Inspection·January 12, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for one (Resident #5) of seven residents reviewed for baseline care plans, in that: The facility failed to ensure a baseline care plan that included Resident #5's C-Collar was developed and implemented within 48 hours of admission. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers which could result in injury, a decline in physical, mental and/or psychosocial well-being. Findings included: Review of Resident #5's undated Face Sheet revealed he was an [AGE] year-old-male admitted on [DATE] with the following diagnoses of non-displaced fracture of seventh vertebra sequent encounter for fracture with routine healing, (Subsequent encounter is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase) muscle weakness, frequent falls and unsteady on feet. Review of Resident #5's Initial MDS dated [DATE] revealed he had a BIMS of 5 indicating he had severe cognitive impairment. MDS section I (medical condition) revealed Resident #5 had fractures and multiple traumas. Review of physician initial orders on 12/20/2022 failed to address Resident #5's Cervical Collar he was wearing due to fracture of the seventh vertebra. Review of Baseline Care Plan dated 12/28/2022 failed to address how to support Resident #5's Cervical Collar during bathing hygiene. During resident observation of 01/10/2023 at 11:55 AM while Resident #5 was being showered CNA C came out of the shower room and asked surveyor which way does the Cervical Collar was supposed to go on Resident #5 because it was removed during his shower. The Charge Nurse was observed coming to the shower room assisting CNA C put back on his Cervical Collar. During an interview with Resident #5 on 01/11/2023 at 9:59 AM he said when he is showered no one holds or supports his head during the shower. He said they take off the collar and wash him and were not always too gentle, stating he was not happy about how he was showered but was not injured. During an interview on 01/11/2023 at 9:16 AM the Therapy Director said her expectations regarding removing Resident #5's C-Collar, she would expect a physician's order to allow the remove of the collar and if removed to have a second person hold Resident #5's neck in place. If Resident #5 had an order the staff would normally loosen each side of the collar and change the supporting pads or put a towel in place to dry the pads and keep Resident #5's neck dry. She said by not giving support with someone who has a cervical vertebra fracture could cause increased harm and prolong the healing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 2 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 process. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/11/23 at 03:22 PM the DON said aides should provide support when taking off the collar with a towel (as support-non-support could cause increased injury and prolong the healing process). DON said, Aides took off collar for the shower. Initial care plans for removing collar may not be there and I am the one to does the initial care plans. Residents Affected - Few Review of Resident #5's care plan dated 01/11/2023 revealed no orders for C-collar removal. No initial care plan addressed how to shower resident or how to remove the Cervial Collar. in any portion of the care plan. Review of Resident #5's Care Plan dated 01/11/2023 revealed the following: Focus: Resident #5 requires use of a C-Collar due to fracture substained from a fall at home He is confused and forgetful and has removed his collar. He is at risk for pain and further injury. Goal: Staff will monitor Resident #5 for removal of Cervical Collar. Intervention: Monitor Resident #5 Cervical Collar on always FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 3 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 3 residents (Resident #3 and Resident #22) for care plan revisions, in that: The facility failed to ensure Resident #3's and Resident #22's care plans were revised to indicate urinary catheter anchors were included to prevent trauma and urinary tract infections. This deficient practice caused tissue trauma, reoccurring urinary tract infections, and place residents at risk for inadequate care. The findings include: Review of Resident #3's undated Face Sheet revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included dehydration (decline in body fluids), chronic obstructive pulmonary disease, (difficulty breathing) urinary retention,(inability to urinate on their own) and dysphasia (difficulty swallowing). Review of Resident #3's quarterly MDS dated [DATE] revealed the following: The resident required extensive assistance of one-to-two-person physical assistance and was always incontinent of bowel and has a Foley catheter for urinary incontinence. BIMS was recorded at 9 indicating Resident #3 was moderately cognitively impaired. Review of Resident #3's Care Plan updated 10/06/2022 revealed: Focus: Resident #3 has a catheter (a tube placed in the bladder via ureter) (the duct by which urine passes from the kidney to the bladder and is at risk for urinary tract infections and injury). Interventions: Monitor for and report to the physician any signs or symptoms of a urinary tract infection such as pelvic pain, burning with urination, blood-tinged urine cloudiness, no output and deepening of urine color. Monitor for pain and discomfort due to the presence of a urinary catheter. The Care Plan did not include a urinary anchor to protect and decrease incidence for urinary tract infections and penile trauma. During an observation of Resident #3's incontinence care by CNA D on 01/11/2023 at 3:20 PM revealed he had an indwelling catheter draining yellow urine and thick sediment in the catheter bag on the right side of his bed. The catheter tubing was not secured to Resident #3's leg with an anchor. When he was turned to his left side, the tubing moved frequently and was stretched during the incontinence care. The Surveyor had to stop catheter care due to traumatizing Resident #3's penis due to pulling and resident calling out in pain. CNA D cleaned Resident #3 buttock due to large bowel movement and returned Resident #3 to his back. After washing hands and changing gloves CNA D continued cleaning Resident #3's catheter. Red tinged secretions were noted on the catheter tube and was cleaned. Observation of Resident #3's penis while catheter care was being provided for revealed his penis was dividing from his meatus (The hole from the inside to the outside is called the urethral meatus). (The term 'meatus' refers to any opening from the inside to the outside.) to one third of his shaft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 4 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (penal shaft, the connection of the meatus to the length of the penis to the pelvic region) with ragged (having an irregular or uneven surface, edge, or outline). Pink (a color with a light red tint) tissue (groups of cells that have a similar structure and act together to perform a specific function) was folded out due to the placement and trauma of the catheter tube. This could possibly be due to the pulling because of not have a catheter anchor (a urinary catheter securement device to keep a Foley Catheter (brand name of urinary catheter) securely in place During an attempt to interview Resident #3 on 01/11/2023 at 3:50 PM Resident #3 was not willing to be interviewed after catheter care. During an interview with CNA D, on 01/11/2023 at 3:40 PM., she said she was being careful because the catheter moves around when they clean him. CNA D was asked if she knew if Resident #3 was supposed to have an anchor for his catheter, she said she did not know or if he ever had one (anchor). CNA D was asked if she was aware if Resident #22 had an anchor in place, and she said no he did not have one. CNA D said she frequently does catheter care for Resident #3 and #22 and knew they never had anchors when she provided care. She said she has worked for the facility off and on for 4 years. During an interview with the DON on 01/11/2023 at 3:50 PM (at Resident #3's bedside) she said she did not use anchors because they would come off especially when Resident #3 was showered three times a week. The DON said, she was aware of the frequent urinary tract infections. DON said, she did not like using band type catheter anchors. Review of Resident #22's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with a diagnosis of neurogenic bladder, chronic obstructive pulmonary disease, schizophrenia, fracture right leg and urinary tract infection. Review of Resident #22's MDS significant change dated 12/12/2022 revealed he required two-person assistance for transfer, dressing and hygiene. The BIMS was recorded at 10 indicating Resident #22 was moderately cognitively impaired. Review of Resident #22's Care Plan updated on 12/30/2022 revealed: Focus: Resident #22 had a Foley catheter and potential at risk for urinary tract infection related to nodular prostate with obstructive uropathy. Goal: Resident #22 will be free from catheter-related trauma through next review date (target 03/22/17). Intervention: Catheter care every shift. Report signs and symptoms of urinary tract infections. During an interview and observation with Resident #22 on 01/11/2023 at 3:00 PM Resident #22 he did not have an anchor holding his catheter. The Surveyor asked permission for the resident to move his covers to look for a catheter anchor. Resident #22 removed his covers, and a catheter anchor was not in place. During an observation and interview with CNA E on 01/12/2023 at 11:00 AM revealed Resident #22's covers were removed, and a catheter anchor was in place. CNA E was asked if she expected an anchor to be in place, she said she did not know if an anchor should be in-place. During observation of catheter care heavy sediment was collected at the drain of the urinary catheter tubing bend. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 5 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/12/2023 at 10:30 AM with Corporate Regional Nurse said physicians are always starting antibiotics for prophylactic for residents who have urinary catheters whether they have and infection or not. During an interview on 01/12/2023 at 10:35 AM DON said the facility did not have a Policy for Urinary Catheter Anchors. Review of Facility policy and procedure revised 02/10/2022 titled, Indwelling Foley Catheter Guidelines revealed the following: Anticipate Outcome: The facility shall identify and assess patients with indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infection and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary. Review of facility's mapping on 01/11/2023 for infections revealed three residents on back hall (Zone 5) with urinary catheters had UTIs (urinary tract infections). Tracking, and Trending for December 2022 revealed Resident #3 had a UTI 12/04/2022 with the antibiotics Cipro 500 mg twice a day for seven days. Resident #22 had a UTI 12/20/2022 using antibiotic Rocephin IV for six days and Bactrim DS for five days. Review of website: https://hytape.com/catheter-securement/best-practices-for-securing-urinary-catheters/?v=920f83e594a1 Revealed: Why do we need best practices for securing urinary catheters? Nurses in some specialties (e.g., wound care nursing, urology, gynecological surgery, etc.) know very well the consequences of improper catheter securement. If Foley or other indwelling urinary catheters are not properly secured, the device can cause trauma to the bladder and urethra, bleeding, bladder spasms, and skin erosion around the urethral meatus.1 Indeed, the term CALUTS stands for catheter-associated lower urinary tract symptoms and includes increased frequency, increased urgency, burning and/or pain during urination, and suprapubic pain.2 On the other hand, catheter dislodgment is usually preventable through proper technique, and preventing dislodgment and catheter-related trauma decreases the need for catheter reinsertion and reduces the physical and psychological burden on indwelling catheter use. Review of the Lippincott Manual of Nursing Practice 9th Edition, page 783 revealed the following regarding securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or another securement device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 6 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 3 residents (Resident #3 and Resident #22) for care plan revisions, in that: The facility failed to ensure Resident #3's and Resident #22's care plans were revised to indicate urinary catheter anchors were included to prevent trauma and urinary tract infections. This deficient practice caused tissue trauma, reoccurring urinary tract infections, and place residents at risk for inadequate care. The findings include: Review of Resident #3's undated Face Sheet revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included dehydration (decline in body fluids), chronic obstructive pulmonary disease, (difficulty breathing) urinary retention,(inability to urinate on their own) and dysphasia (difficulty swallowing). Review of Resident #3's quarterly MDS dated [DATE] revealed the following: The resident required extensive assistance of one-to-two-person physical assistance and was always incontinent of bowel and has a Foley catheter for urinary incontinence. BIMS was recorded at 9 indicating Resident #3 was moderately cognitively impaired. Review of Resident #3's Care Plan updated 10/06/2022 revealed: Focus: Resident #3 has a catheter (a tube placed in the bladder via ureter) (the duct by which urine passes from the kidney to the bladder and is at risk for urinary tract infections and injury). Interventions: Monitor for and report to the physician any signs or symptoms of a urinary tract infection such as pelvic pain, burning with urination, blood-tinged urine cloudiness, no output and deepening of urine color. Monitor for pain and discomfort due to the presence of a urinary catheter. The Care Plan did not include a urinary anchor to protect and decrease incidence for urinary tract infections and penile trauma. During an observation of Resident #3's incontinence care by CNA D on 01/11/2023 at 3:20 PM revealed he had an indwelling catheter draining yellow urine and thick sediment in the catheter bag on the right side of his bed. The catheter tubing was not secured to Resident #3's leg with an anchor. When he was turned to his left side, the tubing moved frequently and was stretched during the incontinence care. The Surveyor had to stop catheter care due to traumatizing Resident #3's penis due to pulling and resident calling out in pain. CNA D cleaned Resident #3 buttock due to large bowel movement and returned Resident #3 to his back. After washing hands and changing gloves CNA D continued cleaning Resident #3's catheter. Red tinged secretions were noted on the catheter tube and was cleaned. Observation of Resident #3's penis while catheter care was being provided for revealed his penis was dividing from his meatus (The hole from the inside to the outside is called the urethral meatus). (The term 'meatus' refers to any opening from the inside to the outside.) one third of his shaft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 7 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (penal shaft, the connection of the meatus to the length of the penis to the pelvic region) with ragged (having an irregular or uneven surface, edge, or outline). Pink (a color with a light red tint) tissue (groups of cells that have a similar structure and act together to perform a specific function) was folded out due to the placement and trauma of the catheter tube. This could possibly be due to the pulling because of not have a catheter anchor (a urinary catheter securement device to keep a Foley Catheter (brand name of urinary catheter) securely in place During an attempt to interview Resident #3 on 01/11/2023 at 3:50 PM Resident #3 was not willing to be interviewed after catheter care. During an interview with CNA D, on 01/11/2023 at 3:40 PM., she said she was being careful because the catheter moves around when they clean him. CNA D was asked if she knew if Resident #3 was supposed to have an anchor for his catheter, she said she did not know or if he ever had one (anchor). CNA D was asked if she was aware if Resident #22 had an anchor in place, and she said no he did not have one. CNA D said she frequently does catheter care for Resident #3 and #22 and knew they never had anchors when she provided care. CNA D said she frequently does catheter care for Resident #3 and #22 and knew they never had anchors when she provided care. She said she has worked for the facility off and on for 4 years. During an interview with the DON on 01/11/2023 at 3:50 PM (at Resident #3's bedside) she said she did not use anchors because they would come off especially when Resident #3 was showered three times a week. The DON said, she was aware of the frequent urinary tract infections. DON said, she did not like using band type catheter anchors. Review of Resident #22's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with a diagnosis of neurogenic bladder, chronic obstructive pulmonary disease, schizophrenia, fracture right leg and urinary tract infection. Review of Resident #22's MDS significant change dated 12/12/2022 revealed he required two-person assistance for transfer, dressing and hygiene. The BIMS was recorded at 10 indicating Resident #22 was moderately cognitively impaired. Review of Resident #22's Care Plan updated on 12/30/2022 revealed: Focus: Resident #22 had a Foley catheter and potential at risk for urinary tract infection related to nodular prostate with obstructive uropathy. Goal: Resident #22 will be free from catheter-related trauma through next review date (target 03/22/17). Intervention: Catheter care every shift. Report signs and symptoms of urinary tract infections. During an interview and observation with Resident #22 on 01/11/2023 at 3:00 PM Resident #22 said, he did not have an anchor holding his catheter. Resident #22 gave Surveyor permission to move his covers to look for a catheter anchor. Resident #22 removed his covers, and a catheter anchor was not in place. During an observation and interview with CNA E on 01/12/2023 at 11:00 AM revealed Resident #22's covers were removed, and a catheter anchor was in place. CNA E was asked if she expected an anchor to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 8 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be in place, she said she did not know if an anchor should be in-place. During observation of catheter care heavy sediment was collected at the drain of the urinary catheter tubing bend. During an interview on 01/12/2023 at 10:30 AM with Corporate Regional Nurse said physicians are always starting antibiotics for prophylactic for residents who have urinary catheters whether they have and infection or not. During an interview on 01/12/2023 at 10:35 AM DON said the facility did not have a Policy for Urinary Catheter Anchors. Review of Facility policy and procedure revised 02/10/2022 titled, Indwelling Foley Catheter Guidelines revealed the following: Anticipate Outcome: The facility shall identify and assess patients with indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infection and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary. Review of facility's mapping on 01/11/2023 for infections revealed three residents on back hall (Zone 5) with urinary catheters had UTIs (urinary tract infections). Tracking, and Trending for December 2022 revealed Resident #3 had a UTI 12/04/2022 with the antibiotics Cipro 500 mg twice a day for seven days. Resident #22 had a UTI 12/20/2022 using antibiotic Rocephin IV for six days and Bactrim DS for five days. Review of website: https://hytape.com/catheter-securement/best-practices-for-securing-urinary-catheters/?v=920f83e594a1 Revealed: Why do we need best practices for securing urinary catheters? Nurses in some specialties (e.g., wound care nursing, urology, gynecological surgery, etc.) know very well the consequences of improper catheter securement. If Foley or other indwelling urinary catheters are not properly secured, the device can cause trauma to the bladder and urethra, bleeding, bladder spasms, and skin erosion around the urethral meatus.1 Indeed, the term CALUTS stands for catheter-associated lower urinary tract symptoms and includes increased frequency, increased urgency, burning and/or pain during urination, and suprapubic pain.2 On the other hand, catheter dislodgment is usually preventable through proper technique, and preventing dislodgment and catheter-related trauma decreases the need for catheter reinsertion and reduces the physical and psychological burden on indwelling catheter use. Review of the Lippincott Manual of Nursing Practice 9th Edition, page 783 revealed the following regarding securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or another securement device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 9 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 1 resident (Resident #195) reviewed for therapeutic diets received the diet ordered per physician orders. The facility failed to provide Resident #195 a reduced concentrated sweets diet at lunch on 01/10/23 and 01/11/23. This failure placed residents receiving therapeutic diets at risk for nutritional deficits, undesired weight gain or loss and a decline in health. Findings included: Record review of the face sheet for Resident #195 dated 1/12/23 indicated the resident was an [AGE] year-old female readmitted to the facility on [DATE]. Diagnosis included diabetes ( a medical condition causing high blood sugar), Alzheimer's, and dysphagia (difficulty swallowing) . Review of the Quarterly MDS assessment, dated 12/19/2022 for Resident #195, indicated the resident had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. The MDS indicated the resident required supervision and assistance of 1 for eating,and she experienced coughing and choking while eating or taking medications. Record review of the Care Plan dated 12/28/22 for resident #195 revealed the following: At Risk for unstable blood sugars, intervention provide diet as ordered Mechanical soft diet Record review of Resident #195's physician orders, dated 01/12/2023 indicated the following: Reduced Concentrated Sweets diet, Mechanical Soft texture During an observation during the lunch meal on 01/10/2023 at 12:10 p.m. Resident #195 was served a regular sized cup of apple crisp. The DON was observed at the door of the dining room checking trays as they came out of the dining room. An interview with the DON on 1/10/23 12:21 PM revealed she did not know what size serving a resident on a reduced concentrated sweets diet should get for dessert. She stated she could ask the dietary manager when they had finished serving. Record review of the undated diet card placed in front of Resident #195's meal tray indicated mechanical soft and low concentrated sweets was listed next to diet. During an observation during the lunch meal on 01/11/2023 at 12:10 PM Resident #195 was served a regular sized cup of chocolate pudding . CNA P was sitting at the table to assist residents. Resident #195 did not respond when the surveyor attempted to interview her. In an interview on 01/11/23 at 12:10 PM with CNA P, CNA P stated she was not responsible for checking the diets. She stated the LVN's or the nurse on duty in the dining room (the DON) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 10 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible. She stated she did not know what size serving or what dessert resident #195 should receive on a low concentrated sweets diet. She stated the nurse and the people in the kitchen that serve the trays should know. Interview on 01/11/23 at 12:49 PM with the Dietary Manager, the Dietary Manager stated the dietary aide (who is also evening cook) is responsible for putting the desserts on the trays. She stated low concentrated sweets diet should have ½ of a regular serving, which would be 1/2 cup of dessert. She stated the dietary aide is responsible for checking the resident's diet slip and serving the correct serving size, the correct texture and also following any restrictions that are listed on the dietary slip. She stated the Nurse should check the resident's tray and the diet slip to ensure the correct texture and serving size goes to the resident. In an interview with the Regional Nurse and the Dietary Consultant ( Dietary Consultant by telephone) on 1/11/23 at 1:30 PM the Dietary Consultant confirmed that a reduced concentrated sweets diet for a diabetic resident was one half of a regular sized dessert cup serving. A full cup would be appropriate for a resident on a regular diet with no restrictions. The nurse consultant stated failure to serve the appropriate diet to resident #195 could result in an elevated blood sugar. In an interview on 01/11/23 03:08 PM the DON stated when checking resident's diets she checks for accuracy of type of meal served. She stated she also looks at the other items on the plate. She was asked if she could tell the difference in a reduced concentrated sweet dessert from a regular dessert, and she stated the reduced concentrated sweets diet would not be as full as a regular dessert. The DON stated she must have missed the full size serving of dessert that surveyor observed #195 receive on 01/10/23 and 01/11/23. Record review of the policy for Diets, Nutrition and Hydration dated revised March 2016 indicated the following: Each resident is provided with three meals daily and a nourishing bedtime snack. Each meal will be provided according to physician's orders Diets may be liberalized to allow more freedom in meal selection. Therapeutic diets and calorie restricted diets are provided for those who are not candidates for a liberalized diet FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 11 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 distribute food in accordance with professional standards for food service safety for residents who eat in the facility's only dining room. Residents Affected - Few The Dietary Aide failed to prevent potential cross contamination by accepting a resident's personal cup, (Resident #11) not sanatizing or gloving prior to accepting resident's cup, returning to the kitchen during meal service, and filling the cup with a drink without wearing gloves or sanatizing hands. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: During meal service on 01/10/2023 at 12:00 Noon Resident #11 was observed going to the kitchen door in his wheelchair and handing his personal cup to the Dietary Aide to fill with a drink. The Dietary Aide accepted the drink without gloves and returning to the kitchen, filled the cup, and returned the cup to Resident #11. Resident #11 returned to his place in the dining room. During an interview with the Dietary Manager on 01/11/2023 at 1:05 PM she said her expectation are kitchen staff should use gloves to accept anything from residents and should not bring them to the kitchen because it has the potential for cross contamination. During an interview with the Dietary Aide on 01/11/2023 at 1:15 PM said, she should have not accepted Resident #11's cup at the kitchen door entrance but should go to the back of the kitchen and brought the drink to the resident and filled his cup rather than causing potential cross contamination. Review of facility's policy and procedure dated 02/13/2020 titled, Infection Control Guidelines Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty between resident contact, after handling contaminated objects . b. Staff shall wash their hands with antiseptic preparation before performing c. patient/resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 12 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 (Resident #22,#24 and #30) who require glucometer checks for abnormal blood sugar on back hall (Zone 5). Residents Affected - Some The glucometer used for checking resident blood sugars was not calibrated on 01/04/2023 and 01/05/2023 as recorded in the glucometer logbook. This failure could put residents at risk of inaccurate blood sugar levels potentially causing adverse reactions. The findings were: Review of facility glucometer log on 01/10/2023 at 12:05 AM revealed 2 days (01/04/2023 and 01/05/2023) calibration was not completed. During an interview on 01/11/2023 at 12:20 AM LVN A said she did not know why no one else calibrated the glucometer on 01/04/2023 or on 01/05/2023. She was not there on those days so apparently no one did the calibrations. She said she is aware the calibration for the glucometer needs to be accurate to ensure resident blood sugars are accurate. During observation on 01/12/2023 at 12:20 AM LVN A calibrated Assure® Platinum glucometer correctly calibrating the glucometer correctly. During an interview on 01/12/2023 at 10:35 AM the Corporate Regional Nurse said it is important to do the calibrations for glucometers but the need for calibration depends on the brand of the glucometer. She said some glucometers only require weekly calibration but depends on the brand of the glucometer and the manufacture recommendations. Her expectations were calibrations need to be done if it is recommended by the manufacture. Facility policy and procedure dated 03/28/2018 titled, Glucometer Use and Maintenance Fundamental Information Follow manufacture's instruction for calibration of glucometers. Review of the website https:// cdn.Boundtree.com on 01/12/2023 revealed the following: Assure® Platinum glucometer recommends: Your sensor needs to be calibrated at least 2 times a day (every 12 hours) or when you get a Calibrate now alert. Calibrating your sensor 2 or 3 times a day is a best practice and may help with sensor accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 13 of 14 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required minimum of 80 square feet of room space per resident in 1 of 40 double occupancy resident rooms by failing to provide a minimum of 160 square feet in resident room # 13. This deficient practice could place residents who may occupy double occupancy resident rooms at risk of not having the personal living space to meet their needs. The findings included: In an interview on 01/10/2023 at 9:30 AM, during entrance conference, the administrator stated the facility had a room size waiver for resident room [ROOM NUMBER] and wished to continue the waiver. In an observation on 01/10/2023 at 11:30 AM, room [ROOM NUMBER] was measured at 156 square feet and did not meet the required minimum of 160 square feet for a double occupancy resident room. The facility's Bed Classifications Form 3740, signed and dated 01/10/2023 by the facility's administrator, documented resident room [ROOM NUMBER] was licensed and certified as a double occupancy resident room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 14 of 14