Health inspection·January 10, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Record review of the DON's employee file revealed she was hired 4-17-1989 with her last EMR/NAR completed 1-27-2022. No annual EMR/NAR had been checked in the last 12 months. Record review of RN H's employee file revealed she was hired 5-23-2019 with her last EMR/NAR completed 5-14-2019. No annual EMR/NAR had been checked in the last 12 months. Residents Affected - Some During an interview on 01-10-2024 at 01:42 PM the HRD reported that due to several changes in management there had been a lapse in consistency with employee records and things had been missed like the EMR/NAR. The HRD reported that if an employee was hired that had been listed on the EMR/NAR due to the EMR/NAR not being checked annually or at hire then it would be an issue, that it could cause a problem with the residents. The HRD stated, We don't want anyone in our building that could be abusive. During an interview on 01-10-2024 at 02:48 PM the Administrator reported that she was the person responsible for running all EMR/NAR background checks and that she had always run them monthly until she left the facility for 6 months and that she did not know what was done during the time she was gone. The Administrator reported that her plan to correct the current deficiencies with EMR/NAR's not being ran was to implement a new orientation guidebook that had all the federally required information included. During an interview on 01-10-2024 at 03:22 PM the Administrator reported that if staff are not checked on the EMR/NAR then they could be listed on the registry for misconduct and the facility could have someone listed on the EMR/NAR registry in the building providing care to residents. The DON was out of the building and not available for interview. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 2 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 and distribute food in accordance with professional standards for food service safety in 1 kitchen reviewed for kitchen sanitation. Residents Affected - Many 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. 4. The facility failed to ensure that proper hand hygiene was practiced during distribution of food. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections. Findings included: On 1/8/24 at 11:04AM an initial observation was made of the kitchen. The dry pantry had evidence of mouse excrement on the floor and shelves. The dietary manager stated she did not believe the droppings were from mice, because she had not seen any mice in the kitchen or pantry. Observation of dry foods pantryrevealed the following: The emergency supply of foods, stacked on one shelf with a sign which read, Emergency Supply Updated 7/7/22. (2) Food service cans cranberry sauce; one with expiration date of 11/8/21 and one with expiration date of 10/31/22. (5) 5oz. cans of tomato juice with an expiration date of 10/30/23. (2) 5-pound, 5oz bags tortillas with an expiration date of 5/24/23. In addition, there were 2 partial bags of tortillas with the same expiration date, closed with document binder clips. (1) 20oz. can crushed pineapple dated 2/13; no visible expiration date. (1) 1-pound box corn starch with an expiration date of 11/12/22. (1) 28oz. can green chili peppers; no visible received on or expiration date. (1) 28oz. can diced tomatoes with green chilis dated 11/27/23; no visible expiration date. (2) partial food service bags tortilla chips closed with document binder clips. (9) 28oz. boxes Cream of Wheat with a use by date of November. No additional date could be read. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 3 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 Observation of the freezer revealed the following: Level of Harm - Minimal harm or potential for actual harm (1) 20-pound box breaded squash, open to air. 1 dozen frozen bagels with a received date of 5/8/23; no visible expiration date. Residents Affected - Many 1 dozen frozen bread sticks with a received date of 9/11; no visible received year or expiration date. (2) 6-pound boxes beef chili and bean red burritos, open to air. 8 frozen egg rolls with a best by date of 2/28/23. Observation of the refrigerator revealed the following: 3-pounds sliced ham lunchmeat; opened date 12/11/23. Zip sealed baggie with 3 slices cooked ham dated 12/2/23. 6 heads lettuce; received date of 12/11/23. (1) food service bag chopped Romaine lettuce, open to air. There was a dirty bath towel, covered in mud, laying by the back door of the kitchen. An interview with the DM on 1/8/24 at 11:22AM revealed a negative outcome of residents eating expired food or food in contact with rodent excrement, could make residents sick. She stated that the towel laying on the floor by the back kitchen door, should not be there. It was being used to wipe mud from dietary worker's feet, as they came in from outside the facility. She was then asked for the Policies and Procedures for food retention times, food storage and pest control. Record Review of the facility's Dry Food and Supplies Storage Policy and Procedures, dated 11/15/17 revealed the following: (1) The practice of First In, First Out will be utilized. Products which do not have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased (the oldest product will be moved to the front, for first use.) Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date or without a date, will be discarded. (2) Bulk food products that are removed from the original containers must be placed in plastic or metal food grade containers with tight fitting lids. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 4 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 (3) Level of Harm - Minimal harm or potential for actual harm All opened products must be resealed effectively and properly labeled, dated and rotated for use. (4) Residents Affected - Many Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Review of the facility's Storage of Frozen and Refrigerated Foods Policy and Procedures, dated 10/2017 revealed the following: (1) Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by date. Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened. Foods prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 7 days from the date prepared. (2) Items stored in the refrigerator must be dated upon receipt. They must also be dated with an expiration date unless they have one from the manufacturer. (3) Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. (4) All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above. No Policy and Procedures for Pest Control in the kitchen were produced. An interview with the MM on 1/8/24 at 2:02PM revealed that pest control services were provided by an outside entity, on the second Friday of every month. Evidence of pest control services was produced. An invoice from Perfect Pest Control, dated 12/1/23 revealed mouse/rat bait stations were placed at an interval of 1 block every 8-12 feet and discussion with kitchen staff, by the pest service, did not indicate rodent activity. The MM stated he monitored the bait stations and had not seen any rodent activity. An observation of the maintenance manager on 1/8/24 at 2:29PM revealed him carrying a glue trap in a sealed clear bag, out of the building, for disposal. A pest sighting log from the same date revealed a rodent had been sighted in the dry storage area of the kitchen, along with a crack, hole or crevice being identified as the source of entry. Observation of the kitchen on 1/9/24 at 9:02AM revealed the emergency supply of foods still on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 5 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 pantry shelf, with the sign which read, Emergency Supply Updated 7/7/22. The dietary manager stated she thought she had gotten all the emergency supply removed from the shelves. She stated she had swept and mopped the panty, yesterday (1/8/24) and did not see any mice droppings when she cleaned. Observation of lunch service on 1/9/24 at 12:10PM revealed dietary service workers not practicing hand hygiene while distributing resident trays. LVN A was observed coming into the dining room and without practicing hand hygiene, began feeding a resident. LVN B was observed standing in line to pick up a resident tray. LVN B touched her face and then placed her hands in her pockets while she waited. LVN B then picked up a tray and delivered it to a resident. CNA C and CNA D were serving resident trays with no hand hygiene practiced between each tray. The AD was observed carrying a resident tray and when the tray was set on the table, the AD touched her hair and then touched the rim of a resident's drink glass with her bare hand. She then served the drink to the resident. An interview with the DON on 1/9/24 at 12:21PM revealed she was not aware that hand hygiene should be practiced between delivery of individual resident trays. When presented with evidence of her staff touching their face, hair and clothing, she stated communicable disease could be transferred from each worker to a resident. The DON stated she would immediately re-train all nursing staff on infection control in the dining room. The DON was observed speaking with LVN A, LVN B, CNA C, CNA D and the AD regarding hand hygiene and infection control in the dining room. Record Review of Food Services Hand Washing Policy dated 11/2017 revealed in part: Food employees shall keep their hands and exposed portions of the arms clean. Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that all involved in food preparation and services consistently utilize good hygienic practices and techniques. Staff should have access to the proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. Antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting. Because the skin carries microorganisms, it is critical that staff involved in food preparation and service, consistently utilize good hygienic practices and techniques including proper hand washing. Dietary staff will wash their hands before starting work and: After touching hair, face, or body. After cleaning tables, equipment or touching dirty dishes. After engaging in any other activity that may contaminate food. Hand washing signage will be displayed at all hand washing sinks. An adequate supply of hand washing soap and paper towels is available during hours of operation. (1) Separate and distinct hand washing facilities will be maintained and stocked with hand soap and paper towels and used only for hand washing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 6 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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) Level of Harm - Minimal harm or potential for actual harm Prepare paper towel for hand drying (i.e., Roll down paper towel if manual dispenser). (3) Residents Affected - Many Turn on water and run until warm. (4) Rinse hands and forearms under clean, running warm water. (5) Apply the amount of cleaner recommended by the manufacturer. (6) Rub hands together vigorously for at least 10 to 15 seconds. a. Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure and b. Creating friction on the surfaces of the hands and arms, fingertips, and areas between the fingers. (7) Thoroughly rinse under clean, running warm water; and (8) Immediately follow the cleaning procedure with thorough drying with a clean paper towel. (9) To avoid re-contaminating their hands food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a hand wash sink. An observation of the dining room on 1/9/24 at 12:30PM revealed there was no separate and distinct hand washing sink in the dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 7 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review the facility failed to provide training to their staff for dementia care for 3 (DT E, HK I, and AD) of 12 employees evaluated for required trainings. Residents Affected - Some DT E was hired 5-30-23 and not training had been provided for Dementia Care on hire. HK I was hired 7-21-2023 and no training had been provided for Dementia Care on hire. AD was hired 11-6-2023 and no training had been provided for Dementia Care on hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care. This failure could result in deterioration in resident condition and exacerbation of the disease process. Findings included: Record review of the DT E's employee file revealed the following: DM was hired 5-30-2023 and no training has been provided on Dementia Care since she was hired. Record review of the HK I's employee file revealed the following: HK I was hired 7-21-2023 and no training has been provided on Dementia Care since he was hired. Record review of the AD's employee file revealed the following: AD was hired 11-6-2023 and no training has been provided on Dementia Care since she was hired. During an interview on 01-10-2024 at 01:42 PM the HRD reported that due to several changes in management there had been a lapse in consistency with employee records and things have been missed. The HRD reported that if an employee was hired that had not been trained adequately then a resident could possibly not receive the care they need and that could affect a resident's condition. During an interview on 01-10-2024 at 02:15 PM the Administrator reported that she had called her corporate office and the required trainings were not included on the 2019 orientation guide, but it had been included on the 2023 new orientation guide, but the facility had not been made aware of the new guide and was still using the 2019 guide. The Administrator reported that this was why some of the trainings were being missed. The Administrator confirmed that she was responsible for the trainings. During an interview on 01-10-2024 at 02:48 PM the Administrator reported that the facility did not require contract staff to complete the required trainings, that contract staff are supposed to keep up with all the requirements, and that dietary and housekeeping staff were contract staff. The Administrator reported that all staff are trained on the facility provided computer system for dementia and that it was assigned to staff for completion. The Administrator reported that all staff are to complete 3 facility provided computer trainings per month and that corporate sets up the trainings. The Administrator reported that indirect staff do not complete dementia training on hire but will have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 8 of 9 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 675013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowell Nursing Center 200 South B Ave Crowell, TX 79227 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it assigned to them in the facility provided computer system at a later date. The Administrator reported that her plan to correct the current deficiencies with training requirements was to implement the new orientation guidebook that had all the federally required information included. During an interview on 01-10-2024 at 03:20 PM the Administrator reported that if staff are not trained on dementia it could lead to resident frustration, the residents could lash out, and the staff would not know how to react. During an interview on 01-10-2024 at 03:21 PM the Administrator reported that if staff are not trained on the required training, then anything would be possible, staff would not be aware of the dynamics, staff would not know how to handle a situation. During an interview on 01-10-2024 at 03:23 PM the HRD reported that it was the responsibility of the administer to pull the new hire requirements for the contract companies. The DON was out of the building and not available for interview. Record review of the facility provided policy titled Policy and Procedures: Abuse, Neglect, and Exploitation implemented 10-24-2022, revealed the following: Policy Explanation and Compliance Guidelines: 1. The facility provided resident protection that include: c. Training for new and existing staff on .and dementia management . No other pertinent policy information was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675013 If continuation sheet Page 9 of 9