Health inspection·July 20, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dining room table with three other residents eating his lunch. He stated the air conditioning stopped working yesterday and was ongoing issue with air conditioning. He stated it had been warm in the dining room for a couple of months the air conditioning did not work well in the dining room. He stated the temperature made it uncomfortable while he ate in the dining room. Interview on 07/18/23 at 1:38 PM with CNA C revealed the air conditioning in the dining room had been ongoing issue for at least 2 months. Observation on 07/18/23 at 1:58 PM revealed resident room [ROOM NUMBER] (Residents #8 and #99) air temperature was 82 degrees Fahrenheit taken by Maintenance Director. It felt warm and stuffy. Interview with Maintenance Director revealed the air was not blowing and he would have to see what was wrong with it. Interview on 07/18/23 at 3:45 PM with Maintenance Director revealed he was still working on fixing room [ROOM NUMBER]'s air conditioner. He stated air conditioner technician was coming out today and will look at fixing the air conditioner chiller. He stated he had to run water over the chiller every 15 minutes on the air conditioning unit all day today so it would not go out on him. He stated the facility was aware of repairs needed to be completed on the air conditioner but had not gotten the repairs completed. Interview on 07/19/23 at 8:32 AM with Resident #99 revealed it was warm in her room this morning and air conditioning did not get fixed in her room. She stated it was warm in in the daytime. She stated the dining room was still hot and had not been fixed. Interview on 07/19/23 at 8:35 AM Resident #41 stated her room was still warm and air conditioning was not fixed. She stated dining room was very hot and air conditioning was not working in the dining room for a couple of months at least. Interview on 07/19/23 at 9:20 AM with Housekeeping Supervisor revealed air conditioner in the dining room had not been working for a while. She stated the facility had air conditioner repair of chiller replaced. She then stated the water pump exploded and was replaced. She stated the chiller started throwing alarms and had a technician come out on 05/31/23. She stated the company gave facility quotes and estimates for air conditioner repair and were turned into corporate. She stated corporate approved the wrong quote, so they were waiting on corporate approval in order to get air conditioning working. In a Confidential Group Interview with 12 residents on 07/19/23 revealed the dining room was warm during the day and facility and had ongoing air conditioning issues at the facility. Observation on 07/19/23 at 12:20 PM taken by Life Safety Surveyor revealed air temperature was 90.1 degrees Fahrenheit in dining room with humidity of 48.1%. Residents were in dining room. Interview on 07/19/23 at 03:05 PM Resident #99 stated her room air temperature was better now after facility put in air conditioner window unit today. She stated last night air conditioner technician had fixed the air conditioning slept okay but this morning it was hot in her room. She stated now she would not have to wait for main air conditioning unit to be fixed. Interview on 07/19/23 at 4:31 PM Resident #38 stated the dining room had been hot the last couple of months especially during meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 2 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/19/23 at 3:32 PM with LVN E revealed the dining room had been hot and stuffy for the last couple of months. She stated resident room [ROOM NUMBER] did seem stuffier and warmer the last couple of days. She stated the residents in room [ROOM NUMBER] had not complained to her about the air conditioning in their room. Interview on 07/19/23 at 3:35 PM with CNA G revealed the dining room had been hotter the last couple of weeks. She stated the facility had ongoing issues with air conditioning. Interview on 07/19/23 3:40 PM with CNA F revealed the dining room had been hot since she started working at the facility. Interview on 07/20/23 at 11:05 AM with CNA I stated facility had issues with the air conditioning in the dining room for the last couple of months. Interview on 07/20/23 at 10:15 AM with Activity Director stated the last couple of months the facility had an issue with air conditioning and dining room would get hot during the day. Interview on 07/18/23 at 2:40 PM with the Administrator revealed about a month ago they had issues with air conditioner chiller and pump which were fixed. He stated yesterday the chiller went out and the Maintenance Director was working on fixing the air conditioner. He stated the air conditioning in the dining room was working. Interview on 07/19/23 with Maintenance Director revealed he was working on getting the air conditioner working in the dining room today to get the temperature cooler for the residents. Review of invoice for air conditioning repair dated 06/05/23 reflected the last time air conditioner was repaired. The DON stated on 07/20/23 at 11:20 AM the facility did not have a specific policy on air conditioning. Review of facility's policy Resident Rights revised August 2009 reflected Federal and state laws guarantee certain basic rights to all resident of this facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 3 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 to prevent urinary tract infections for one (Resident #28) of two resident reviewed for catheter care. CNA C and CNA D failed to keep Resident #28's urine catheter bag below the level of the bladder during a mechanical lift transfer. This failure could place residents at risk for urinary tract infections. Findings included: Review of Resident #28's Quarterly MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident had a BIMs of 15 which indicated he was cognitively intact. Resident had a foley catheter and was always incontinent of bowel. He required extensive two-person assistance for transfers and had infection of the foot. Diagnoses included neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), paraplegia (paralysis of lower body), multiple sclerosis (nervous system disease that affects your brain and spinal cord) and type 2 diabetes mellitus. Record review of Resident #28's care plan 06/19/23 reflected, .Problem .Potential for complications related to indwelling urinary catheter. Patient refused to wear leg strap .Interventions .Monitor, document, notify MD prn s/sx of complications related to catheter use, including UTI, trauma, bleeding .Maintain closed drainage system, with drainage bag lower than bladder level at all times . Review of Resident #28's Physician Orders Report dated 06/19/23 to 07/19/23 reflected, . Change catheter Q month .Flush foley w/500 ml saline Q HS . Observation on 07/18/23 at 10:05 a.m. revealed CNA C and CNA D completing ADL care on Resident #28 and placing him on mechanical lift sling in preparation to transfer from bed to wheelchair. CNA D placed the Resident #28's urinary catheter bag on top of his abdomen. Agency LVN A entered the room and stated she needed to complete wound care before they got the resident up (urinary bag remained on resident's abdomen). Agency LVN A completed the wound care. CNA C and CNA D positioned the mechanical lift over the resident and hooked up the sling. CNA D took the urinary drainage bag and hooked it on the front arms of the mechanical lift, above the resident's head. CNA C raised the mechanical lift and both staff transferred the resident to his wheelchair. The urinary bag remined level with the resident's head during the transfer. Urine was observed backing up in the tubing back toward the resident's bladder. Resident #28 was lowered into his wheelchair and staff hooked the urinary catheter bag on the wheelchair. In an interview on 07/18/23 at 10:40 a.m. with CNAs C and D, both stated the urinary drainage bag was to be always kept below the resident's bladder. CNA D stated she knew better, and CNA C stated she should have held the catheter bag while they are transferring the resident. Both staff stated by failing to do this it put the resident at risk for urinary tract infections. Record review of CNA C's skills verification checklist dated 05/01/23 reflected she was competent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 4 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 in Peri-care-Foley catheter tubing care. Level of Harm - Minimal harm or potential for actual harm Record review of CNA D's skills verification checklist dated 05/24/23 reflected she was competent in Peri-care-Foley catheter tubing care. Residents Affected - Few In an interview with the DON on 07/20/23 at 08:51 a.m. she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag in the resident's lap was not maintaining it below the bladder nor hooking it to the bars of the mechanical lift. She stated by not keeping it below the bladder urine could back up into the bladder and increase the risk of urinary tract infections. The facility's policy titled, Catheter Care, Urinary, dated September 2014, reflected, .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 5 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Residents Affected - Some The facility failed to provide RN coverage for 8 consecutive hours daily on Saturdays and Sundays in May to July 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings included: Record Review of facility's timesheets and sign in sheets for staff for May 2023 to June 2023 reflected the following: -05/06/23 reflected LVNs E, L, T and ZC worked at facility -05/07/23 reflected LVNs L, T and ZC worked at facility -05/13/23 reflected LVNs T, R Agency LVN S, and Agency LVN T worked at facility -05/14/23 reflected LVN P, LVN R, Agency LVN S and Agency LVN ZB worked at facility. -05/20/23 reflected LVN E, LVN T, LVN ZC and Agency LVN U -05/21/23 reflected LVN E, LVN T, LVN ZC and Agency LVN U -05/27/23 reflected LVN L, LVN R, Agency LVN S and Agency LVN V -05/28/23 reflected LVN L, LVN R, Agency LVN S and Agency LVN V -06/03/23 reflected LVN E, LVN ZC, Agency LVN S and Agency LVN W -06/04/23 reflected LVN E, LVN ZC, Agency LVN S and Agency LVN W -06/10/23 reflected LVN L, LVN R, Agency LVN S and Agency LVN W -06/11/23 reflected LVN L, LVN R, Agency LVN S and Agency LVN W -06/17/23 reflected LVN E, LVN ZC, Agency LVN Y and Agency LVN X -06/18/23 reflected LVN E, LVN ZC, Agency LVN X, previous ADON (RN) was at facility for 1 hour -06/24/23 reflected LVN L, LVN ZC, Agency LVN S worked at the facility. The previous ADON (RN) was at facility for 4.25 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 6 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0727 Level of Harm - Minimal harm or potential for actual harm -06/25/23 reflected LVN L, LVN ZC, Agency LVN S worked at the facility. The previous ADON (RN) was at facility for 4.25 hours. There was no RN coverage for Saturdays and Sundays for May 2023. 06/18/12, 06/24/23 and 06/25/23 had partial RN coverage. Residents Affected - Some Review of facility's sign-in sheets for July 2023 reflected the following: -07/01/23 reflected LVN E, LVN ZC, Agency LVN Y and Agency LVN Z -07/02/23 reflected LVN E, Agency LVN Y, Agency LVN Z -07/08/23 reflected LVN L, Agency LVN X, Agency LVN S and Agency LVN ZA -07/09/23 reflected LVN L, Agency LVN S, Agency LVN S, Agency LVN ZA -07/15/23 reflected LVN L, LVN ZC, Agency LVN A, Agency LVN S. -07/16/23 reflected Agency LVN A, LVN ZC, Agency LVN S and Agency LVN W There was no RN coverage on Saturdays and Sundays for July 2023. Interview on 07/19/23 at 3:35 PM with CNA G revealed she worked this past weekend when there was only 2 LVNs and no RN coverage. She was not aware of RN being at the facility on the weekends. She was only aware of the DON being the only RN at their facility. She stated the DON worked during the week and did not work on the weekends. Interview on 07/19/23 3:40 PM with CNA F revealed only 2 LVNS were on her shift when she worked every other weekend. She stated the only RN she knew worked at facility was DON and she did not come to the facility on the weekends. Interview on 07/20/23 at 10:30 AM with LVN E stated there was no RN coverage on weekends since she worked here. She stated the facility only had LVNs on weekend shifts with no RN. She stated the DON was the only RN who worked at the facility during the week. Interview on 07/20/23 at 11:05 AM with CNA I stated there were 2 nurses on weekend not sure if LVN or RN because they do not usually identify to us if LVN or RN. He stated DON did not come to building on weekends for RN coverage. Interview on 07/20/23 at 10:15 AM with the Activity Director stated she did come to the facilities on the weekends to assist with activities especially if she was having a group activity. She stated there was no RN coverage on the weekends. Interview on 07/20/23 at 8:50 AM with the DON revealed she was aware facility had no RN coverage on weekends. She only has the 2 LVNs on weekend with no RN coverage. She stated she did not come to facility on weekends. She stated LVNs could contact her by phone if needed something urgent but did not have an RN who came to the facility on weekends. She stated she was the only RN that was employed by the facility. She stated the facility did use agency nurses to assist with nursing staff coverage, but the agency nurses were LVNs not RNs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 7 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/20/23 at 11:20 AM with the DON revealed the facility did not have a specific RN coverage policy. Interview on 07/20/23 at 1:15 PM with Administrator revealed he was aware the facility did not have RN coverage on the weekends. He stated the DON provided RN coverage during the week. He stated he had only been at the facility as Interim Administrator for less than a month. Review of facility's policy Departmental Supervision revised August 2006 reflected 1. A Registered or Licensed Practical/Vocational Nurse is on duty twenty-four hours per day, seven days per week to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse is employed as the Director of Nursing Services .is on duty during the day shift Monday through Friday. The policy did not reflect about RN coverage on the weekends. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 8 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #28 and #7) of six residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #28. 2. LVN B failed to follow the procedure for accurate administration of Resident #7's Flonase (corticosteroids to treat allergy's) Nasal Spray. LVN B did not ensure Resident #7 cleared his nasal passages before use. These failures placed residents at risk of not receiving therapeutic dosage of medication. Findings included: 1. Review of Resident #28's Quarterly MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident had a BIMs of 15 which indicated he was cognitively intact. Diagnoses included type 2 diabetes mellitus. Review of Resident #28's Physician Orders Report dated 06/19/23 to 07/19/23 reflected, . Novolin R Flex pen 100 units/ml (3ml) amt: per sliding scale .251 to 300 = 8 Units .Before meals and at bedtime . An observation of the medication pass on 07/18/23 at 11:20 a.m. revealed Agency LVN A checked Resident #28's FSBS and obtained a reading of 263. Agency LVN A returned to the medication cart and disposed of the lancet and test strip and placed the glucometer on top of the medication cart. Agency LVN A looked at the MAR and determined resident would need insulin according to sliding scale and opened the medication cart and retrieved Resident #28's Novolin R Flex Pen. Agency LVN A placed a needle on the insulin pen and dialed 8 units without priming the pen first. Agency LVN A then administered the Insulin to Resident #28. In an interview with Agency LVN A on 07/18/23 at 11:25 a.m. she stated was unaware the Insulin Pen had to be primed before administering the required does. Review of Agency LNV A's Agency Nurse Competencies dated 03/29/23 reflected she was competent in Medication administration and blood sugar checks with glucometer cleaning. 2. Review of Resident #7's undated Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included dementia and allergic rhinitis (inflammation of the mucous membranes of the nose). Review of Resident #7's Physician Order Report dated 06/19/23-07/19/23 reflected, .Flonase Allergy Relief spray, suspension; 50 mcg/actuation; amt: 1 spray; nasal . An observation of the medication pass on 07/19/23 at 7:55 a.m. revealed LVN B at the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 9 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cart pulling Resident #7's a.m. medications. LVN B pulled a bottle of Flonase nasal spray. LVN B put on gloves, shook the bottle of nose spray, and placed the nose spray into each of the resident's nostrils without having the resident blow his nose and administered one spray in each nostril. In an interview with LVN B on 12/11/19 at 8:00 a.m. when asked what the procedure was for administering nose spray, she stated she did not know she was supposed to have the resident blow his nose. She stated she had never read the instructions from the package insert and they were not in the box of nasal spray. In an interview with the DON on 07/20/23 at 08:45 a.m. she stated staff were to prime the Insulin pens first to ensure they removed the air and ensure the resident received the required amount of Insulin. She stated staff were to have residents blow their nose prior to giving nasal spray to ensure the passageways were cleared of any mucus so the resident received the full benefit of the nasal spray. She stated failing to follow procedures could result in residents not receiving the full amount of medication ordered. Review of manufacturer instructions obtained from https://www.novo-pi.com/novolinr.pdf searched on 07/21/23 reflected, .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right does of insulin turn the doses selection to select 2 units Keep the needle pointing upwards, press the push-button all the way in .A drop of insulin should appear .if not repeat the procedure no more than 6 times . Review of the Facility's undated procedure titled, How to use and Insulin Pen, reflected, .To clear the air out of the pen: Remove the cap from the needle, turn the dose dial to 2 units, Hold the pen so the needle is up in the air, Push the end of the pen in to clear the air, Watch the tip of needle for a drop of insulin. You may need to do the more than once to see the drop of insulin on the needle . Review of the facility's policy, Medication Administration .Nose drops, dated January 2023, reflected, .Have resident gently blow nose to clear the nostrils . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 10 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary [NAME] J) of two dietary staff reviewed for qualifications. 1. The facility failed to employ a qualified Dietary Manager. 2. The facility failed to ensure Dietary [NAME] J had a current food handlers license. This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed. Findings included: Interview on 07/18/23 at 09:45 AM with Dietary [NAME] J revealed she was by herself after 2pm, no dietary aide or dishwasher during the week. Dietary [NAME] J stated the facility had been without a Dietary Manager for 3 weeks. Interview on 07/20/23 at 1:15 PM with Administrator revealed the Dietary Manager quit last month. The Administrator stated they were currently looking for a Dietary Manager. Record Review of Dietary [NAME] J's employee file reflected her date of hire was 01/20/22. Dietary [NAME] J' food handler's training certificate reflected she completed it on 08/18/20 and expired on 08//18/22. Interview on 07/20/23 at 2:30 PM with Dietary [NAME] J revealed she was aware her food handler's license training was not current. She had not completed it yet. She stated she would complete the food handler's training today and provide it to the facility. Interview on 07/20/23 at 2:04 PM with Consultant RD revealed she was aware the facility did not have current Dietary Manager, but it had happened recently within the last month. She stated she visited the facility once a month and since there was no Dietary Manager she met with Dietary [NAME] J to review kitchen sanitation. She stated Dietary personnel who worked in the facility were required to complete food handler's license and keep it current. She stated Dietary [NAME] J had her phone number and could reach out to her if she had any questions. Review of Dietary Department Schedule for June 2023 reflected on 06/27/23 Dietary Manager walked out and quit. Review of Dietary Department Schedule for July 2023 reflected no Dietary Manager and Dietary [NAME] J was the only dietary staff Monday through Wednesday and Fridays from 3 pm to 8 pm. Review of facility's policy Food Service Manager revised December 2008 reflected The daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. 1. The Food Services Manager is a qualified supervisor licensed by the state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 11 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 2. The facility failed to ensure items in the kitchen and dry storage were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to ensure that two of three refrigerators and two freezers' outsides were free from dirt, dust and dead bugs/pests. 4. The facility failed to discard items stored in reach-in refrigerator, kitchen area or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 5. The facility failed to ensure the handwashing sink was free from leaking/running water (hot side). 6. The facility failed to ensure the kitchen remained free of bugs and insects (pests). 7. The facility failed to ensure the ice machine was free from brownish yellowish stains inside the ice chest. 8. The facility failed to ensure the ice machine was free bugs/pests inside the ice chest. 9. The facility failed to ensure bread held in the kitchen was free from mold. These failures could place residents at risk for food-borne illness and cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 12 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 Findings Included: Level of Harm - Minimal harm or potential for actual harm Observations of the Kitchen on 07/18/23 at 09:35 AM revealed the following: -The hand sink's hot water leaks at more than a drip even when both sides are turned off. Residents Affected - Many -On top of the microwave was a pack of small tortillas, no label of item description, no open date, no manufacturer's expiration date, and no consume by or discard by date. -1-16 oz. bag of small marshmallows, open to air. Manufacturer's best by date 08/04/23, there was no received by date, no open date, and no consume by or discard date. -small white basket with various items inside- an inhaler without a name or prescription label, a small hanging weight scale, 2 digital thermometers, a yellow highlighter, 2 pkts. of hot chocolate, and binder clips. Observations of the dry storage area (inside kitchen, not a separate room) 07/18/23 at 09:49 AM revealed the following: -one -6 lbs. 10 oz. can [NAME] Peas, no received date, dented on the top side of the can. -one-6 lbs. 10 oz. can [NAME] Peas no received date, no manufacturer's expiration date. -one-6 lbs. 10 oz. can [NAME] Peas, received by date 06/02, dented on bottom side of can, no manufacturer's expiration date. -one-6.6 lbs. can of Tomato sauce receive 05/18, dented on side, no manufacturer's expiration date. -one-24 oz. bag of strawberry gelatin mix, open to air, no open date, no received by date, no consume by or discard by date. There was no manufacturer's expiration date. -one-32 oz. bag of powdered sugar, previously opened, dated 06/30/23, no consume by or discard by date, manufacturer's date illegible (has been smudged). -one-5 lbs. bag of Baking Cocoa 10-12% Fat, open to air dated 05/11, no open date, no consume by or discard by date, no manufacturer's expiration date. -one-20 lbs. tub of Rice, there was no label of item description, no open date, no consume by or discard by date. -one-20 lbs. tub of cornmeal, dated 10/19/23. There was no received by date, no consume by, or discard date or a manufacturer's expiration date. -Two-20 oz. loafs of bread, open to air. [NAME] was no received dates, no open date, no manufacturer's expiration date, no consume by or discard by date. -two-17 oz bags of spilt top hoagies rolls dated 06/29/23, had mold on multiple areas of at least 4 of the 8 rolls in each bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 13 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 -two-20 oz loves of thin sliced white bread, no received by date, manufacturer's best by date 06/27/23. Level of Harm - Minimal harm or potential for actual harm -one- large fly noted flying around while the surveyor was looking at the bread, it landed on the edge of the prep table. Residents Affected - Many Observations of the reach-in refrigerator on 07/18/23 at 10:27 AM revealed the following: -one small zip top bag of crumbs, no label of item description, no open date, no consume by or discard by date. -one small clear plastic bowl covered with plastic wrap with a small square piece of cake. There was no label of item description, no open date, no consume by or discard date. -one- large zip top bag with 5 lbs. bag of shredded mozzarella cheese inside, open to air. There was no received by date on the original packaging, no open date, no consume by or discard date note. Manufacturer packed date 04/24/23. -one small fly noted flying around the kitchen. -one-8 oz. [NAME] jack cheese cubes, manufacturer's expiration date 10/13/23. There was no received by date and no open date. -one-64 oz. container of Peach [NAME] Cranberry Juice, no received by date, no open date, no consume by or discard date. -one-64 oz. container of Strawberry [NAME] Cranberry Juice, no received by date, no open date, no consume by or discard date. -one-5 lbs. tub of sour cream, manufacturer expiration date 07/07/23, open date 07/17/23. There was no received by date. -one pack of turkey ham lunch meat, no label of item description, no received by date, no manufacturer best by date noted. -one pack turkey salami lunch meat, no label of item description, no received by date, no manufacturer best by date noted. -one-pack of turkey bologna lunch meat, no label of item description, no received by date, no manufacturer best by date noted. -one medium clear square contain with green lid labeled cheese date 03/16/23 had yellow sliced cheese. At the bottom of the container was some of the cheese was melted and some of the sliced cheese was melted into this melted re-solidified cheese. There was also some liquid noted at the bottom of the container, the integrity/consistency of the cheese in this container had been altered. Observation of the ice machine on 07/18/23 at 02:02 PM revealed the following: -The machine is located outside the kitchen in the dining room. On the left side of the ice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 14 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 machine, there was a vent/grate, it was dusty and dirty. Level of Harm - Minimal harm or potential for actual harm -Beneath the vent, at the corner leading to the front of the machine was a white hardened crusty like calcified substance. Residents Affected - Many -Inside the chest, the outer rim of the ice chute had brown and yellow stain the length of the chute. -In the ice itself, was a small dark colored dead bug/insect noted. In an Interview on 07/18/23 at 09:45 AM with Dietary [NAME] J. She stated she had been there over 1 year. She stated she was by herself after 2pm, no dietary aide or dishwasher. Dietary [NAME] j stated they (the facility) had been without a Dietary Manager for 3 weeks; the ADMIN had been helping out with ordering & taking things off the delivery truck. She stated she thought the census was 51 but she usually prepares a meal for 60, which covers her double portion resident. Dietary [NAME] J stated weekend crew does the putting away of dry storage, usually on Saturday. She stated the facility got delivery in on Thursday night when there was a bit more of a crew then to help put away freezer and fridge. When asked who was responsible for labeling, Dietary [NAME] J stated if you take something out of the case, put case's received by date and date opened on the item. She stated dry storage is not put away today, weekend staff did not do it as they normally do. She stated the fridge and freezer temps was not done due to being by herself she tries to focus on the bigger/more important tasks. Review of the Facility's Dietary Services Policy and Procedure Manual, Origination date 2001, revised December 2008, reflected Policy: Statement- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1 Food Services, or other designated staff, will maintain clean food storage area at all time. 4. Non-refrigerated food, disposable dishware and napkins will be store in a designate dry storage unit which is temperature and humidity controlled, free of insects and rodent and kept clean. 5. Food in designated dry storage area s shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a fist in-first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 11. Functioning of the refrigeration and food temperatures will be monitored at designate intervals throughout the day by the Food Service Manger or designee and documented according to state-specific requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 15 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the QAPI meetings for one of one facility, reviewed for QAPI, in that: Residents Affected - Some The facility failed to ensure the Medical Director attended QAPI meetings since 09/23/22. This failure placed residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings include: Review of the facility's QAPI meeting sign in sheets for July 2022 to June 2023 reflected QAPI meetings were held monthly. The QAPI meeting sign in sheet dated 09/23/22 reflected Medical Director met with facility QAPI. The Medical Director did not meet when facility had QAPI meetings in October 2022, 12/13/22, 1/19/23, 2/16/23, 3/16/23, 4/20/23, 5/16/23 and 6/29/23 with QAPI. Interview on 07/19/23 at 5:10 PM the Administrator stated there had only been one QAPI meeting since he started as the Administrator at the facility. He stated the Medical Director did not attend the June QAPI meeting. He stated the DON went over information with the Medical Director he needed to know about QAPI separately. Interview on 07/20/23 at 8:50 AM the DON stated the Medical Director had not been coming to the QAPI meetings since she had been at facility. She stated the Administrator was responsible for coordinating and scheduling the QAPI meetings. She stated she did meet with Medical Director weekly and went over concerns with him. She stated there had been a lot of turnover with Administrators at the facility not staying very long. She stated she thought it was difficult for the facility to schedule with the Medical Director the QAPI meetings. Interview on 07/20/23 at 10:15 AM with Activity Director revealed she had attended the QAPI meetings monthly and could only remember one time the Medical Director met with them for QAPI. Interview on 07/20/23 at 10:46 AM the Medical Director stated he was not communicated to nor informed about the facility's QAPI meetings monthly. The Medical Director stated he was aware he was required to attend QAPI meetings at least quarterly. He stated there had been turnover of administrators in the building since they moved last year to another facility. He stated the DON communicated to him on Fridays when he came to facility about areas discussed in the QAPI meetings, but he did not meet with the other members of QAPI. He stated he had no issues with other facilities he worked with in contacting him to schedule the QAPI meetings so he could attend. He stated a few months ago the front office person did contact him to schedule the QAPI meetings with the facility. The Medical Director stated he would find out about the QAPI meetings after already occurred at facility. Review of facility's policy Quality Assurance and Performance Improvement (QAPI) Committee revised April 2014 The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI Program .The following individuals will serve on the committee: .Medical Director .The committee will meet monthly at an appointed time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 16 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Resident #28, Resident #35, and Resident#7) of six residents and four of six staff members reviewed for infection control. Residents Affected - Some 1. Agency LVN A failed to perform hand hygiene during wound care for Resident # 28. 2. CNA C and CNA D failed to perform hand hygiene after performing ADL care and mechanical lift transfer on Resident # 28 and before leaving the resident's room. 3. LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #35 and Resident #7. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Observation on 07/18/23 at 10:05 a.m. revealed CNA C and CNA D completing ADL care on Resident #28 and placing him on mechanical lift sling in preparation to transfer from bed to wheelchair. CNA D placed the Resident #28's urinary catheter bag on top of his abdomen. Agency LVN A entered the room with wound care supplies in her hand. Agency LVN A stated she needed to complete wound care before they got the resident up (urinary bag remained on resident's abdomen). Agency LVN A put on gloves without performing hand hygiene and removed the old dressing off Resident #28's right big toe. Agency LVN A changed gloves but did not perform hand hygiene, and cleaned the toe with normal saline, applied the ointment and a clean dressing. Agency LVN A them removed her gloves and performed hand hygiene. CNA C and CNA D positioned the mechanical lift over the resident and hooked up the sling. CNA D took the urinary drainage bag and hooked it on the front arms of the mechanical lift, above the resident's head. CNA C raised the mechanical lift and both staff transferred the resident to his wheelchair. Resident #28 was lowered into his wheelchair and staff hooked the urinary catheter bag on the wheelchair. After positioning the resident, both staff gathered up the dirty linen and trash, removed their gloves and exited the room without performing hand hygiene. CNA C went to the linen cart to obtain clean linen, while CNA D walked down the hall with the trash. CNA D was observed using the hand sanitizer in the hallway. CNA C re-entered Resident #28's room with the resident's bedside table which had been placed in the hallway to make room for the mechanical lift. CNA C then exited the room without performing hand hygiene. In an interview on 07/18/23 at 10:35 a.m. with CNAs C and D, both stated they were to perform hand hygiene after they completed ADL care and after they had transferred the resident. Both stated they were to perform hand hygiene after entering a resident's room and before exiting a room and stated they had failed to do this. Both staff stated failing to perform hand hygiene placed resident at risk of cross contamination and could spread infection. In an interview with Agency LVN A on 07/18/23 at 11:28a.m. she stated was required to perform hand hygiene before and after wound care. She stated she was not aware she had to perform hand hygiene during wound care. She stated she knew she had to change her gloves after she had removed the dirty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 17 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 dressing, but stated she was not aware she had to perform hand after changing her gloves. Level of Harm - Minimal harm or potential for actual harm 2. Observation on 07/19/23 at 7:50 a.m. revealed LVN B performing morning medication pass, during which time LVN B checked the blood pressures on Resident #35. LVN B did not sanitize the blood pressure cuff after using it on Resident #35. LVN B put the blood pressure cuff on top of the medication cart after use. Residents Affected - Some Observation on 07/19/23 at 7:55 a.m. revealed LVN B continued to perform morning medication pass, during which time she checked the blood pressure on Resident #7. LVN B used the same blood pressure cuff right after using it on Resident#35. LVN B did not sanitize the blood pressure cuff before or after using it on Resident #7. Interview on 07/19/23 at 8:00 a.m., LVN B stated blood pressure cuffs should be sanitized with wipes between each resident use (before and after use on each resident) to prevent transmitting of infection from one resident to another. LVN B stated she knew she had forgotten something. Interview on 07/20/23 at 8:50 a.m. with the DON it was her expectation for all staff to perform hand hygiene after entering a resident's room, after glove changes and before exiting a resident's room. she stated her expectation were for staff to sanitize all reusable equipment between each resident use. The DON stated by failing to follow these procedures it placed residents at risk of cross contamination of infections from one resident to another. The DON stated she was responsible for training staff on infection control. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated August 2015, reflected, This facility consider hand hygiene the primary means to prevent the spread of infections .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .Use an alcohol-base hand rub containing at least 62% alcohol; or, alternatively, soap ( antimicrobial or non-antimicrobial) and water for the following situations .Before and after contact with a residents .before performing any non-surgical invasive procedures .Before and after handling an invasive device ( e.g. urinary catheters .) Before handling clean or soiled dressings, gauze pads, etc.After handling used dressings, contaminated equipment, etc.After contact with objects (e.g., medical equipment i) in the immediate vicinity of the resident .After removing gloves . Record review of facility's undated policy Infection Prevention and Control Program, reflected, .Environmental Cleaning/Disinfection .non-critical items are those that come in contact with intact skin but not mucous membranes. (Blood pressure cuffs .bedside tables) .Decontamination is cleaning and/or disinfecting an object to render it safe for handling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 18 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to maintain mechanical and electrical equipment in safe operating condition for residents in one of one dining room and 300 hall reviewed for physical environment. Residents Affected - Many 1. The facility failed to ensure dining room air conditioning was working properly to maintain safe and comfortable air temperatures for residents in the dining room. 2. The facility failed to ensure Residents #99 and #41 had working air conditioner in their room. 3. The facility failed to ensure resident room [ROOM NUMBER] and hall 300 had working air conditioner. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation and Interview on 07/18/23 at 10:06 AM with Resident #41 revealed it was hot in her room for the last 2 days. She stated facility was aware of it and gave 2 fans to try to keep the room cooler. Observation of Resident #41's room revealed it was warm and stuffy with 2 fans blowing. Observations on 07/18/23 from 10:11 AM 10:28 AM on hall 300 revealed it was warm but at end of hall 300 the air conditioning was working so it felt cooler than the hallway. Observation on 07/18/23 at 10:12 AM revealed resident room [ROOM NUMBER] was warm. Resident #9 stated it was hot today in her room and the hall was hotter than usual. She stated the facility was having issues with air conditioner. Observation on 07/18/23 at 11:33 AM revealed resident room [ROOM NUMBER]'s air temperature was 86 degrees taken by Maintenance Director. Interview with Maintenance Director revealed the air conditioner in resident room [ROOM NUMBER] was turned off so Maintenance Director turned it on. He stated the air conditioner should have been turned on. Observation on 07/18/23 at 11:35 AM revealed resident room [ROOM NUMBER]'s air temperature was 83 degrees. Observation and Interview on 07/18/23 at 11:37 AM revealed resident room's air temperature was taken by Maintenance Director which was 82 degrees Fahrenheit. He stated resident room [ROOM NUMBER]'s air conditioner was turned off, so he turned it on. Observation and Interview on 07/18/23 at 11:50 AM revealed the dining room temperature was 82 degrees Fahrenheit taken by Maintenance Director. There were residents in the dining room. He stated the chiller was not working for the air conditioning affected the dining room temperature. He stated the chiller went out yesterday (07/17/23) afternoon and he was working on trying to get it fixed. Observation on 07/18/23 at 12:18 PM revealed dining room was feeling warm. There was a food warmer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 19 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many next to the main entrance, with a box fan facing into the dining room. Residents were in dining room for lunch. Interview on 07/18/23 at 12:31 PM with Resident #99 revealed her room was hot on 200 hall and dining room was hot too. She stated the air conditioning was not working. She stated she had difficulty sleeping due to the heat. She stated the dining room was hot for a couple of months. She stated the hot temperatures in the dining room made it uncomfortable to eat in the dining room. Observation and Interview on 07/18/23 at 12:33 PM with Resident #8 revealed she was eating lunch. She stated it was warm in the dining room and the facility had ongoing issues with air conditioning. Observation and Interview on 07/18/23 at 12:35 PM with Resident #23 revealed he was sitting at dining room table with three other residents eating his lunch. He stated the air conditioning stopped working yesterday and was ongoing issue with air conditioning. He stated it had been warm in the dining room for a couple of months the air conditioning did not work well in the dining room. He stated the temperature made it uncomfortable while he ate in the dining room. Interview on 07/18/23 at 1:38 PM with CNA C revealed the air conditioning in the dining room had been ongoing issue for at least 2 months. Observation on 07/18/23 at 1:58 PM revealed resident room [ROOM NUMBER] (Residents #8 and #99) air temperature was 82 degrees Fahrenheit taken by Maintenance Director. It felt warm and stuffy. Interview with Maintenance Director revealed the air was not blowing and he would have to see what was wrong with it. Interview on 07/18/23 at 3:45 PM with Maintenance Director revealed he was still working on fixing room [ROOM NUMBER]'s air conditioner. He stated air conditioner technician was coming out today and will look at fixing the air conditioner chiller. He stated he had to run water over the chiller every 15 minutes on the air conditioning unit all day today so it would not go out on him. He stated the facility was aware of repairs needed to be completed on the air conditioner but had not gotten the repairs completed. Interview on 07/19/23 at 8:32 AM with Resident #99 revealed it was warm in her room this morning and air conditioning did not get fixed in her room. She stated it was warm in in the daytime. She stated the dining room was still hot and had not been fixed. Interview on 07/19/23 at 8:35 AM Resident #41 stated her room was still warm and air conditioning was not fixed. She stated dining room was very hot and air conditioning was not working in the dining room for a couple of months at least. Interview on 07/18/23 at 10:18 AM with Agency CNA H stated the air conditioning went out on the hallway yesterday afternoon and Maintenance was aware of it. She stated one of the residents was moved to another hall due to getting too hot. She stated the air conditioning unit at the end of the hallway in the common area was working so she tried to encourage residents to come down there where it was cooler. Interview on 07/19/23 at 9:20 AM with Housekeeping Supervisor revealed air conditioner in the dining room had not been working for a while. She stated the facility had air conditioner repair of chiller replaced. She then stated the water pump exploded and was replaced. She stated the chiller (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 20 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many started throwing alarms and had a technician come out on 05/31/23. She stated the company gave facility quotes and estimates for air conditioner repair and were turned into corporate. She stated corporate approved the wrong quote, so they were waiting on corporate approval in order to get air conditioning working. In a Confidential Group Interview with 12 residents on 07/19/23 at 11:19 AM revealed the dining room was warm during the day and facility had ongoing air conditioning issues. Observation on 07/19/23 at 12:20 PM taken by Life Safety Surveyor revealed air temperature was 90.1 degrees Fahrenheit in dining room with humidity of 48.1%. Residents were in dining room Interview on 07/19/23 at 03:05 PM Resident #99 stated her room air temperature was better now after facility put in air conditioner window unit today. She stated last night air conditioner technician had fixed the air conditioning slept okay but this morning it was hot in her room. She stated now she would not have to wait for main air conditioning unit to be fixed. Interview on 07/19/23 at 3:32 PM with LVN E revealed the dining room had been hot and stuffy for the last couple of months. She stated resident room [ROOM NUMBER] did seem stuffier and warmer the last couple of days. She stated the residents in room [ROOM NUMBER] had not complained to her about the air conditioning in their room. Interview on 07/19/23 at 3:35 PM with CNA G revealed the dining room had been hotter the last couple of weeks. She stated the facility had ongoing issues with air conditioning. Interview on 07/19/23 3:40 PM with CNA F revealed the dining room had been hot since she started working at the facility. Interview on 07/20/23 at 11:05 AM with CNA I stated facility had issues with the air conditioning in the dining room for the last couple of months. Interview on 07/20/23 at 10:15 AM with Activity Director stated the last couple of months the facility had an issue with air conditioning and dining room would get hot during the day. Interview on 07/18/23 at 2:40 PM with the Administrator revealed about a month ago they had issues with air conditioner chiller and pump which were fixed. He stated yesterday the chiller went out and the Maintenance Director was working on fixing the air conditioner. He stated the air conditioning in the dining room was working. Interview on 07/19/23 with Maintenance Director revealed he was working on getting the air conditioner working in the dining room today to get the temperature cooler for the residents. Review of invoice for air conditioning repair dated 06/05/23 reflected the last time air conditioner was repaired. Review of Maintenance Log from October 2022 to July 2023 reflected on 05/20/23 the air conditioning was not working in the whole facility. There were no other entries about air conditioning. The DON stated on 07/20/23 at 11:20 AM the facility did not have a specific policy on air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 21 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 conditioning. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 22 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review. the facility failed to provide a safe, functional, sanitary, and comfortable environment for dining room and three of four resident halls (200, 300 hall and 400 hall) reviewed for physical environment. 1. The facility failed to ensure the secure unit (300 hall) common area was maintained with floorboards in place and the wall not exposed. One of two doors in common area did not have a door sealant in place. 2. The facility failed to ensure resident room [ROOM NUMBER]'s closet ceiling was not leaking and had blackish stains on ceiling. 3. The facility failed to ensure resident rooms' 404 and 406 had a shower in working order. 4. The facility failed to ensure resident room [ROOM NUMBER] had a working air conditioner which did not leak. 5. The facility failed to ensure hall 200 overhead lights were free of dead bugs. 6.The facility failed to ensure resident common area at end of 400 hall was kept clean and window seals were cleaned. These failures placed residents at risk for an unsanitary and unsafe environment. Findings included: 1. Observations of the secure unit common area on 07/18/23 at 10:22 AM and 11:43 AM revealed the a floor board approximately 1 foot by 3 inches was detaching and a floorboard was completely detached approximately 8 inches x 3 inches . The small divider wall approximately 3 feet tall revealed at the end floorboard detached of about 6 inches along with 1 of 2 corner plastic protector completely off with pieces of wall sticking out. The door at end of hallway was missing door sealant approximately ½ inch on left bottom side of door about 6 inches length missing. Interview on 07/18/23 at 11:45 AM with Agency CNA H revealed she had noticed the floorboards coming up near the door to smoking area but the plastic coming off the wall had just happened. She stated she did not inform anyone about it. Interview on 07/18/23 at 11:47 AM revealed Maintenance Director stated he was not informed of the issues with the floorboards and the divider wall. He stated he expected facility staff to notify him about it. He stated he had only been at facility for less than a month and there was a lot of repairs needed to be completed. He stated the door did not seal properly on the left bottom side but had not noticed it before. He stated the door not sealing properly could allow bugs to come in. 2. Observation and Interview on 07/18/23 at 11:37 AM revealed resident room's air temperature was taken by Maintenance Director which was 82 degrees Fahrenheit. He stated resident room [ROOM NUMBER]'s air conditioner was turned off, so he turned it on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 23 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/18/23 at 11:38 AM revealed Agency CNA H stated they kept resident room [ROOM NUMBER]'s air conditioner off since the closet leaked when air conditioner was on. Observation on 07/18/23 at 11:39 AM revealed in resident room [ROOM NUMBER]'s closet had a trash can filled up with cloudy dark water with foul smell and ceiling in closet was bent down and had a blackish stain of about 10 inches opening above the trash can. The air conditioner was turned on and the ceiling had drops of water coming from ceiling. Interview on 07/18/23 at 11:40 AM with Maintenance Director revealed he was not aware of resident room [ROOM NUMBER]'s closet ceiling leaking. He stated the ceiling had mold on it and he shut off the air conditioner. 3. Observations on 07/19/23 at 3:50 PM and 4:06 PM revealed bathroom shower wall on left side wall between resident rooms [ROOM NUMBERS] had under faucet of shower there were numerous missing tiles of over 30 tiles (each tile about 4 x 4 inch) exposing inner wall of sheet rock across six rows of tiles across by seven rows length. There was an open hole in wall of approximately 5 tiles across and 5 tiles length. On shower floor three tiles were on ground along with pieces of sheet rock and grayish dirt on shower floor. Interview on 07/19/23 at 3:52 PM with CNA G revealed the shower room between resident rooms [ROOM NUMBERS] had missing tile and open wall for approximately 2 months. She stated the Maintenance Director, Housekeeping Supervisor and DON were aware of shower wall needing to be replaced. She stated Resident #27 did use her toilet, but they had to take resident to another shower room since shower could not be used until it was repaired. Interview on 07/20/23 at 9:05 AM with the DON revealed she was aware of resident shower room between 404 and 406 needed to be fixed. She stated she did not know what the delay was in fixing it, but Maintenance Director and Housekeeping Supervisor were aware of it. She stated they had moved Resident #27 to 100 hall due to the shower needed to be fixed but she kept coming back to her old room [ROOM NUMBER] so she was moved back to room [ROOM NUMBER]. She stated the CNAs took her to 100 hall resident shower room to shower her since the shower needed to be fixed. Interview on 07/20/23 at 12:50 PM with Housekeeping Supervisor revealed she was the Maintenance Director and Housekeeping Supervisor prior to current Maintenance Director being hired a couple of weeks ago. She stated on 05/30/23 and 05/31/23 the facility had different repair companies to come out to give the facility a quote which included the shower on 400 hall. She stated she got the different bids from different companies and sent them to Corporate and previous Business Office Manager for approval. She stated on 06/05/23 Corporate told her to request a check but did not specify which company to have repair it and then on 06/11/23 previous Business Office Manager reached out to Corporate to find out which company they wanted to go with for the shower repairs. She stated the facility was waiting for approval of which company to use and send money to company for the repairs to be completed for the shower. 4. Observation on 07/18/23 at 11:39 AM revealed in occupied resident room [ROOM NUMBER], there was a towel under the window unit air conditioner, it was leaking. The towel was soaking wet. Interview on 07/18/23 at 3:45 PM with Maintenance Director revealed he was not aware of resident room [ROOM NUMBER]'s air conditioner leaking. He stated he would have to look at it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 24 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Observation on 07/19/23 at 10:24 AM on 200 hall revealed there were six overhead lights, four of the lights had dead bugs inside the light covers. At the end of the hall right before the rehab gym in both left and right corners there are spider webs and spiders with dead bugs observed on the web. Interview on 07/19/23 at 2:38 PM with Housekeeper M revealed maintenance would clean the light covers. She stated that if the bugs get too bad then they notify maintenance and maintenance puts out bait traps. 6. Observation on 07/18/23 at 1:25 PM and 9:10 AM revealed at the end of the 400 hall the common area there were dead bugs, dust, and dirt on window seals Three dead bugs observed on floor. Interview on 07/19/23 at 9:13 AM with Housekeeping Supervisor revealed she did notice the window seals needed to be cleaned after surveyor brought it to her attention. She stated housekeeping tried to clean resident halls and the common areas daily. She stated the window seals needed to be cleaned and floor did have dead bugs on it. Review of facility's policy Environmental Services Safety Procedures implemented 01/01/23 reflected to ensure general safety procedures are followed in the course of performing housekeeping and/or laundry duties. The policy was not specific about housekeeping or maintenance requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 25 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 an effective pest control program was implemented so the facility was free of pests and rodents for the facility's dining room and three of four halls (Halls 200, 300 and 400) reviewed for pest control. Residents Affected - Some 1. The facility failed to keep an effective pest control program to ensure dining room was free of flies, gnats and spiders. The facility failed to ensure bug zapper in dining room was serviced and not full of flies and gnat. The facility failed to ensure ice machine was free of dead gnat. 2. The facility failed to ensure hall 300 and dining area for hall 300 was free of bugs. 3. The facility failed to ensure halls 200 and 400 were free of bug activity. These failures could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: 1. Observations during residents' lunch on 07/18/23 at 12:18 PM in dining room revealed in front of the 2nd set of sliding doors from the kitchen entrance, in the top left corner was a spider web with a live small spider. The 1st set of sliding doors, a dime-sized dark colored spider crawl across the sliding door in the dining room. Observation on 07/18/23 at 2:02 PM revealed a dead dark colored bug on the ice in the ice machine. Interview on 07/18/23 at 2:05 PM with Dietary [NAME] J revealed there was a bug on the ice and appeared to be a gnat. She stated she will need to clean out all the ice out of ice machine. Observation on 07/18/23 at 2:27 PM revealed Dietary [NAME] J was scooping ice out of ice machine while ice machine was still on. Interview on 07/18/23 at 2:28 PM with the DON revealed the ice machine will need to be turned off, all ice disposed of and then cleaned out properly before it can be used again. Observation on 07/19/23 at 1:00 PM revealed a bug zapper the size of a small neon sign, mounted up on the wall in the dining room to the left of the kitchen entrance door. It had a green neon light inside (to draw the bugs in). In the background, there were about 10 small black squares on 2 rows. On each square there was at least 25 gnats (10x20=250x2= 500) there was some moths and flies inside as well scattered over the other bugs. To the left of the bug zapper was a spider web with some dead bugs and a spider. Above that, where the wall meets the ceiling, there was about 1 foot (length of a standard 12 ruler) of spider webs dotted with dead bugs and spiders. Interview on 07/19/23 at 1:20 PM with Housekeeper N revealed the device on the wall with neon green light in the dining room killed bugs and it had a lot of bugs on it, some flies but most were gnats. Housekeeper N stated she guessed maintenance cleaned it. She said she thought it should be cleaned twice a week. She stated to the left of the bug zapper, were cobwebs, bugs, spiders, and dirt. She stated the harm this poses to the residents was the bug zapper could catch on fire. Housekeeper N (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 26 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said at the facility she has seen water bugs; June bugs and she thinks some cockroaches on the 300 hall in the last room on the left side and just water bugs in the laundry room. She stated she reported these sightings to the Housekeeping Supervisor. Interview on 07/19/23 at 2:05 PM with Maintenance Director revealed he had requested a maintenance log from the Administrator as well as all the reports of bug/pest sightings he was told they received. He said that the facility would be getting a new pest control tech and facility accepted his bid just today. Maintenance Director was asked to identify the device on the wall with the neon green light and stated it was a bug zapper. He further stated emptying out the bug zapper is contracted out as part of the service with pest control. He stated the risk to residents could be hazardous and a health issue with the decomposing bugs are not good. At 2:12 PM revealed Maintenance Director turned the bug zapper off. Maintenance Director stated, it's not supposed to be that full, no bug could land on it anyway. He stated it was gnats, moths and flies on the inside. He also described what he saw to the left of the bug zapper was a spider's web with may fly entrapped. 2. Observation on 07/18/23 at 10:20 AM revealed Resident #45 was lying down on couch in common area. There was a dark bug turned over on ground about 2 feet away from the couch. Observation on 07/18/23 at 10:22 AM revealed Resident #35 was sleeping in her bed on the secure unit in room [ROOM NUMBER]. There were two flies in her room landing on her bedding. Interview on 07/18/23 at 11:10 AM with Agency CNA H revealed she had noticed bugs including flies and water bugs. She stated the bugs were bad after smoking break for residents. Observations on 07/18/23 at 10:24 AM and 11:44 AM revealed door at end of hallway of secure unit had an opening with absence of door sealant of about ½ inch on left bottom side of door about 6 inches length. Interview on 07/18/23 at 11:47 AM with Maintenance Director revealed pest control had not come out since he had started working at the facility less than a month ago. He stated the bugs could come in more after smoke breaks. He stated he did not know when pest control came out or how often. He stated the door did not seal properly on the left bottom side but had not noticed it before. He stated the door not sealing properly could allow bugs to come in. Observation on 07/18/23 at 12:52 PM revealed three flies were in dining area of 300 hall while residents on the secure unit were eating lunch. One of the flies landed on table where a male resident was eating his lunch. Confidential Group Interview with 12 residents on 07/19/23 at 11:19 AM revealed the facility had ongoing issues with pests including huge water bugs, roaches, spiders and dark ant-like bugs. Observation on 07/19/23 at 10:24 AM on 200 hall revealed there were six overhead lights, four of the lights had dead bugs inside the light covers. At the end of the hall right before the rehab gym in both left and right corners there are spider webs and spiders with dead bugs observed on the web. Interview on 07/19/23 at 2:38 PM with Housekeeper M revealed maintenance would clean the light covers. She stated that if the bugs get too bad then they notify maintenance and maintenance puts out bait traps. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 27 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0925 Level of Harm - Minimal harm or potential for actual harm Interviews on 07/19/23 at 9:38 AM and 3:32 PM with LVN E revealed she had only seen water bugs at the facility. She said, I put it in the maintenance book and tell maintenance. At the time when I entered the issues the then maintenance person did nothing. I have not seen anyone here spraying. Since the new person (maintenance director) I have not seen any issues. LVN E stated last time she saw pest control technician was back in June 2023 sometime. Residents Affected - Some Interview on 07/19/23 at 3:35 PM with CNA G revealed the facility had issues with flies and water bugs. She stated she had seen a water bug on Resident #5's bedding when she gave her a bed bath. She stated she flicked it off and it scootered away. She stated she did not report the water bug to the Maintenance Director. She stated the water bugs were worse on 400 hall. Interview on 07/19/23 3:40 PM with CNA F revealed the facility had issues with flies, gnats and water bugs. She had not seen pest control come out to the facility to treat the bugs. Observation on 07/19/23 at 3:49 PM revealed two flies landed on Resident #2's blanket while she was lying in bed. Interview on 07/19/23at 4:25 PM with Resident #149 reflected she had seen water bugs in her room and last time was 2 days ago. She stated it came in from hallway and it moved quick. She stated the bug was dark color and big bug. Interview on 07/19/23 at 4:31 PM with Resident #38 revealed the flies and gnats were bad in the facility. He had seen big dark colored water bugs. He stated the flies were in the dining room when they ate and in his room for a while but could not specify how long. Interview on 07/20/23 at 11:05 AM with CNA I revealed he had seen water bugs and flies at the facility. He stated last week he had turned on shower and water bug came out of the shower drain. He did not know when the pest control came out last. He did not report it to Maintenance Director. Interview on 07/20/23 at 11:55 AM with Pest Control Technician revealed he came out to the facility monthly and was scheduled to come out today to service the facility for gnats. He stated since he had been coming out the facility since January 2023 he had discussed with the facility about issues with gnats. He stated about 2 or 3 months ago when he serviced the facility they had issues with gnats and flies, so he had reached out to corporate about getting fly lights to assist with fly and gnat issues. He stated the fly light in the kitchen was not able to be serviced due to the device was too old and could not get glue traps to replace. He stated he can only treat resident rooms when residents are not in their room. He stated the facility had an ongoing issue with drain flies due to drains not being cleaned properly. He stated he had not seen roaches at the facility and was not informed of issues with water bugs in the facility. He stated if staff were reporting water bugs coming out of the drains it mean there was some kind of issue of bugs harboring in the drains. He stated the last couple of times he had come out to facility he had seen issues with June bugs. He stated he was not notified by the facility the pest control log had been misplaced. Interview on 07/20/23 at 12:50 PM with Housekeeping Supervisor revealed she was the Maintenance Director and Housekeeping Supervisor prior to current Maintenance Director being hired a couple of weeks ago. She stated the facility did have issues with flies, water bugs and roaches. She state the pest control came out monthly to service the building. She stated she did not know the pest control book was missing. She stated there had been a pest control log before. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 28 of 29 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 675067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gainesville Convalescent Center 1900 O'Neal St Gainesville, TX 76240 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/20/23 at 9:10 AM with Administrator revealed he could not locate the pest control book and did not find a pest control log for the facility . He stated they were in the process of changing pest control companies. Record Review of facility's maintenance log for October 2022 to July 2023 reflected the date of 05/11/23 on halls 300 and 400 to spray for roaches and ants. Pest Control company was called. There were no other entries about bugs or pests. Review of pest control documentation for April 2023 to June 2023 reflected the following: -06/01/23 pest control serviced the building. Housekeeping Supervisor reported cockroaches on Hall D (300 hall). Pest Control saw no pest control activity. -05/03/23 facility reported cockroaches in the interior. Pest control sprayed liquid residual in interior. -04/04/23 pest control visited, and Housekeeping Supervisor reported gnat activity in the kitchen. Pest Control did fly treatment in areas of activity Review of facility's pest control policy undated reflected the facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 29 of 29