Health inspection·December 16, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated she had received one the day before), 11/27/23 (refused, notes on sheet indicate that the resident said the water was too cold), 12/5/23, 12/10/23, and 12/15/23.This data indicated that Res#1 had only received/offered showers/bed baths 9 days out of 35 days of data available notating showers/bed baths. Record review of Point of Care ADL Category Report, dated 11/15/23 to 12/15/23, indicated that from 11/21/23 to 12/15/23 shower/bathing activity either did not occur or was left entirely blank. Record review of Resident #1's skin assessments for the months of November 2023 and December 2023 revealed no skin degradation. In an interview on 12/16/23 with the ADM at 10:08 AM, the ADM indicated that the facility had been having issues with hot water over the last two to two and a half weeks. She stated that it was a problem with the pumps with the boilers but that they had always had at least one pump functioning, providing some hot water. She stated that new pump had been ordered and should be at the facility and installed on 12/16/23. She stated that there was only one day that only two halls were without adequate hot water. In an interview on 12/16/23 with Resident #6 at 10:55 AM, revealed sometimes the water was hot in the morning at the facility, and that he had taken a cold shower that morning. But he normally only took a shower about once a week as his choice, and that he did not like to get bed baths. In an interview on 12/16/23 with Resident #1 at 11:05 AM revealed she had not taken a shower for over two weeks, she indicated the hot water was out, and the staff had not offered her a bed bath or a shower. Resident #1 indicated her regular shower days were Tuesday, Thursday, and Saturday. She stated she would like to take three showers a week. In an interview on 12/16/23 with the ADON at 11:17 AM, revealed the facility had been experiencing a hot water issue for the last two weeks. She stated that they always had at least one hall with hot water working during that time and they had shifted showers for the residents to the morning hours because there was more hot water at that time. She stated the facility did not have good adherence to notating showers because the facility was using a lot of agency staff lately. In an interview on 12/16/23 with Res #2 at 11:46 AM, Resident #2 revealed that he had not taken a shower in two weeks, but that he had received several bed baths with warm to hot towels. In an interview on 12/16/23 with LVN A at 11:59 AM, LVN A revealed the facility had an issue with having enough hot water for the last two weeks. The staff had been heating water in microwaves and testing that it is not too hot and using that water on towels for performing bed baths. The staff do have a book at each nursing station that has to be filled out to notate showers and bed baths. the staff also notate when residents refuse to take showers. LVN A stated she had not seen any rise in any skin degradation as that would the first issue to look for. When residents do not get showers, it could affect their skin, their self-esteem or cause mental harm. In an interview on 12/16/23 with CNA E at 12:31 PM, CNA E stated that there had been some issues with hot water over the last two weeks. She stated that she did not have any residents that had not had not received showers or bed baths. She stated that when staff gave showers to residents, the shower is supposed to be noted on a shower sheet whether it did or did not happen, and that the shower sheets are to be turned in everyday to the nurse's station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 2 of 5 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 12/16/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 12/16/23 with Resident #3 at 12:33 PM, Resident #3 stated she had not taken a shower in nearly two weeks, and she does not elect to get bed baths. She stated that she had been offered showers and that she had no other issues with her care or treatment at the facility. In an interview on 12/16/23 with the Maintenance Director at 2:15 PM, Maintenance Director revealed that there had been issues with the boiler for hot water in the facility for around two weeks. He stated that a pump had been ordered and received and installed on 12/04/23 and then the other pump went out a few days later and that had been placed on order and should be arriving at the facility on 12/16/23. He stated that the facility always had some hot water available, and he had been keeping the system operating until the next ordered pump comes. In an interview on 12/16/23 with the Relative #22 at 2:24 PM, revealed Resident #1 told him that she had not had a bath or shower in the last 19 days. He denied she had been offered any showers or bed baths. Resident #1 still had a very sharp mind, and she had not complained of anything in the past, so he took this very seriously. In an interview on 12/16/23 with the DON at 2:58 PM, revealed she was not sure if the policy for the facility was two or three showers per week at the facility. She stated that although there was a gap in Resident #1's shower sheets and shower data in the electronic health record, she was sure that there was not a 19-day gap in Resident #1's showers. She stated that if a resident were to miss that many showers it could contribute to skin degradation and may affect the mood and mental status of the residents. In an interview on 12/16/23 with CNA B at 4:07 PM, CNA B revealed that all of the CNA's in the building offered bed-baths or showers to all of the residents. He stated some residents might refuse both. He stated that the staff are instructed to fill out a shower sheet for each resident that they assisted with a shower/bed bath and that those sheets were to be turned into the nurse's station at the end of each shift. He stated that the CNA that normally assists Res #1 had not been to the facility for over a week due to recently giving birth. He stated that he had not heard any complaints from the residents about showers, and that they had been doing more bed baths for the last two weeks. Review of the facility's admission Agreement reflected Residents will be given 3 showers a week . Review of the facility's undated policy entitled Shower/Tub Bath Level II, stated that The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s)who assisted the resident with the shower/tub. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 3 of 5 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 12/16/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one (Resident #8) of fourteen residents on the secure unit, 300 wing reviewed for quality of care. The facility failed to ensure several doors in the secure unit were not found to be open and able to be secured, allowing residents possible access to hazardous chemicals stored in the janitors closet of the secure wing, and an activity supplies closet. This failure could expose residents to undue harm, chemical exposure or poisoning. Findings included: Record review of Resident #8's face sheet, dated 12/16/23, revealed that the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, Unspecified Dementia, Diabetes mellitus, and Insomnia. Record review of Resident #8's Minimal Data Sheet (MDS) assessment dated [DATE] revealed the resident had a Brief interview for Mental Status (BIMS) Score of 0 indicating severe cognitive impact. Further review of Resident #8's MDS revealed that the resident was ambulatory and required minimal assistance with ambulation. Review of Resident #8's Care Plan dated 09/20/23 revealed that the resident, : wanders in other resident's rooms/space. Elopement attempts/High risk. Goals: Will have behavior identified so that staff may intervene quickly wit listed interventions, daily through the next review date. Approach: Redirect resident to common areas or his room when wandering into others area. Problem: Resident resides in secure unit and is at risk for injury from wandering into unsafe environment, impaired safety awareness. Resident is at risk for injuries from others while residing in secure unit due to cognition. Approach: Keep environment free from possible hazards. Observation on 12/16/23 at 11:31 AM revealed that Resident #8 was seated in a regular chair near to the entrance of the Secure Unit, 300 wing. The resident was observed for several minutes by himself and not in direct sight of either of the two staff members working on the Secure unit at that time, with one staff member inside of the nurses station at the far end of the hallway and the other staff member tending to residents in the activity/dining area out of sight of the investigator at the opposite far end of the hall The resident appeared to be sitting alone less than 4 feet away from both the unsecured Activity Storage Closet and 5 feet away from the unsecured Janitors Closet. Observation and interview on 12/16/23 with the DON and the ADON at 4;46 PM. DON and ADON of the Secure unit, 300 Hall. The DON opened both the Janitor's closet and the Activity Storage closet in the Secure unit. The DON and the ADON were unable to demonstrate that they could secure the doors. Observations of the contents of the Activity Storage closet revealed that the closet many items stacked on top of each other nearly to the ceiling of the closet. DON stated that the stacked items could pose a hazard to residents if the items fell on the residents. Observations of the unsecured Janitors closet revealed that the closet contained opened gallon containers of: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 4 of 5 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 12/16/2023 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 0689 - All Purpose Odor Controller and Waste Degrader Level of Harm - Minimal harm or potential for actual harm - Water Soluble Odor Neutralizer - Window Ready Ammoniated Glass Cleaner Residents Affected - Some In addition, the Janitors closet also contained a spray bottle of Room Sense 200 Disinfectant Cleaner The DON stated that if a resident were to drink or spill those chemicals in their eyes it could harm to residents. In an interview on 12/16/23 with CNA C at 5:36 PM on the Secure Unit, CNA C stated that she was an agency employee but worked regularly at the facility for 8-9 months. She stated that she had noticed the entire door handle to the Activity Storage closet had been missing for the past two days. She stated that she had not seen any residents go into the Activity Storage Closet or the janitors Closet but because the doors could not lock, the residents could get into those areas at any time. In an interview on 12/16/23 with LVN A at 5:42 PM, LVN A revealed that she had been working at the facility for the last 17 years. She stated that she had been working on the Secure unit for a few years exclusively four nights a week. She stated that she had seen many residents wander around the area of the janitors closet many times. She stated that the handle to the Activity Storage closet might have been broken off for maybe two months . She stated that she was concerned residents might have access to the chemicals in the janitors closet and that if residents were able to get those chemicals, they could harm themselves. In an interview on 12/16/23 with the DON at 5:48 PM, DON revealed that she had directed the staff to remove the chemicals from the Janitors closet on the secure wing and that she had sent he Maintenance Director out to buy locks for the unsecured doors. She explained that the facility could not find the keys for those doors and that she would have the handle to the Activity Storage closet replaced as soon as possible. In an interview on 12/16/23 with CNA D at 6:59 PM, CNA D revealed that she had been working on the Secure unit for over a year. She stated that she had seen residents get into both the Activity Storage Closet and the janitors closet on the Secure Unit. She stated that the handles on the doors and the locks may have been broken for over two months and that she had reported it to her nurse when she first noted it. Review of the facility's policy entitled Safety and Supervision of Residents, dated 2007 (revised), it stated that Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .2. Safety risks and environmental hazards are identified on an ongoing process .Resident Risks and Environmental Hazards: 1.environmental hazards include: e. Unsafe wandering .F. Poison Control . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675067 If continuation sheet Page 5 of 5