hall and did not wear eye protection upon entering resident room for 2 of 2 persons with unknown Covid status and 1 of 1 Covid positive residents. This failure placed all residents at risk for exposure by staff to Covid 19. Findings included: Record review of Resident #94 Facesheet dated 8/30/22 revealed: A [AGE] year-old female with an admission date of 8/24/22. Her diagnosis list included: Cerebral infarction (Primary), Celiac disease, Malnutrition, Atrial fibrillation, Contact with and suspected exposure to other viral communicable diseases, Hemiplegia. Record review of Resident #94 Vaccination Status revealed: Refusal for Covid-19, Flu, Pneumonia vaccinations. During an observation on 08/28/22 at 12:20 PM, CNA-A failed to don eye protection when CNA-A went into Resident #94 room to deliver a meal tray that was unknown covid status due to hospital stay. Record review of Resident #6 Facesheet dated 08/30/22 revealed: A [AGE] year-old male admitted to the facility 7/30/04 with a diagnosis list that included: Dementia, Malnutrition, Covid-19 (11/12/20), Schizophrenia, Glaucoma, Communicating hydrocephalous, Exposure to other viral communicable diseases. Record review of Resident #6 Vaccination status revealed: 1 dose of Covid-19 10/01/21. During an observation on 08/28/22 at 12:23 PM, CNA-A failed to don eye protection when CNA-A went into Resident #6 room to deliver a meal tray that was unknown covid status due to exposure to Covid. Record review of Resident #14 Facesheet dated 8/30/22 revealed: A [AGE] year-old male admitted to the facility on [DATE] with a diagnosis list that included: Alzheimer's disease, Gastrointestinal hemorrhage, Covid-19 (08/18/22), Pneumonia, Malnutrition. Record review of Resident #14 Vaccination status revealed: Historical 2nd dose Covid-19 04/02/21. During an observation on 08/28/22 at 12:25 PM CNA-A failed to don eye protection when CNA-A went into Resident #14 room to deliver a meal tray that was Covid positive. During an interview on 08/26/22 at 12:27 PM, DON said any of the residents that are on the warm unit for PUI for Covid or hot unit because of Confirmed Covid, the staff should have on either a face shield or goggles to protect their eyes. Prescription glasses does not constitute eye protection. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 said there were boxes of supplies in the room midway down that hall that were full of face shields, the staff can use those and store them in that room on the table with their name on them. Staff is supposed to clean the shield each time they leave a resident room on the warm/hot unit with the bleach sani wipes. During an interview on 08/28/22 at 12:29 PM, CNA-A said the staff was supposed to change all PPE each time on the warm/hot unit. PPE included a N95 mask, gown, gloves and with the hot Covid positive resident rooms a face shield was included. CNA-A said he was not aware that a face shield was required with a resident on the warm unit. He said the reason for a face shield was to protect the person from small particles that could include spit. He said that even when a resident talked, they could emit small particles of spit. CNA-A said he was an agency aide that worked every weekend for the past 6 months and he was usually the only person that worked on the warm/hot unit on the weekends. He said that residents on the warm unit were either exposed in the facility through a roommate to Covid or they were a new admission from the hospital, where there was a very real chance, they could have contracted Covid and just not showing positive yet. CNA-A said he did not wear the face shield for the 2 residents that were on the warm unit as PUI because he thought he did not have to. CNA-A said he did not wear a face shield for the resident that was Covid positive because that resident was due to leave the quarantine area the next day as this was day 10 of quarantine for that resident. He said he had been trained by the facility with ICP that included donning and doffing of PPE. During an interview on 08/28/22 at 12:42 PM, DON said all agency had to do an orientation for the facility before they started working with the residents. She said donning and doffing PPE was a part of the orientation training. DON said the reason CNA-A did not wear the face shield could have been because it had been a while since he did the training and maybe he just forgot. During an interview on 08/28/22 at 03:00 PM, DON said that any resident that tested positive for Covid 19 were quarantined for 10 full days. Any resident that was exposed through a roommate testing positive for Covid was quarantined for 10 days. She said any resident that was a new admission was quarantined for 5 days if they were fully vaccinated or 10 days if they were unvaccinated. In the case of the residents on the warm unit, Resident # 94 was a new admission on [DATE] and she was unvaccinated. Resident # 6 was exposed through a roommate on 8/10/22, then had a roommate on the warm unit that tested positive on 8/18/22 and Resident # 14 tested positive for Covid on 8/18/22. DON and ADON provided CNA-A orientation training and check off training for donning/doffing PPE. Record review of CNA-A orientation training was signed by CNA-A and DON was dated 07/01/22 by CNA-A and 07/12/22 by DON. It included orientation training on donning/doffing PPE. Record review of CNA-A donning/doffing competency training was signed by ADON but was undated It included determining and assembling appropriate PPE, donning goggles or face shield and doffing goggles/face shield. ADON checked that yes, CNA-A showed competency with these tasks. Record review of ICPP Manual dated 2018 revealed: SARS precautions to use as follows airborne precautions preferred droplet if AIIR precautions unavailable; N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol generating procedures and Supershedders highest risk for transmission via small droplet nuclei and large droplets 93, 94, 96. Vigilant environmental disinfection. Record review of Facility Policy labeled Positive Resident in Facility Protocol undated revealed: Hot zone-residents with active Covid-19. Warm zone- new admissions/readmissions who are not fully (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 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 vaccinated, residents with exposure to Covid-19, ie their roommate was positive . Place any resident who is positive in the Hot Zone. Place any negative roommates of the positive resident or other residents exposed in the Warm Zone . Place PPE (gloves, gowns, N95, eye protection) carts at the entrance of each resident who is on the Warm or Hot Zone . Staff caring for a Warm or Hot Zone resident should don all appropriate PPE when entering room and doff PPE when exiting the room . Re-inservice on contact/droplet precautions. Record review of CDC Precautions Guidelines accessed at https://www.cdc.gov/sars/guidance/i-infection/healthcare.html on 9/1/22 revealed: Gloves, gown, respiratory protection, and eye protection . should be donned before entering a SARS patient's room or designated SARS patient-care area . Healthcare workers should wear gown, gloves, respiratory protection, and eye protection . Droplet Precautions: Make sure eyes, nose, mouth are fully covered before room entry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 11 of 11