Inspection·October 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to show it had been completed. She stated the procedures for the mechanical Hoyer lift was a two person transfer with one staff to operate and the other staff to monitor the resident and transfer. The staff were to always lock the wheelchair as well as the Hoyer lift before transferring a resident. The DON stated once the Hoyer lift was at the resident's bed, the Hoyer was to again be locked before the resident was lowered. The DON stated she and the ADON were to monitor in-services with staff for transgering with a Hoyer lift, but had not documented them in the in-service logs. The DON stated the negative affect could have been a possible injury to the resident. The DON stated the lack of sufficient monitoring and training of staff led to the failure. The DON stated her expectation was staff were to lock the wheel chair and the hoyer lift when transferring residents. She stated her expectations were to monitor staff thoroughly with proper in-services, making sure they understood the policies and procedures. Record Review of personnel files for CNA and NA revealed no evidence of training for the Hydraulic Hoyer Lift. Record Review of the facility policy titled Hydraulic Lift not dated, revealed: Goals 1. The resident will achieve safe transfer to bed or chair via a mechanical lift device. 2. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair Procedure 6. Lock the wheel chair or Geri chair 8. Lock or unlock the base wheels according to the lift manufacturer's recommendation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 2 of 5 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 10/25/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure CNA's and NA's were able to demonstrate appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 (CNA, NA) staff reviewed for Hoyer Lift transfers. The facility failed to ensure the CNA and NA had competency in skills and techniques necessary to care for residents' needs. This failure could place residents requiring incontinent care at risk for the spread of infections, skin breakdown, and decreased quality of life. Findings include: Record Review of Resident #31's electronic face sheet revealed resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: Abnormalities of the gait and mobility, Disorders of the bone in the upper arm, and Stiffness of the right and left arm. Review of Resident #31's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score (08) indicating moderate cognitive impairment. Section G: Transfer: Extensive assistance with two-person physical assist. Review of Resident's #31's electronic comprehensive care plan initiated 08/27/2023, revealed: Problem: Self-care deficit: requires assistance. Focus: The resident has had an actual fall related to weakness. Resident #31 is a Hoyer Lift for transfers and requires staff assistance for ADL care. Goals: The resident will resume usual activities without further incident through the review date. During an observation on 10/24/2023 at 9:24 AM the CNA and the NA did not lock the Hoyer Lift while transferring Resident #31 from his wheelchair to his bed. During an interview on 10/24/2023 at 9:40 AM the CNA stated the wheelchair and Hoyer Lift should have been locked before lifting Resident #31. She stated once at the bed and before lowering the resident, the Hoyer Lift should also have been locked. The CNA stated she had not locked the resident wheelchair or Hoyer Lift at any time during the transfer and in not doing so, the Hoyer could have rolled resulting in the resident falling. The CNA stated she had been trained she should have locked the wheels to Hoyer Lift and wheelchair prior to transferring the resident. During an interview on 10/24/2023 at 10:42 AM the DON stated her expectation was that staff are trained and know how to correctly use a Hoyer Lift. The DON stated herslef and therapy staff had performed staff in-services every quarter for resident transfers with Hoyer Lift, but had no documentation of in-services being completed. She stated the procedures for the mechanical Hoyer lift was a two person transfer with one staff to operate and the other staff to monitor the resident and transfer. The Staff were to always lock the wheelchair as well as the Hoyer lift before transferring all resident. The DON stated once the Hoyer lift were at the resident bed, the Hoyer was to again be locked before the resident was lowered. The DON stated herself and ADON were to monitor staff and provide in-services for transferring residents with [NAME] lift. The DON stated she was not able to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 3 of 5 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 10/25/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm documentation of completion of in-services for Hoyer Lifts. The DON stated the negative affect could have been a possible injury to residents. The DON stated the lack of sufficient monitoring and training of staff led to the failure. The DON stated her expectation was staff were to lock the wheel chair and the hoyer lift when transferring residents. She stated her expectations were to monitor staff thoroughly with proper in-services, making sure they understood the policies and procedures. Residents Affected - Few Record Review of personnel files CNA and NA revealed no evidence of training for the Hydraulic Hoyer Lift. Record Review of facility policy titled Hydraulic Lift not dated, revealed: Goals 1. The resident will achieve safe transfer to bed or chair via a mechanical lift device. 2. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair Procedure 6. Lock the wheel chair or gerichair 8. Lock or unlock the base wheels according to the lift manufacturer's recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 4 of 5 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 10/25/2023 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 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 observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. Residents Affected - Few The facility failed to ensure safe and sanitary storage of food and food dispensers that were accessible to residents. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation in the dining area on 10/23/2023 at 10:45 AM revealed Resident #35 was at the resident nutrition station. Resident #35 opened the unlocked sugar and cream dispenser. Resident #35 was observed placing his fingers up and in the valves that dispensed the products and licking his fingers. During an interview on 10/23/2023 at 12:23 PM the DM stated the CNAs were responsible for setting up the drink bar. The DM stated she was not aware of who was responsible for monitoring the drink station. During an interview on 10/23/2023 at 12:27 PM the Dietician stated the dispenser used to remain locked all the times because there was a resident who used to open it up and get the contents out. The Dietician stated that resident had passed, so the staff did not have to keep it locked. The Dietician stated she did not know of any residents that would open the dispenser up. The Dietician stated the dispenser was hard to open even when it was unlocked. The Dietician sated there were no residents that were getting into the dispenser. The Dietician stated there was no one to monitor the nutrition bar, but staff monitored it when in the dining room. The Dietician stated she did not believe there was any potential for harm to residents if they were to get into the dispenser. During an interview on 10/23/2023 at 12:35 PM the ADMN stated her expectation was that the sugar/creamer dispenser should have been locked. The ADMN stated she had never seen a resident open the dispenser. The ADMN stated all facility staff were to monitor when walking thru the dining area. The ADMN stated the negative impact to residents could have been the spread infection. The ADMN stated staff not properly securing the lock to the dispenser led to the failure. During an interview on 10/25/2023 at 2:30 PM the DON stated they did not have any other kitchen policies to provide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675008 If continuation sheet Page 5 of 5