Health inspection·June 16, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Once the police arrived at the facility, they (Administrator) asked Agency Aide A to be arrested due to making the shooting threat. When the police searched Agency Aide A's vehicle, they located a gun, and the Agency Aide was charged with terroristic threat. Interview on 06/16/23 at 10:59 AM with the ADON revealed she was working as a charge nurse on the 500 hall. Agency Aide A said she wanted to go home because she had hurt her back then she heard yelling between Agency Aide A and CNA B. The ADON said she went to get LVN B and they saw both Agency Aide A and CNA B going outside to the parking lot. The aides first went to their vehicles, and then met each other in the middle and began physically fight. The ADON called the police and while they were waiting for them to show up, Agency Aide A said, I'm gonna come back and shoot up the whole place including that bitch while pointing at CNA B. Once the police arrived, both aides were questioned. Agency Aide A told the police she had a gun, and the police were seen taking the gun from the vehicle. The ADON further stated she did not recall seeing any residents in the hall when the aides began to yell at each other, but they were quickly taken outside. The ADON stated no resident had mentioned anything to her after the incident. Interview on 06/16/23 at 10:41 AM with LVN C revealed he was working the night of the incident, and he had been asked to go to the 500 nurses' station. LVN C could hear yelling as he was approaching the nurses' station, and then he saw Agency Aide A and CNA B exiting outside. Each aide went to their vehicle as they were trying to coordinate where they could go to fight, and then they began to fight. As the other facility staff were trying to separate the two aides, the ADON was calling the police. Once the aides were separated, while they waited on the police, Agency Aide A made the comment she was going to shoot you all and this place. When the police arrived, both the aides were interrogated. LVN C stated the police found a gun in Agency Aide A's vehicle, and she was arrested. LVN C stated he only assumed residents were already in their rooms sleeping or getting ready for bed. He stated they may have overheard the aides yelling, but there were no residents that witnessed the physical altercation outside of the facility. Interview on 06/22/23 at 11:06 AM with LVN D revealed Agency Aide A and CNA B began to have words with each other. LVN D stated she told the aides to keep their voices down. Agency Aide A and CNA B began to say they were going to fight each other, and LVN D continued to tell the aides to stop. The aides then exited out of a door on the 500 hall into the parking lot outside and soon began to physically fight. The ADON called the police, and while they waited for them to show up, Agency Aide A said, Y'all can't keep me here and I'm gonna shoot this place up, y'alll and then pointed to CNA B. LVN D further stated the police had taken a gun from Agency Aide A's car, and she was arrested. LVN D said most all of the residents were sleeping at the time of the incident. LVN D stated she only recalled Resident #1 going to his room door when he heard the yelling, but she told him to go back into his room. She stated the resident never mentioned the incident again. Interview on 06/16/23 at 11:22 AM with Resident #1 revealed he did not recall any incidents where staff members were arguing and fighting. Interview on 06/16/23 from 9:47 AM to 11:56 AM with eight alert and oriented residents revealed they did not recall any incident where the staff were heard arguing or yelling with each other. Agency Aide A could not be contacted because did not have a contact number for her. Review of the police report dated 05/27/23 at 10:28 PM reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675136 If continuation sheet Page 2 of 6 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 675136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Denton Rehabilitation and Nursing Center 3345 Medpark Dr. Denton, TX 76210 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 0607 .Offense Code: Terroristic Threat Cause Fear of Imminent SBI (Serious Bodily Injury) Level of Harm - Minimal harm or potential for actual harm Arrestee: (Agency Aide A) Residents Affected - Few Evidence: Caliber: 9mm pistol recovered from glove box of vehicle 9mm bullets recovered in magazine and chamber Interview on 06/16/23 at 11:32 AM with the Administrator revealed this incident was not reported to the State Survey Agency because there were no residents involved, in the hallway, and no resident reported hearing or seeing anything. The staff were only in the building for a short time before they went outside where the physical altercation took place. The Administrator further stated another reason was because the police were very convincing in saying Agency Aide A was being very compliant at the time of the arrest and was very remorseful of what she had done. The police told the Administrator, they felt like there was no real threat because Agency Aide A had volunteered the gun in her vehicle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675136 If continuation sheet Page 3 of 6 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 675136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Denton Rehabilitation and Nursing Center 3345 Medpark Dr. Denton, TX 76210 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately or not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of two incidents reviewed for reporting. The facility failed to report to the State Survey Agency when Agency Aide A made a terroristic threat to shoot up the facility and to shoot CNA B following a physical altercation, which resulted in the police arresting Agency Aide A in the facility's parking lot after finding a handgun in her vehicle. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Interview on 06/16/23 at 9:22 AM with the Administrator and the DON revealed during a weekend, 05/27/23, an Agency Aide A and a CNA B had been involved in a physical altercation on the facility property. It was reported that Agency Aide A stated her back was hurting and wanted to go home during her shift. CNA B heard the comment Agency Aide A said about going home and so she (CNA B) made a remark back to Agency Aide A. Both aides began to yell at each other around the nurses' station on the 500 hall and then decided to take the argument outside of the facility, leaving through an exit door on the 500 hall. Once Agency Aide A and CNA B were outside, they began to physically fight in the parking lot, and the incident was witnessed by three of the facility's staff members. Eventually the two aides were separated by the staff, and the police were called. Sometime during the time they were waiting for the police, Agency Aide A made the comment she was going to shoot up the place and shoot CNA B. Once the police arrived at the facility, they (Administrator) asked Agency Aide A to be arrested due to making the shooting threat and when the police searched Agency Aide A's vehicle, they located a gun, and Agency Aide A was charged with terroristic threat. Interview on 06/16/23 at 10:59 AM with the ADON revealed she was working as a charge nurse on the 500 hall. Agency Aide A said she wanted to go home because she had hurt her back then she heard yelling between Agency Aide A and CNA B. The ADON said she went to get LVN B and they saw both Agency Aide A and CNA B going outside to the parking lot. The aides first went to their vehicles, and then met each other in the middle and began physically fight. The ADON called the police and while they were waiting for them to show up, Agency Aide A said, I'm gonna come back and shoot up the whole place including that bitch and was pointing at CNA B. Once the police arrived, both aides were questioned, Agency Aide A told the police she had a gun, and the police were seen taking the gun from the vehicle. The ADON further stated she did not recall seeing any residents in the hall when the aides began to yell at each other, but they were quickly taken outside, and no resident had mentioned anything to her after the incident. Interview on 06/16/23 at 10:41 AM with LVN C revealed he was working the night of the incident, and he had been asked to go to the 500 nurses' station. LVN C could hear yelling as he was approaching the nurses' station, and then he saw Agency Aide A and CNA B exiting outside. Each aide went to their vehicle as they were trying to coordinate where they could go to fight, and then they began to fight. As the other facility staff were trying to separate the two aides the ADON was calling the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675136 If continuation sheet Page 4 of 6 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 675136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Denton Rehabilitation and Nursing Center 3345 Medpark Dr. Denton, TX 76210 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few police. Once the aides were separated, while they waited on the police, Agency Aide A made the comment she was going to shoot you all and this place. When the police arrived both the aides were interrogated, and the police found a gun in Agency Aide A's vehicle, and she was arrested. LVN C stated he only assumed residents were already in their rooms sleeping or getting ready for bed. LVN C stated they may have overheard the aides yelling, but there were no residents that witnessed the physical altercation outside of the facility. Interview on 06/22/23 at 11:06 AM with LVN D revealed Agency Aide A and CNA B began to have words with each other, and LVN D was telling the aides to keep their voices down. Agency Aide A and CNA B began to say they were going to fight each other, and LVN D continued to tell the aides to stop. The aides then exited out of a door on the 500 hall into the parking lot outside and soon began to physically fight. The ADON called the police and while they waited for them to show up Agency Aide A said, Y'all can't keep me here and I'm gonna shoot this place up, y'all and then pointed to CNA B. LVN D further stated the police had taken a gun from Agency Aide A's vehicle, and she was arrested. LVN D said most all of the residents were sleeping at the time of the incident, and she only recalled Resident #1 going to his room door when he heard the yelling, but she (LVN D) told him to go back into his room and the resident never mentioned the incident again. Interview on 06/16/23 at 11:22 AM with Resident #1 revealed he did not recall any incidents where staff members were arguing and fighting. Interview on 06/16/23 from 9:47 AM to 11:56 AM with eight alert and oriented residents revealed they did not recall any incident where the staff were heard arguing or yelling with each other. Agency Aide A could not be contacted because did not have a contact number for her. Review of the police report dated 05/27/23 at 10:28 PM reflected the following: .Offense Code: Terroristic Threat Cause Fear of Imminent SBI (Serious Bodily Injury) Arrestee: (Agency Aide A) Evidence: Caliber: 9mm pistol recovered from glove box of vehicle 9mm bullets recovered in magazine and chamber Interview on 06/16/23 at 11:32 AM with the Administrator revealed this incident was not reported to the State Survey Agency because there were no residents involved, in the hallway, and no resident reported hearing or seeing anything. The staff were only in the building for a short time before they went outside where the physical altercation took place. The Administrator further stated another reason was because the police were very convincing in saying Agency Aide A was being very compliant at the time of the arrest and was very remorseful of what she had done. The police told the Administrator, they felt like there was no real threat because Agency Aide A had volunteered the gun in her vehicle. Review of the facility's Prohibition of Abuse, Neglect, and Exploitation (ANE) Standard Practice policy and procedure, updated 10/01/17, reflected the following: Standards: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675136 If continuation sheet Page 5 of 6 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 675136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Denton Rehabilitation and Nursing Center 3345 Medpark Dr. Denton, TX 76210 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 0609 Level of Harm - Minimal harm or potential for actual harm This Facility's abuse prohibition program includes standards and practice guidelines that address the essential components of an ANE prohibition program to include screening, prevention, identification, investigation, protection, reporting, and response. .Reporting Residents Affected - Few .4. The Facility will report the allegations and substantiated occurrences of ANE to the state agency and to all other agencies as required by law FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675136 If continuation sheet Page 6 of 6