Inspection·January 25, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Record review of facilities policy titled Homelike Environment revised February 2021 indicated in part: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 2 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #34) of 4 residents reviewed for accident and hazards: The facility failed to ensure Resident #34's bed was on its lowest position while the resident was in his bed. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards. Findings included: Record review of Resident #34's admission record dated 01/24/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #34's care plan dated 01/23/24 indicated in part: Focus: Resident is High risk for falls r/t dementia. GOAL: The resident will be free of falls through the review date. Interventions: Keep bed in low position with fall mat beside bed. Bed at lowest position and fall mat in place. Record review of Resident #34's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Functional abilities and goals - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = 01 indicating Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #34's incident report dated 01/11/2024 indicated in part: Location: Resident's room. Nursing description: Heard resident calling for help. Nurse walked in room and found resident on the floor. Resident on the floor bed not in lowest position fall mat on the floor, resident in between bed and floor mat. Resident with right hip on floor, right arm behind his back, left leg and arm straight, With two assists, resident assisted back to bed. Denies pain in either shoulder. Full ROM with both shoulders. Full ROM to right hip. c/o low amount of pain during ROM. No pain to right hip when right hip joint is still. No pain to left leg. Full ROM to left leg. Dr. notified of fall and pain with right hip movement. Resident description: Resident unable to give description. Immediate action taken. Spoke with one CNAs and one TNA who put the resident to bed. Both stated bed would not go to lowest position. Nurse requested when equipment isn't working write it down in maintenance log. Bed put in maintenance log. LPN put bed in lowest position, did take longer than normal for bed to go to the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 3 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 0689 Level of Harm - Actual harm Residents Affected - Few Record review of the facility self-report 476720 PIR dated 01/12/24 indicated in part: Resident #34 was found on the floor next to his bed and complained of right hip pain. X-ray was done and revealed a non-displaced right hip fracture. Review of hospital document date 01/11/24 indicated in part: Return to NH. Dx 1. Incomplete right inter-trochanter fracture non-surgical 2. AKA. This is a non-surgical fracture. Note: (An intertrochanteric fracture is a specific type of hip fracture, intertrochanteric means between the trochanters, which are bony protrusions on the femur or thighbone). Review of final radiology report document date 01/12/24 indicated in part: Impression subtle lucency through the right intertrochanteric region which may be secondary to a nondisplaced fracture. During an observation and interview on 01/23/24 at 12:24 PM Resident #34 was in the main dining room sitting up on his wheelchair awake and alert eating his lunch. Resident was asked if he recalled falling out of bed and he said he had never fallen out of bed before and had no complaints. During an interview and observation on 01/24/24 at 12:46 PM CNA A said she was working the floor on 01/11/2024 the day Resident #34 fell. CNA A said the bed was not fully down because the bed remote was not working correctly and she felt at fault because the resident had fallen and fractured his hip. The aide went to the resident's room and demonstrated at what height the bed was which was approximately 22 inches off the floor. CNA A said RN C performed the assessment and then they placed the resident back onto the bed and later the x-ray people came and took x-rays of the resident. During an interview on 01/24/24 at 03:00 PM RN C said on 01/11/24 she was at the nurses station and heard Resident #34 calling out for help. RN C said she walked into the room and noted the bed was not in its lowest position. RN C said the resident was on the floor on his right hip and was not on the mat, the resident was in between the bed and the mat on the floor. RN C said she assessed him and everything seemed okay at that time. RN C said CNA A said the bed would not go all the way down to the floor as it was not working properly. RN C said she asked the aide why she had not reported it to maintenance and the aide did not say anything and just started walking towards the maintenance log to book to document it. RN C said the bed worked just fine when she pressed the down button on the remote as the bed went all the way to the floor that same day. RN C said she called the doctor and family member to report the fall. RN C said it took a little while for doctor to get back and he ordered an x-ray which was done later in the day and it was positive non-displaced fracture. During an interview on 01/24/24 at 03:24 PM CNA A said Resident #34's bed was actually working that day, 01/11/24, and she just had not lower it all the way down. CNA A said she had gotten nervous and did not recall how the incident actually all occurred. During a telephone interview on 01/25/24 at 11:32 AM Resident #34's doctor said the resident's osteopenia (a condition in which bone mineral density is low) diagnosis could have contributed to the fracture even if the bed was in a low position. The doctor said he was aware of the fall and that corrective measures had been put into place. Record review of the maintenance log dated 01/11/24 indicated in part: Date 1/11. Room/Location Resident #34 bed in 14A. What needs to be repaired Resident #34's bed won't go in low position. Date\Time of repair Nothing wrong with bed works 2:30pm. During an interview on 01/25/24 at 12:46 PM the Maintenance Supervisor was asked about the maintenance log report where it indicated about Resident #34's bed no going to low position on 01/11/24. He said he had checked the bed and remote and that it was working fine when he checked it and did not need any repairs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 4 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 0689 Level of Harm - Actual harm During an interview on 01/25/24 at 03:12 PM the Administrator was made aware of how Resident #34's bed not being on lowest position due to staff not lowering it all the way down could have contributed to the resident sustaining a fracture. The Administrator said it was her expectations for staff to report any issue with beds not working properly right away to prevent falls. Residents Affected - Few Record Review of the facility's policy titled, Fall prevention program dated 07/20/21 indicated in part: All residents will be assessed for the risk of falls at the time of admissions on a quarterly basis and upon significant change in condition thereafter. Based on the results of this assessments, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A fall can be defined as when a resident is found on the floor, a resident slide to the floor unassisted, a resident rolls off the bed/chair onto the floor including bedside mat. The following is a list of commonly used interventions that may be considered to minimize falls and injury - Resident room is maintained clutter free, bed maintained in low position with bedside mat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 5 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Front medication room) of 2 medication rooms inspected for medication storage. The medication room had expired vial of Tuberculin (TB) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 01/23/24 at 02:28 PM revealed the medication room located by the front nurses station with RN D present. The door was locked so the nurse unlocked it. There was a small refrigerator in the medication room that contained an open vial of TB solution. The TB solution box had an open date of 08/01/2023 and the manufacturer's instructions on the box indicated Discard opened product after 30 days. RN D said she was not aware that the solution had been expired. During an interview on 01/23/24 at 02:36 PM the DON was shown the TB box and he said the solution had expired and he would dispose of it. The DON said if the expired solution was used it could lead to possible contamination on the person being tested. During an interview on 01/25/24 at 02:44 PM the Administrator said she was not sure regarding the TB storage instructions as her expertise was not in clinical. The Administrator said the TB vial should be disposed after 30 days if it indicated on it. She said it was all of nursing staff's job to check the medication room for expired medications and dispose of them. The Administrator said it was ultimately the ADON and the DON to monitor the medication rooms. The Administrator said it was not her clinical expertise but she would think an adverse reaction could occur if the used an expired TB solution. Record review of policy titled Medication labeling and storage dated 02/2023 indicated in part: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Medication labeling - The medication label includes at a minimum - expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 6 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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. Based on observation, interview, and record review, the facility failed to store all drugs in locked compartments for 1 of 1 medications storage compartment. The facility failed to ensure medication carts were locked when unattended for 2 (North hall cart and the Medicare hall cart) of 4 medication carts reviewed for drug storage. The discontinued controlled medications and biologicals kept in the DON's office were not kept behind 2 separate locks at all times. The medication carts for the North and Medicare halls were unlocked and unattended by staff. These failures could place the facility at risk of drug diversion and access to medications or accidental ingestion. Findings include: During an observation on 01/23/24 at beginning 12:16 PM the Medicare hall medication cart was seen unlocked and unattended for approximately 6 minutes. Inside the medication cart were several insulin pens, pill bottles and blister packets that contained several types of medication pills. There were some residents in the areas. During an interview on 01/23/24 at 12:22 PM the DON said the medication carts were supposed to be locked when unattended. The DON was shown the unlocked and unattended medication cart. The DON called RN D who was in the dining room and she came and locked the cart. During an interview on 01/23/24 at 02:34 PM RN D said she normally locked the medication cart when she stepped away from it. The RN said she locked the cart to prevent other people from having access to the cart. The RN said if the cart was left unlocked a resident could possibly get into it and ingest some of the medications. During an observation and interview at 01/24/24 at 03:38 PM the discontinued controlled medication cabinet was inspected with the ADON present. The ADON said the discontinued medication were kept in the DON's office restroom which had a hasp and a lock on it which was already unlocked. The ADON opened the restroom door and inside was a large cabinet that contained one lock which the ADON unlocked. The ADON said the second lock was the lock that was on the restroom door which was unlocked. The ADON said the lock on the restroom door was normally locked. The ADON was made aware that the DON's office had been observed by the surveyor on a couple of occasions and the office was unattended and the restroom lock was not locked therefore the discontinued medications not kept behind 2 locks at all times. Inside the discontinued medication cabinet there were several discontinued controlled medications such as liquid morphine, clonazepam and tramadol pills. During an observation and interview at 01/24/24 at 04:30 PM RN C entered a resident's room to administer some medication and left her medication cart unlocked. While in the resident's room, RN C said she normally locked the medication cart whenever she stepped away from the cart. After RN C returned to the cart, she noticed the cart was unlocked. RN C said the reason she locked her cart was to prevent from others getting into the cart and possibly ingesting some medications, sticking themselves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 7 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 with syringes and also there were several insulin pens in the cart. RN C said she thought she had locked the cart before she entered the room but must have forgotten. During an interview on 01/25/24 at 02:48 PM the Administrator said if the nurse was not at the medication cart, then it should be kept locked. The Administrator said the nurse that used the medication cart was responsible for making sure the cart was locked if they were not using it. The Administrator said if the cart was left unlocked a resident could get into the cart or even an employee. The Administrator said the failure possibly occurred because the nurse forgot to lock the cart when they stepped away. During an interview on 01/25/24 at 02:52 PM the Administrator said it was her expectation for the discontinued controlled medications to be stored behind 2 locks. The Administrator said it was the DON and ADON's responsibility to make sure the medications were kept locked. The Administrator said if the medications were not kept locked it could lead to anyone having access to the medications. The Administrator said the failure occurred because one of the 2 locks had malfunctioned and it had not been replaced. The Administrator said the lock had been now replaced. Record review of policy titled Medication labeling and storage dated 02/2023 indicated in part: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartment including but not limited to drawers, cabinets, carts containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Controlled substance (Listed as scheduled II-V of the comprehensive drug abuse prevention and control act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package during distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Record review of policy titled Security of medication cart dated 04/2007 indicated in part: The medication cart shall be secured during medication passes. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. Record review of policy titled Controlled substances dated 11/2022 indicated in part: The facility complies with all laws, regulations and other requirements related to handling storage disposal and documentation of controlled medications (listed as schedule II-V of the comprehensive drug abuse prevention and control act of 1976). Storing controlled substances - controlled substances are separately locked in permanently affixed compartments except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 8 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen. The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen. These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 01/23/24 beginning at 11:15 AM in the kitchen revealed: 6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes) 2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads In an interview on 01/23/24 at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when. In an interview on 01/24/24 at 11:30 AM [NAME] B stated that the expired water should be stored in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 9 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. [NAME] B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. [NAME] B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space. In an interview on 01/24/24 at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere. In an interview on 01/25/24 at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on 1/23/24 and 1/24/24 and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. Record review of facility policy titled Food Receiving and Storage dated October 2022 revealed, in part: Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 10 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and #40) of 13 residents reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA A changed her gloves after they became contaminated while providing incontinent care for Resident #3 and Resident #40. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Resident #3 Record review of Resident #3's admission record dated 01/25/24 indicated she was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain damage), e. coli infection (bacterial infection), UTI (bladder infection), and heart failure (heart fails to pump blood adequately). She was [AGE] years of age. Record review of Resident #3's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =Always incontinent. Bowel Continence = Always incontinent. Record review of Resident #3's care plan dated 01/04/24 indicated in part: Problem: resident has bowel/ bladder incontinence r/t Activity Intolerance, Impaired Mobility, Loss of peritoneal/bowel tone. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Clean peri-area with each incontinence episode. Check and change every 2 hours as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Interventions: Monitor and document for signs and symptoms of Urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of #3's physician orders states, Apply peri-guard external ointment between gluteal folds topically every shift related to rash. Resident #40 Record review of Resident #40's admission record dated 01/25/24 indicated she was admitted to the facility on [DATE] with diagnoses which cerebral infarction (brain damage caused by obstructed blood flow), hemiplegia (paralysis to one side of body), dementia (impairment of memory and judgment), and dysphagia (difficulty swallowing). She was [AGE] years of age. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 11 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 Record review of Resident #40's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =Always incontinent. Bowel Continence = Always incontinent. Level of Harm - Minimal harm or potential for actual harm Record review of Resident 's care plan dated 01/16/24 indicated in part: Residents Affected - Few Problem has an ADL self-care performance deficit r/t Limited Mobility, Stroke. Goal: The resident will maintain current level of function in ADL's through the review date. Interventions: Monitor/document/report PRN s/sx of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Excessive sweating, Abdomen: tenderness, guarding, rigidity, fecal compaction. During an observation on 01/24/24 at 10:15 AM CNA A washed her hands, closed the door, pulled the curtain, and donned clean gloves. CNA A pulled the residents pants down then pulled down the front of the brief and tucked it in. CNA A wiped Resident #40's front peri area with wet wipes times 4 and doffed (removed) her gloves. CNA A donned (applied) clean gloves and assisted the resident to roll to her left side and removed the brief. CNA A wiped the residents bottom with wet wipes times 4 and doffed gloves. CNA A donned clean gloves and placed a clean brief under the resident, rolled the resident to her back and secured the brief, doffed gloves and washed her hands. During an observation on 01/24/24 at 4:45PM CNA A entered the room, closed the door, and told resident #3 about changing the brief as she positioned the resident bed to lying position. CNA A donned clean gloves, pulled the front of the brief down and folded it in. CNA A wiped the front peri area with wet wipes times 5 but stated she was soiled and continued wiping until clean. CNA stated resident has diarrhea. CNA A assisted resident to roll to the right side and hold the bar. CNA A removed the soiled brief and doffed her soiled gloves. CNA A donned clean gloves. CNA A wiped residents bottom 8 times with wet wipes until clean then applied rash ointment. CNA A doffed soiled gloves and donned clean gloves, placed the clean brief under the resident, rolled resident to her back and secured the brief. Resident positioned for comfort by CNA A then doffed gloves and washed hands. CNA A failed to wash hands or use hand sanitizer between glove changes. During an interview on 01/24/24 at 5:00 PM CNA A was asked to describe the correct steps for incontinent care. CNA A stated that she knew that she was supposed to use hand sanitizer between glove changes but did not have any, so she didn't use any. CNA A stated that the failure could cause diarrhea to spread to other residents. During an interview on 01/25/24 at 1:20PM Lead CNA stated that she trains all new staff. Lead CNA stated that when a new CNA is hired, she shadows them for a few days. Lead CNA stated that she performs random audits about every 3 months. Lead CNA stated that the correct procedure is to wipe with 1 wet wipe and throw it away, wipe with the 2nd wet wipe and throw it away, then wipe with the 3rd wet wipe and throw it away. Then doff gloves and hand sanitize and don clean gloves. Turn the resident, wipe with 1 wet wipe and throw it away, wipe with 2nd wet wipe and throw away, to wipe with 3rd wet wipe and throw it away. Then doff gloves and hand sanitize, then don clean gloves. Place clean brief, secure the brief, and dress resident, make them comfortable. It is the expectation that staff washes hands or uses hand sanitizer between glove changes. During an interview on 01/25/24 at 11:42 AM the ADON stated that it is the facility expectation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 12 of 13 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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 that staff uses hand sanitizer or washes hands between glove changes during incontinent care. The ADON stated that she does all training for nursing staff and lead CNA performs training for CNA staff. Record review of the facility's policy titled Personal protective equipment-gloves revised July 2009 indicated in part: Residents Affected - Few Policy statement: Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. Wash your hands after removing gloves. Record review of the facility's competency check off titled Infection control Pericare-Incontinent Care and revised January 2023 indicated in part: Wash hand and apply gloves and remove brief. Wash hands and dry thoroughly. Apply gloves. a. Wet washcloth/cleaning wipe and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. c. Ask resident to turn on her side with top leg bent. d. Rinse wash cloth / new cleansing wipe and apply soap or skin cleansing agent. e. Wash rectal area thoroughly, wiping from the base of labia towards buttocks. f. Rinse and dry thoroughly. Wash hands, dry thoroughly, sanitize and apply gloves when going from dirty to clean. Apply thin layer of skin barrier and replace clean brief. Wash hands and dry thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675017 If continuation sheet Page 13 of 13