Inspection·September 22, 2023

F 0880 3. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 2's electronic face sheet dated 09/22/2023 revealed [AGE] year-old female with the following diagnoses COVID-19 and Chronic Obstructive Pulmonary Disease. Residents Affected - Some Record review of Resident #2's MDS dated [DATE] reflected a BIMS score of 12, indicating cognitively intact. Record review of Resident # 2's physician order with a start date of 09/02/2023 and end date of 09/24/2023 stated Resident to Aerosol Precautions 4. Record review of Resident # 5's electronic face sheet dated 09/22/2023 revealed [AGE] year-old female admitted on [DATE] with the following diagnoses COVID -19 and breast cancer. Record review of Resident #5's MDS dated [DATE] reflected a BIMS score of 0, indicating severe cognitive impairment. Record review of Resident # 5's physician order with a start date of 09/17/2023 and end date of 09/26/2023 stated Resident to Aerosol Precautions 5. Record review of Resident # 6's electronic face sheet dated 09/22/2023 revealed [AGE] year-old female admitted on [DATE] with the following diagnoses COVID-19. Record review of Resident #6's MDS dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident # 6's physician order with a start date of 09/17/2023 and end date of 09/26/2023 stated Resident to Aerosol Precautions During an observation on 09/20/ 2023 between 11:00 AM and 11:20 AM of Hall B revealed: 1. Resident #4's door had signs on door that stated Resident #4 was on aerosol precautions. CNA A exited the shower room, wearing a surgical mask, and was ushing Resident #4 in her wheel chair. CNA A gave Resident #4 a surgical mask and pushed Resident #4, in her wheelchair, to her room, passing rooms that were not on aerosol droplet precautions. CNA A proceeded to put on a gown, gloves, N95 mask and face shield before entering Resident #4's room. 2. HA B and HA C entered Resident # 3's room, the door had signs that stated Resident # 3 was on aerosol precautions, wearing a surgical mask and gloves. HA B and HA C did not put on a gown or change from surgical mask to N95 mask. HA C exited Resident # 3's room wearing a surgical mask and went across the hall to speak to another resident who was not on aerosol precautions. HA B exited Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 2 of 4 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 09/22/2023 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 #3's room, wearing surgical mask, and walked to room on the other end of hall passed rooms that were not on aerosol precautions. During an interview on 09/20/2023 at 11:25 AM HA C stated she was not aware that she needed to wear specific PPE when entering Resident # 3's room. HA C stated she and HA B had entered Resident #3's room wearing only a surgical mask and provided personal care to Resident #3. During an interview on 09/20/2023 at 11:30 AM HA B stated she did not put on PPE when she entered Resident # 3's room, she only wore the surgical mask. HA B stated no one had told her that Resident #3 was on aerosol precautions. She stated usually looks at sign on door, but did not, Important to change PPE before going to next resident, stop prevent of COVID spread. During an interview on 09/20/2023 at 11:35 AM CNA A stated she was only wearing a surgical mask while she showered Resident # 4. CNA A stated she was not informed that she should have worn a gown, N95, shield and gloves while showering Resident #4. CNA A stated she knew she was supposed to wear PPE in Resident # 4's room. CNA A stated she had received training on PPE and infection control. CNA A stated it was important to wear PPE to stop cross contamination and spread of COVID. CNA A stated the charge nurse notifies staff at beginning of shift of residents who are on isolation precautions or Covid positive During an observation on 09/20/2023 at 12:20 PM during meal service on Hall A revealed RN D exited room [ROOM NUMBER] (Resident on Aerosol Precautions) RN D doffed (put on) rest of PPE but did not change surgical mask. RN D then walked down Hall A passing rooms that were not on isolation, touched meal cart, donned(took off) gown, gloves, shield and did not change from surgical to N95 mask. During an interview on 09/20/2023 at 12:30 PM RN D stated she was not sure if she needed to wear a N95 mask. RN D stated she had worn the same surgical mask in Resident #2' room while setting up her lunch tray, and exited her room, walked down the hall and entered room [ROOM NUMBER] and set up Resident # 5 and Resident #6's lunch trays, without changing her surgical mask. RN D stated she had not put on a N95 mask. RN D stated Resident #2, Resident #5 and Resident #6 were on isolation due to being COVID positive. RN D stated she had received training on PPE. RN D stated she wasn't sure, the appropriate PPE to wear when going in rooms. RN D stated reason to wear a N95 was to help with preventing the spread of COVID. During an interview on 09/20/2023 at 3:10 PM the DON stated staff should have worn a N 95 mask on when entering either a hot (resident COVID positive) or a warm (resident on isolation due to exposure) room. The DON stated staff should not have worn a surgical mask. The DON stated at beginning of each shift staff were informed which residents were on Aerosol Contact Precautions. The DON stated resident rooms that were on isolation also had signs on doors stating resident was on Aerosol Contact Precautions. The DON stated staff not following Aerosol Precautions could have led to spread of COVID. The DON stated new staff and not paying attention led to failure of not wearing appropriate PPE. The DON stated staff have been trained on Aerosol Contact Precautions. During an interview on 09/22/2023 at 12:10 PM the ADMN stated her expectation was staff were to wear N95 mask when entering a resident room that was considered hot (resident COVID positive) or a warm (resident on isolation due to exposure) room and providing personal care for those residents. The ADMN stated the DON, ADON, Nurse Manager and ADMN were all responsible for monitoring staff. The ADMN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 3 of 4 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 09/22/2023 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 stated administration monitored staff by being out on the halls and especially during meal service. The ADMN stated not wearing appropriate PPE could have led to infections to spread. The ADMN stated what led to failure of staff not wearing appropriate mask was staff did not pay attention. Record review of facility policy titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVI-19)Pandemic, dated May 8, 2023 revealed,: HCP (Health Care Provider) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N 95 filters or higher, gown, gloves and eye protection. Record review of door sign titled, Aerosol Contact Precautions with out a date revealed: STOP Aerosol Contact Precautions . Everyone must . Respirator Use a NIOSH-Approved N95 or equivalent or higher-level respirator especially during aerosolizing procedures . Wear eye protection (face shield or goggles) Gown and glove at door Record review of in-service titled COVID-19 Response Plan dated 09/12/2023 revealed CNA A, HA B and HA C had signed in-service roster. Record review of in-service titled Aerosol Contact Precautions dated 09/12/2023 revealed CNA A, HA B and HA C had signed in-service roster. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 4 of 4