Health inspection·October 11, 2023

F 0656 plan failed to indicate Resident #26 was to wear a splint to her right hand. Level of Harm - Minimal harm or potential for actual harm Record review of a Therapy Screening Form dated 8/07/2023 indicated Resident #26 had limited range of motion to her right upper extremity and was at risk for contractures. Residents Affected - Few Record review of an Occupational Therapy Discharge summary dated [DATE] indicated Resident #26 met the goal to safely wear a resting hand splint on her right hand and right wrist for up to 2 hours with minimal symptoms of redness, swelling, discomfort, or pain. During an observation on 10/09/2023 at 9:51 a.m., revealed Resident #26 was not wearing a right-hand splint. During an observation on 10/09/2023 at 10:56 a.m., revealed Resident #26 was not wearing a right-hand splint. During an observation on 10/10/2023 at 10:46 a.m., revealed Resident #26 was not wearing a right-hand splint. During an interview on 10/10/2023 at 9:30 a.m., Resident #26's family member said he visited Resident #26 every day. The family member said the hand splint had not been placed on Resident #26 for numerous days. During an interview on 10/10/2023 at 2:43 p.m., the MDS coordinator reviewed the entire comprehensive care plan and said she believed she discontinued the care plan for Resident #26 to wear the right hand/wrist splint when she discontinued restorative care. The MDS coordinator said she was responsible for the care planning of splints. The MDS coordinator said she updated the care plans as she reviewed the 24-hour report and after receiving daily updates. The MDS coordinator said Resident #26's hand contracture could worsen without the splint application to her right hand/wrist. During an interview on 10/10/2023 at 2:16 p.m., LVN A said she was Resident #26's nurse. LVN A said she was responsible for applying Resident #26's right-hand splint as ordered. LVN A said she had documented today on the electronic record she applied Resident #26's splint but she said she failed to correct the documentation when Resident #26's refused the splint. LVN A said she documented the application of the splint on 10/09/2023 but she failed to apply Resident #26's right-hand splint. LVN A said contractures could worsen without application of the splints. During an interview on 10/11/2023 at 12:01 p.m., the DON said she communicated with the MDS coordinator for care plan needs. The DON said the care plan directed Resident #26's care needs including the right-hand splint. The DON said she expected the right-hand splint to be applied, monitored, removed, and a skin check completed daily as ordered. The DON said she had not monitored the placement of the splints daily. During an interview on 10/11/2023 at 12:49 p.m., the Administrator said every resident should have a care plan, the care plan must be updated to better treat the residents. The Administrator said the care plan needs were discussed in the morning meeting and the care plan was updated at that time. The Administrator said the MDS coordinator was responsible for ensuring the care plan was updated and the DON was responsible for monitoring. The Administrator said when the care plan was not updated then an aspect of the resident's care could go underserved or at a provided at a suboptimal level. The Administrator said he expected Resident #26's right hand splint to be in place as ordered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 2 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0656 prevent loss of range of motion increasing the right-hand contracture. Level of Harm - Minimal harm or potential for actual harm 2.Record review of Resident #29's face sheet, dated 10/10/23 indicated Resident #29 was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), major depression (a mood disorder that causes a persistent feeling of sadness), and generalized anxiety (a feeling of fear, dread, and uneasiness). Residents Affected - Few Record review of Resident #29's quarterly MDS assessment, dated 09/05/23, indicated Resident #29 was usually understood and usually understood by others. Resident #29's BIMs score was 05, which indicated she was cognitively severely impaired. Resident #29 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, bathing, and eating. The MDS indicated she had 5 days of antidepressant medication and 1 day of antianxiety medication during the 7-day look-back period. Record review of Resident #29's physician's orders dated 08/17/23 indicated, Cymbalta 60mg, give 1 tablet by mouth at bedtime for depression. Record review of Resident #29's physician's orders dated 09/08/23 indicated, Lorazepam 0.5mg, give 1 tablet by mouth twice a day for anxiety. Record review of Resident #29's physician's orders dated 07/05/23 indicated, Trazodone 50mg, give 1 tablet by mouth at night for depression. Record review of Resident #29's MAR record dated 10/01/23 through 10/11/23 revealed Resident #29 received Cymbalta 60mg, Lorazepam 0.5mg, and Trazodone 50mg as ordered. Record review of Resident #29's comprehensive care plan, dated 06/06/22, revealed Resident #29's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not addressed in the resident's care plan. During an interview on 10/10/23 at 3:05 p.m., the MDS coordinator verbally confirmed Resident #29's diagnoses of major depressive disorder with medications use of Cymbalta and Trazadone and generalized anxiety disorder with the medication use of Lorazepam were not addressed by the resident's care plan. The MDS coordinator said she was responsible for ensuring the care plans were updated. The MDS coordinator said the diagnoses and medication should have been listed in Resident #29's care plan and those omissions were an oversight. The MDS coordinator said the nurses/caregivers may not be aware of how to properly care for Resident #29 because her diagnoses and/or medications were not listed in her plan of care. During an interview on 10/11/23 at 11:20 a.m., the ADON said any nurse could add things to a resident's care plan. She said the MDS nurse was responsible for the care plans and the DON was the overseer of care plans. The ADON said they had morning meetings and clinical meetings Monday through Friday where they talked about changes and sometimes the MDS nurse would add or update care plans during those meetings. She said it was important to have a care plan for the care of each resident. She said the intent of the care plan was for staff to be able to meet the resident's needs. During an interview on 10/11/23 at 12:03 p.m., the DON said the MDS nurse was responsible for ensuring care plans were updated with any changes. She said the MDS nurse came to the morning meetings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 3 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and had access to the resident's orders and the 24-hour report to update the resident's care plans as needed. She said she was not sure where the breakdown occurred for Resident #29's care plan which had not been implemented with her current diagnoses and medications. The DON said care plans should be complete and accurate to ensure residents receive proper care. During an interview on 10/11/23 at 12:49 p.m., the Administrator said he expected all residents to have a care plan. He said they talked about the resident's care and needs during the morning meeting, and he expected the care plan to be updated to reflect the resident's care. He said the MDS nurse was responsible, and the DON was the overseer of care plans. He said the facility needed to tailor a care plan for each individual resident because all resident needs were not the same. He said without care plans being accurate, it was his opinion that care could be missed. Record review of a policy, Care Plans, Comprehensive Person-Centered, dated 10-2022 and reviewed January 2023 indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 4 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #38) residents reviewed for care plan revisions. The facility failed to ensure Resident #38's care plan was updated to reflect she was receiving Valium ([Diazepam] a medication used to relieve symptoms of anxiety and used off-labeled to treat insomnia) and discontinuation of anxiety medication of Lorazepam and Buspar. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #38's face sheet, dated 10/10/23 indicated Resident #38 was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included generalized anxiety (a feeling of fear, dread, and uneasiness), dementia (the loss of cognitive functioning thinking, remembering, and reasoning), major depression (a mood disorder that causes a persistent feeling of sadness), and insomnia (common sleep disorder that can make it hard to fall asleep). Record review of Resident #38's quarterly MDS assessment, dated 08/01/23, indicated Resident #38 was sometimes understood and sometimes understood by others. Resident #38's BIMs score was 05, which indicated she was cognitively severely impaired. Resident #38 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. The MDS indicated she received 7 days of antianxiety medication during the 7-day look-back assessment period. Record review of Resident #38's physician's orders dated 07/26/23 indicated, Diazepam 5mg, give 1 tablet at bedtime for insomnia. Record review of Resident #38's physician's orders dated 08/17/23 indicated, Diazepam 2mg, give 1 tablet twice a day for anxiety. Record review of Resident #38's physician's orders dated 07/10/23 indicated discontinuation of Lorazepam 1mg for anxiety. Record review of Resident #38's physician's orders dated 08/17/23 indicated, discontinuation of Buspar 10mg for anxiety. Record review of Resident #38's MAR record dated 10/01/23 through 10/11/23 revealed Resident #38 received Valium as ordered. It The MAR did not reveal the medications of Buspar or Lorazepam. Record review of Resident #38's comprehensive care plan, dated 04/12/23 indicated Resident #38 used antianxiety medication related to anxiety. The interventions of the care plan were for staff to administer Buspar and Lorazepam medication as ordered by the physician and monitor for side effects and effectiveness every shift. Resident #38's care plan did not address Valium. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 5 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 10/09/23 at 10:58 a.m., the MDS coordinator said she was responsible for updating care plans. She said she updated care plans based on the information she received from morning meetings, 24-hour reports, physician's orders, or during her quarterly, significant changes, and/or annual assessments. The MDS coordinator verified by looking at Resident #38's care plan and said she had not updated her care plan to reflect Valium. She said it was important to update the care plan because it indicated how to take care of the residents. During an interview on 10/11/23 at 11:20 a.m., the ADON said any nurse could update a care plan. The ADON said they had morning meetings and clinical meetings Monday through Friday where they talked about changes. She said the MDS nurse was responsible for updating care plans and the DON was the overseer. She said the intent of the care plan was to show what needs to be done to meet the resident's needs and if care plans were not being updated some vital information could be missed. During an interview on 10/11/23 at 12:03 p.m., the DON said all nurses could update a care plan. She said the MDS nurse was responsible for making sure all care plans were updated and she was the overseer. The DON said she was unsure why Resident #38's care plan had not been updated for discontinuation of Lorazepam or Buspar and updated to reflex Valium. The DON said it was important to update a care plan because it reflected the resident's care and needs. During an interview on 10/11/23 at 12:49 p.m., the Administrator said the care plan should reflect a picture of the resident's care needs. He said if a resident had a change of medication, then his/her care plan should reflect the change. The Administrator said the MDS nurse and DON were responsible for updating and monitoring the care plan for needed revisions. Record review of facility policy titled, Care Plans, Comprehensive Person-Centered, dated 01/23, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident.#13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 6 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 3 residents (Resident #s 36 and 37) reviewed for ADLs. Residents Affected - Few The facility failed to provide fingernail care for Resident #s 36 and 37. These failures could place residents at risk of not receiving services and care, infection, and a decreased quality of life. Findings included: 1) Record review of a face sheet dated 10/10/2023 indicated Resident #36 was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of moderate intellectual disability, difficulty swallowing, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #36 was usually understood and usually understood others. The MDS indicated Resident #36 was severely cognitively impaired. The MDS indicated Resident #36 had not rejected care. The MDS indicated Resident #36 required extensive assistance of two staff for bed mobility, and transfers. The MDS indicated Resident #36 required extensive assistance of one staff with dressing, eating, toilet use and personal hygiene. Record review of the comprehensive care plan dated 5/06/2021 and revised 8/17/2023 indicated Resident #36 had an ADL self-care performance deficit. The goal of the care plan was Resident #36 would maintain his current level of function. The care plan interventions for Resident #36 included he required extensive assistance of one person for personal hygiene. Record review of the Documentation Survey Report V2 dated October 2023 indicated under the section of personal hygiene indicated Resident #36 had personal hygiene care on 10/01/2023 with limited assistance of one staff. During an observation on 10/08/2023 at 9:14 a.m., revealed Resident #36 had ¼ inch long jagged fingernails with a brown, black colored material underneath the fingernails. During an observation on 10/09/2023 at 8:00 a.m., revealed Resident #36 continued to have jagged fingernails with brown, black colored material underneath the fingernails while consuming his morning meal. Resident #36 was not interviewable. 2) Record review of a face sheet dated 10/10/2023 indicated Resident #37 was an [AGE] year old male who admitted to the facility on [DATE] with the diagnoses of diabetes, intellectual disabilities, and obesity. Record review of a Significant Change MDS dated [DATE] indicated Resident #37 was sometimes understood and understood others. The MDS indicated Resident #37 had not refused care during the assessment period. The MDS indicated Resident #37 required extensive assistance of two staff with personal hygiene, bed mobility, transfers, and dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 7 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the comprehensive care plan dated 8/17/2021 and revised on 8/28/2021 indicated Resident #37 had an ADL self-care deficit. The goal of the care plan was Resident #37 would improve his current level of function. The intervention for Resident #37 included he required total assistance by 2 staff for personal hygiene. During an observation on 10/08/2023 9:14 a.m., revealed Resident #37's fingernails were jagged with black material underneath them. During an observation on 10/09/2023 at 8:00 a.m., revealed Resident #37 continued to have dirty, jagged fingernails while consuming breakfast. Resident #37 was not interviewable. Record review of the Documentation Survey Report V2 dated October 2023 indicated Resident #37 received total assistance with personal hygiene once on 10/01/2023. During an interview on 10/10/2023 at 2:00 p.m., the Shower Aide said nail care should be done daily by the nurse aides or nurses. The Shower Aide said she did nail care in the shower. The Shower Aide said without good nail care infections could occur. The Shower Aide said she had showered Resident #'s 36 and 37. During an interview on 10/10/2023 at 2:10 p.m., CNA B said Resident #36's fingernails should be done every other day while Resident #37 required daily nail care. CNA B said both Resident #36 and #37 were showered on Monday, Wednesday, and Friday on the day shift. CNA B said when the resident's nail were not clean infections could occur from feces underneath the fingernails. During an interview on 10/10/2023 at 2:16 p.m., LVN A said the treatment nurse was responsible for nail care. LVN A said she expected the CNAs to ensure fingernails were clean to prevent infections. During an interview on 10/11/2023 at 8:04 a.m., the Treatment Nurse said she and the weekend RN were responsible for cutting and cleaning residents fingernails. The Treatment Nurse said she had never been employed anywhere where the CNAs were not responsible for nail care. The Treatment Nurse said she had cleaned Resident #s 36 and 37 nails 10/10/2023. The Treatment Nurse was unable to indicate why Resident #36 and #37's fingernails were dirty. The Treatment Nurse said sometimes residents got fecal material underneath their nails. During an interview on 10/11/2023 at 11:16 a.m., the ADON said fingernail care was generally completed by the treatment nurses. The ADON said the Activity Director also had a nail day and nails could have been cleaned during the activity. The ADON said nurse aides should have cleaned the fingernails when dirty. The ADON said the nurse managers monitored the ADLs by reviewing the electronic documentation record, and with walking rounds at least daily. The ADON indicated the facility management had assigned residents for the company program neighbor where that was monitored but the program has not been fully implemented yet. The ADON said skin tears, skin infections, and oral/fecal infections could occur due to dirty fingernails. During an interview on 10/11/2023 at 12:01 p.m., the DON said she expected the residents to be clean and well-groomed including their fingernails. The DON said she had several systems in place to ensure nail care was completed. The DON said she expected the CNAs to provide nail care during showers or anytime the fingernails were dirty; the wound nurse should look at the fingernails, the transportation aide will do fingernails when not on transport and the activity director has a nail day. The DON said she had seen Resident #36 and Resident #37's nails were dirty on 10/10/2023 and had asked a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 8 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0677 CNA to perform nail care. The DON said the CNA must have gotten busy and forgotten the task. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/2023 at 12:49 p.m., the Administrator said he expected the residents to have nail care on a timely basis to ensure the fingernails were free of debris and look presentable. The Administrator said the DON was ultimately responsible to ensure ADL's were completed. The Administrator said dirty fingernails could possibly lead to a dignity issue, and possibly an infection control problem. The Administrator said ADLs were monitored in the electronic documentation record. Residents Affected - Few Record review of an Activities of Daily Living, supporting policy dated March 2018 indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 9 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews 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 of 11 (Resident #30) residents reviewed for accidents hazards and supervision. The facility failed to secure and store a microwave. This failure could place residents at risk for injury. The findings included: Record review of a face sheet dated 10/10/2023 indicated Resident #30 was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of kidney disease, high blood pressure, and cirrhosis of the liver (impaired liver function). Record review of an Annual MDS dated [DATE] indicated Resident #30 was understood and understood others. The MDS indicated Resident #30's BIMS score was 13 indicating an intact cognition. The MDS indicated Resident #30 required cueing for recall. The MDS indicated Resident #30 had a balance deficit indicating he was not steady but able to stabilize himself without staff assistance. The MDS indicated Resident #30's height was 6 feet or 72 inches. Record review of a comprehensive care plan dated 7/13/2021 and revised on 10/17/2021 indicated Resident #30 had impaired cognitive function or impaired thought process related to metabolic encephalopathy (a problem in the brain caused by a chemical imbalance). The goal of the care plan was Resident #30 would be able to communicate basic needs on a daily basis. The interventions included ask yes/no questions to determine Resident #30's needs and document changes in function. During an observation and interview on 10/08/2023 at 9:15 a.m., revealed Resident #30 had a microwave sitting on the top of a dorm size refrigerator. The dorm sized refrigerator was sitting on top of a bedside table. The height of the stacked appliances was 6 feet. The stacked items were not secured with any brackets or securing devices to the floor or wall. Resident #30 said the microwave was his personal microwave and the Administrator allowed him to have the microwave in his room. During an interview on 10/10/2023 at 2:57 p.m., LVN C said she was the nurse for Resident #30. LVN C said she had voiced concern regarding Resident #30's microwave to the administration. LVN C said the height of the microwave was an issue, burns could occur with removing food from the microwave at that height. LVN C said for the surveyor to see the Administrator for further questions regarding the microwave. During an interview on 10/11/2023 at 12:01 p.m., the DON said the decision to allow Resident #30 to have a microwave in his room was not her decision. The DON said she had no say regarding the risks the microwave imposed. The DON said he could heat up his food too hot causing burns, reheating insufficiently causing food borne illness, and could fall on Resident #30 or another resident. During an interview on 10/11/2023 at 12:49 p.m., the Administrator said he was not used to having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 10 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 - Minimal harm or potential for actual harm Residents Affected - Few residents having a microwave in their rooms. The Administrator said Resident #30 was considered competent to use his microwave, and his roommate could not use the microwave. The Administrator indicated the appliances tripled stacked to a height of six foot did give him pause. The Administrator said there were residents who wandered residing in the facility. The Administrator said another resident could wander in the room and this could potentially cause an accident for the other resident. The Administrator said he had called his corporate and requested permission to allow the microwave in Resident #30's room. During a record review of a policy for Resident Incident and Visitor Accident Report dated 10/08/2020 and reviewed January 2023 reflected iit did not address safety hazards with heating devices such as microwaves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 11 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 a resident who was incontinent of bladder received appropriate treatment and services, and an indwelling catheter is not used unless there is valid medical justification for catheterization and the catheter is discontinued as soon as clinically warranted for 1 of 2 residents (Resident #150) reviewed for urinary catheters. 1. Resident #150 had an indwelling urinary catheter since admission on [DATE] without a physician's order with an acceptable diagnosis for use. 2. The facility failed to ensure Resident #150's order for bladder training for Foley catheter removal was implemented. These deficient practices could affect residents who had urinary catheters at risk of not receiving care needed. Findings included: Record review of Resident #150's face sheet dated 10/10/23 indicated that she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of anxiety (a feeling of nervousness or unease), urinary tract infection, and high blood pressure. Record review of Resident #150's Entry MDS dated [DATE] indicated she did not have a completed comprehensive assessment and it was not due. Record review of Resident #150's baseline care plan 09/29/23 indicated she had an indwelling catheter. Record review of Resident #150's hospital Discharge summary dated [DATE] indicated she had a Foley catheter in the hospital for acute urinary retention, and she would discharge from the hospital to the facility with Foley catheter with a need for bladder training at the facility. Record review of Resident #150's physician's orders active as of the date 10/10/23 indicated she had the following orders: Foley Catheter 16 FR 30 CC bulb change PRN as needed with a start date of 10/03/23 with no diagnosis. During an observation on 10/08/23 at 09:41 AM revealed Resident #150 was lying in bed and had a Foley catheter at bed side hanging to gravity with dark amber urine noted. During an observation on 10/08/23 at 12:10 PM revealed Resident #150 was up in her wheelchair in dining room with a Foley catheter with a dignity bag noted. During an interview on 10/11/23 at 11:13 AM LVN A said she was the nurse who admitted Resident #150 to the facility and her diagnoses was urinary retention. She said she did not input the orders nor diagnosis for the Resident #150 and did not see the discharge summary to complete bladder training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 12 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 for the resident. She said she was unsure of who input the orders or diagnoses in the computer. She said the resident admitted at the end of her shift, so she only completed the admission assessment. She said it was important for Resident #150 to have the diagnosis for use of the Foley catheter and bladder training. LVN A said not knowing that the discharge summary had the bladder training in place could place the resident at risk for having the catheter and not truly need it. Residents Affected - Few During an interview on 10/11/23 at 11:42 AM the ADON said when residents admitted to the facility the charge nurse was responsible for completing the admission and ensuring orders and diagnosis were in the computer. She said the MDS nurse followed up on the orders and diagnosis the day of or after admission to ensure the diagnosis was in the computer. The ADON said it was important to have a proper diagnosis for use of a Foley catheter and the bladder training if ordered, should have been begun and the catheter discontinued if possible. She said the failure placed the resident a risk for infection. During an interview on 10/11/23 at 12:32 PM the DON said normally when a resident was admitted she would look at the diagnosis but did not with Resident #150 and she said she missed the discharge summary saying they needed to provide the bladder training on admission. She said all catheters should have a diagnosis at the time of admission, or it should have been taken out. The DON said in the case with Resident #150 she was busy completing investigations and missed checking her admission paperwork. She said Resident #150 should have had bladder training and had the catheter removed to determine if the catheter could be left out or replaced. The DON said she was fully involved in admitting residents, but the charge nurses should be aware of the need for a diagnosis for the catheters. She said the failure placed the resident at risk for infection. During an interview on 10/11/23 at 01:18 PM the Administrator said when residents were admitted to the facility, the nurses should have been very thorough at going through the discharge orders and ensuring they corresponded with the medical director to ensure they were following the physician's orders. He said the nurses were responsible for ensuring orders were in place for catheters and diagnosis and he expected the DON to monitor them. The Administrator said the risk to the resident was an increased risk for infection, UTIs, and discomfort. Record review of the facility's policy for Foley Catheters date 01/2023 revealed it did not address any information related to orders and diagnosis for use of Foley catheters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 13 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications and documented in the clinical record for 2 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #23 and Resident #150). 1.The facility failed to adequately monitor Resident #23's behaviors regarding his antidepressant and antianxiety medications. 2.The facility failed to adequately monitor Resident #150's behaviors regarding his antidepressant and antianxiety medications. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1.Record review of Resident #23's face sheet dated 10/10/23 indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of diabetes (a group of diseases that result in too much sugar in blood), major depression, anxiety (a feeling of nervousness or unease), and high blood pressure. Record review of Resident #23's admission MDS dated [DATE] indicated that she was usually understood and sometimes understood others. The MDS indicated Resident #23 had a BIMS score of 5 which indicated her cognition was severely impaired. The MDS also indicated Resident #23 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and was totally dependent on staff on bathing. The MDS indicated Resident #23 received antianxiety medications and antidepressant medications on 7 days of 7 days of the look back period. Record review of Resident #23's care plan initiated on 08/31/23 indicated she used an antianxiety medication and had intervention to monitor/document/report PRN any adverse reactions to antianxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. The care plan also indicated that she used an antidepressant and had an intervention to monitor/document/report PRN any adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in ADLs, continence, no voiding, constipation, diarrhea, gait changes, tremors, balance problems, muscle cramps, falls, dizziness, fatigue, and insomnia. Record review of Resident #23's physician's orders active as of the date 10/10/23 indicated that she had the following orders: Bupropion HCL ER (antidepressant medication) 150mg tablet by mouth one time a day for depression with a start date of 08/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 14 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0758 Level of Harm - Minimal harm or potential for actual harm Diazepam (antianxiety medication) 2mg tablet one tablet by mouth two times a day for anxiety with a start date of 08/19/23. Fluoxetine HCL (antidepressant medication) 3 10mg capsules by mouth at bedtime for depression with a start date of 08/18/23. Residents Affected - Few The physician's orders report did not indicate Resident #23 had any behavior monitoring for the use of antidepressant or antianxiety medications. Record review of Resident # 23's medication administration record dated 10/01/23-10/31/23 indicated she had been receiving Bupropion HCL ER (antidepressant medication) 150mg tablet by mouth one time a day for depression, Diazepam (antianxiety medication) 2mg tablet one tablet by mouth two times a day for anxiety, and Fluoxetine HCL (antidepressant medication) 3 10mg capsules by mouth at bedtime for depression, but there was no monitoring in place. 2.Record review of Resident #150's face sheet dated 10/10/23 indicated that she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of anxiety (a feeling of nervousness or unease), urinary tract infection, and high blood pressure. Record review of Resident #150's Entry MDS dated [DATE] indicated she did not have a completed comprehensive assessment and it was not due. Record review of Resident #150's baseline care plan 09/29/23 indicated she did not take an antidepressant medication nor an antianxiety medication on admission. Record review of Resident #150's physician's orders active as of the date 10/10/23 indicated she had the following orders: Buspirone HCL (antianxiety medication) 15mg tablet by mouth every day and evening for anxiety with a start date of 10/04/23. Duloxetine HCL delayed released particles (antidepressant medication) 30mg capsule by mouth at bedtime for depression with a start date of 10/03/23. The physician's orders report did not indicate Resident #23 had any behavior monitoring for the use of antidepressant or antianxiety medications. Record review of #150's medication administration record dated 10/01/23-10/31/23 indicated she had been receiving Buspirone HCL (antianxiety medication) 15mg tablet by mouth every day and evening for anxiety and Duloxetine HCL delayed released particles (antidepressant medication) 30mg capsule by mouth at bedtime for depression, but there was no monitoring in place. During an interview on 10/11/23 at 09:16 AM LVN C said she could not find any monitoring of the antidepressant nor the antianxiety medications in Resident #23's nor Resident #150's records. LVN C said she was unsure of who was responsible for placing the orders in for monitoring when they received an order for an antianxiety or antidepressant medication. She said she had never placed the order in for the monitoring of the medications. LVN C said without the orders for monitoring being placed in the computer, the nurses could not monitor for the side effects of the medication for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 15 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/11/23 at 11:45 AM the ADON said when the floor nurse placed the orders in the computer for the antianxiety and antidepressant medications, they should have entered the order for monitoring of the medications. She said the charge nurses were responsible for placing the monitoring order in the computer for the antianxiety and antidepressant medications. The ADON said the ADON and DON reviewed the orders daily for the medications that were input in the system on the day before. She said she and the DON missed seeing the medications because they were working on investigations. The ADON said the risk to the resident was for them to have had unnecessary medications and the charge nurse not knowing what side effects or symptoms look for while the residents were taking the medication. During an interview on 10/11/23 at 12:40 PM the DON said when the antianxiety or antidepressant medications ordered were placed into the system, the monitoring orders should have been placed in the system. The DON said she normally monitored the orders daily to ensure they were placed into the system as well as the monitoring. She said she had a face-to-face in-service with the charge nurses and discussed placing the monitoring with medications but did not document it. The DON said the failure would cause the charge nurse to not know what interventions or side effects to look for with the residents were taking the antianxiety or antidepressant medications, nor would the nurse know the behaviors to monitor for. During an interview on 10/11/23 at 01:25 PM the Administrator said his expectation was for the monitoring to be in place for any orders for psychotropic medications. He said any resident with the antianxiety or antidepressant medications should have been monitored to identify how the resident was responding to the medication and be aware of the need tailor the medication regimen to the residents' needs. The Administrator said without the monitoring in place, the residents' mental state, could decline or it could cause an exacerbation of behaviors or side effects, or prevent the residents from relief as the medications should have provided. The Administrator said the DON was responsible for ensuring the monitoring was in place. Record review of the facility's Psychotropic/ Psychoactive Medication Policy revised 01/2023 indicated: Policy Statement A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Antipsychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. Other medications which affect brain activity will also be subject to psychotropic medication requirements if documented use is a substitution for a psychotropic medication rather than the approved or original indication. Psychotropic medications are used only when appropriate and at the lowest possible dose to enhance the residents' quality of life, maximize functional ability or promote overall well-being. Policy Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 16 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 0758 1. Level of Harm - Minimal harm or potential for actual harm Residents will be monitored for behaviors to include behavior changes and for side effects and complications related to psychoactive medications, for example, sedation, lethargy, agitation, mental status changes, or behavior changes that affect ability to perform adl's or interact with others that causes the resident to withdrawal or decline from usual social patterns or shows the resident has a decreased engagement in activities and or cause diminished ability to think or concentrate. Abnormal involuntary movement, and anorexia daily Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 17 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 - Few 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 ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 2 medication carts and 1 of 1 medication room observed for medication storage. The facility failed to ensure the lock box that contained narcotic medications was permanently affixed to the refrigerator in the medication room. The facility did not ensure East Hall medication cart was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion. Findings include: During an observation and interview on 10/08/2023 at 8:15 AM, revealed LVN D left the medication cart unattended in the middle of the [NAME] hallway unlocked. LVN D stated she thought a resident was about to fall and left the cart to help the resident. During an observation and interview on 10/10/2023 at 3:24 PM, revealed the facility's medication room storage was observed and inside the medication refrigerator was the narcotic lock box that was not permanently affixed. LVN A stated there were narcotic medications inside the lock box. LVN A opened the narcotic medication box and inside was one card of Dronabinol 5mg which was a narcotic. LVN A stated she was unaware the narcotic medication box needed to be permanently affixed to the refrigerator. LVN A stated the nurses were the only ones with keys to the medication room so hopefully no one could get into the medication room to take the narcotic box. LVN A stated if someone were to have access to the narcotic medication box and took medication that was not prescribed to them, they would have to look up the side effects and call the doctor immediately. During an interview on 10/10/2023 at 3:52 PM, LVN D stated it was her responsibility to ensure the medication cart was locked. LVN D stated a resident was leaning over like she was going to fall out of bed, and she ran in to help her. LVN D stated she normally pulled the medication cart in front of resident's room, closed the computer screen and locked the cart when giving medications. LVN D stated if the medication cart was unlocked anybody could take anything out. LVN D stated one of the residents could get something that could be dangerous to them, or they could overdose. LVN D stated it was important to lock the medication cart so no one coul steal out of it and to keep everyone honest. During an interview on 10/10/2023 at 4:00 PM, the DON stated she expected the medication carts to be locked whenever they are not in the nurse's sight. The DON stated she monitored the medication cart when walking around and if she saw them unlocked, she would lock them. The DON stated if the medication cart was left unlocked someone could get into it that shouldn't. The DON stated leaving the medication cart unlocked could harm a resident if a resident got into the cart and took something they could have an adverse reaction to. The DON stated she was aware the narcotic box should be affixed to the refrigerator. The DON Stated it was important for the narcotic box to be affixed to the refrigerator so nobody could remove it. The DON stated someone could take the narcotic box and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 18 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 resident does not have their medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/2023 at 11:50 AM, the ADON stated the nurse that has the key was responsible for locking the medication cart. The ADON stated she expected the medication carts to be locked when the nurse was not there to supervise it. The ADON stated it was important to keep the medication cart lock because a confused resident get into it. The ADON stated she monitored when walking by the medication cart. The ADON stated leaving a medication cart unlocked could be harmful if a resident got something out that could harm them. The ADON stated she was aware the narcotic medication box in the refrigerator was supposed to be affixed to the refrigerator. The ADON stated the narcotic box in the refrigerator was affixed at one time and wasn't aware the narcotic box was no longer affixed to the refrigerator. The ADON stated it was important for the narcotic box to be affixed to the refrigerator so no one could carry it off. Residents Affected - Few During an interview on 10/11/2023 at 1:06 PM, the Administer stated he expected the medication carts to be locked anytime they are not directly in use, if the medication cart was out of the nurses sight it needs to be locked. The Administer stated the nurses are responsible for locking the medication cart. The Administer stated the DON monitored by spot checks. The Administer stated it was important the medication carts are locked because you don't want someone to have access to the medication if they're not the one who was authorized to have access. The Administer stated that could affect the resident by providing unrestricted access to otherwise restricted medication. The Administer stated he was not aware the narcotic medication box should be affixed to the refrigerator. The Administer stated it was important to affix the narcotic to the refrigerator because it makes it more difficult to take and provides a second layer of security. The Administer stated if someone took the narcotic medication box it could result in one of the residents not having their necessary medication available until the pharmacy sends replacement medication. The Administer stated for anyone stealing medication that were very dangerous in amounts that were uncontrolled and unsupervised. Record review of the facility's policy titled, Medication Labeling and Storage dated 2/2023, revealed, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 19 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #150 and Resident #14) reviewed for infection control practices. Residents Affected - Few The facility failed to ensure CNA E changed her gloves and performed hand hygiene while providing Peri-care and catheter care to Resident #150. The facility failed to ensure CNA H changed gloves or performed hand hygiene while providing incontinent care for Resident #14. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #150's face sheet dated 10/10/23indicated that she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of anxiety (a feeling of nervousness or unease), urinary tract infection, and high blood pressure. Record review of Resident #150's Entry MDS dated [DATE] indicated she did not have a completed comprehensive assessment and it was not due. Record review of Resident #150's baseline care plan 09/29/23 indicated she had an indwelling catheter. Her baseline care plan also indicated she required 1-person physical assist with personal hygiene, toileting, transfers, ad bathing. During an observation and interview on 10/09/23 at 2:41 PM, revealed CNA E and CNA F entered Resident #150's room to perform peri care and catheter care. CNA E and CNA F said they had already washed their hands. CNA E and CNA F applied gloves. CNA E performed peri care and catheter care while CNA F was assisting her. CNA E used the same gloves throughout the whole peri care and catheter care process. CNA E never changed her gloves or performed hand hygiene. CNA E said she should have changed her gloves and used hand sanitizer after cleaning Resident #150 and before applying the clean brief because her gloves were considered dirty. CNA E said she was nervous and not changing gloves and hand hygiene during care could have caused Resident #150 a urinary tract infection. CNA E said she had been checked off for peri care and incontinent care. Record review of the facility CNA competencies revised 1/2023 indicated CNA E completed competency for catheter care and incontinent care on 07/26/23 with all skills met by LVN G. During an interview on 10/11/23 at 11:39 AM the ADON said her expectation was for the CNAs to change their gloves between clean and dirty. She said LVN A and LVN G were responsible for completing peri-care check offs and catheter care check offs. She said monthly check offs were performed for hand washing with all the CNAs. The issue it could cause by not changing gloves in between dirty and clean could cause infection and UTI. It could be worsening for a resident who already had a UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 20 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/11/23 at 12:37 PM the DON said her expectations were for the CNAs to complete catheter care as trained. She said she expected the CNAs to change gloves, wash or sanitize between dirty and clean and after completion of care. The DON said LVN G was responsible for checking the CNAs off for peri care and ensuring they could provide care properly. The DON said she monitored and provided the packets they used when they were due for training. She said the failure of the CNAs improperly providing catheter care placed Resident #150 at risk for infection. During an interview on 10/11/23 at 01:21 PM the Administrator said the CNAs were expected to clean residents and change gloves and wash hands when going from a dirty area to a clean area. He was not as familiar with the catheter care as the peri care. The Administrator said the risk to the resident was risk of infection, as well as infection to the CNAs. He said the nursing managers were responsible for ensuring the CNAs provided proper peri care and catheter care. 2.Record review of Resident #14's face sheet, dated 10/10/23 indicated Resident #14 was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included, respiratory failure (a serious condition that makes it difficult to breathe on your own), Diabetes (a condition that happens when your blood sugar (glucose) is too high), major depression (a mood disorder that causes a persistent feeling of sadness), generalized anxiety (a feeling of fear, dread, and uneasiness) and hypertension (high blood pressure). Record review of Resident #14's significant change in status MDS assessment, dated 08/15/23, indicated Resident #14 was usually understood and usually understood others. Resident #14's BIMs score was 06, which indicated she was cognitively severely impaired. Resident #14 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. The MDS indicated Resident #14 was always incontinent of the bladder and frequently incontinence of the bowel. Record review of Resident #14's comprehensive care plan, dated 03/12/22 indicated Resident #14 had an ADL self-care performance deficit related to decreased mobility, obesity, and cognitive impairment. Resident #14 was incontinent of bowel and bladder. The interventions of the care plan were for staff to check Resident #14 every 2 hours and provide assistance with toilet use. During an observation and interview on 10/08/23 at 10:40 a.m., revealed CNA H was providing incontinent care for Resident #14 who had an incontinent episode. CNA H wiped the vaginal area and then without changing his gloves or performing hand hygiene assisted Resident #14 to turn onto her left side. CNA H started cleaning the buttock area, then applied her brief without hand hygiene or changing his gloves. CNA H took off his gloves, left the room, proceeded into another resident's room, and then performed hand hygiene. CNA H said he was not aware he needed to perform hand hygiene or change his gloves during peri-care from peri care from front to back or when he went from a dirty surface to a clean surface. He said he forgot to perform hand hygiene before leaving the room. He said he had been trained on hand washing and peri care. He said he knew without hand hygiene he could spread germs. Record review of competencies skills revealed CNA H had been checked off on handwashing 08/09/23 but did not reveal a checkoff on peri-care. During an interview on 12/15/2022 at 5:54 PM, the ADON said she expected CNAs to perform incontinent care correctly. The ADON said CNAs were expected to change their gloves and provide hand hygiene between dirty and clean. She said the CNAs were checked off by LVN A and LVN G monthly. The ADON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 21 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was unsure why CNA H failed to change his gloves and perform hand hygiene appropriately. The ADON said changing gloves and performing hand hygiene correctly could prevent cross-contamination, UTIs, and infection. During an interview on 10/11/23 at 12:03 p.m., the DON said she expected staff to perform incontinent care and hand hygiene correctly as per protocol. She said hand hygiene should be performed when hands were soiled, from dirty to clean, and when entering or exiting a room. She said LVN G was responsible for skill checkoffs on hire and yearly and she was the overseer. She said she did not know why CNA H did not have his peri-care skill checkoffs completed. The DON said failure to perform hand hygiene properly could lead to infection issues. During an interview on 10/11/23 at 12:49 p.m., the Administrator said he expected the aides to perform incontinent care and hand hygiene per policy. He said nurse management was responsible for ensuring the aides were competent in their skill sets. The Administrator said if the aides were not following policy and procedure on incontinent care and hand hygiene it could lead to infection issues. Record review of the facility policy, hand washing, and hand hygiene policy dated 03/01/20 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. when hands are visibly soiled, and b. After contact with a resident with infectious diarrhea. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: A. Before and after coming on duty, B. Before and after direct contact with residents, I. After contact with a resident's intact skin, M. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine, 10. Hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of the facility policy PERINEAL CARE POLICY AND PROCEDURE revised 10-2020 indicated: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Equipment and Supplies: gloves, bed protector, basin, soap/peri-wash, water, toilet paper, washcloths, towels, trash bag and protective barriers. Steps in the Procedure: . 3. Toilet resident if on toileting program (even if wet) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 22 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 4. Level of Harm - Minimal harm or potential for actual harm Wash hands and apply gloves . 8. Rinse thoroughly if using soap. Dry with a towel. Residents Affected - Few 9. Change gloves. Reposition patient for comfort . Record review of the facility policy Catheter Care, Urinary revised January 2023 indicated: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections . Steps in the Procedure 1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly . 1. Put on gloves . 2. Place bed protector under resident. 3. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 4. Pour wash water down the commode. Flush the commode. 5. Place soiled linen into designated container. 6. Put on clean gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 23 of 24 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 675051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeview Rehabilitation & Healthcare Center 502 East Coke Rd Winnsboro, TX 75494 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 7. Level of Harm - Minimal harm or potential for actual harm Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675051 If continuation sheet Page 24 of 24