Inspection·January 18, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pain. - The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident will not have discomfort related to side effects of analgesia. Date Initiated: 12/20/23; Intervention:- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Ensure sling is in place to right arm. - Evaluate the effectiveness of pain interventions . Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM , withdrawal, or resistance to care. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 12/20/23. Focus: The resident has an ADL Self Care Performance Deficit. Date Initiated: 03/01/23; Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score). Revised on: 11/13/23; Intervention: Required staff x1 assist with Bathing, Bed Mobility, Dressing, and Toilet use. Resident #1 required a lift for all Transfers. Revised on: 03/08/22. Record review of Resident #1's physician order dated 12/20/23 revealed Tramadol Tablet 50mg - give one tablet by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Tylenol with Codeine #3 Tablet 300-30mg (Acetaminophen-Codeine) - give two tablets by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Record review of Resident #1's Treatment Administration Record printed on 12/20/23 revealed Tramadol and Tylenol PRN pain medications were not given from 12/01/23 to 12/20/23; and no pain level was documented from 12/01/23 to 12/20/23. The page was blank. Record review of Resident #1's incident report dated 12/20/23 completed by LVN B indicated the incident happened in Resident #1's room. Nursing Description: Late Entry for 12/16/23 at 1:31pm Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to be hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and this behavior is very unlike resident. Resident Description: Resident #1 unable to give description. Immediate Action Taken: Order placed to obtain X-ray and called to get portable x-ray completed. Resident #1's family member notified, and NP notified. Injury Type: Fracture; Injury Location: Right upper arm. Record review of Resident #1's ER After Visit Summary dated 12/16/23 indicated the reason for visit: Arm Injury; Diagnosis: Closed displaced oblique fracture (occur when your bone is broken at an angle) of shaft of right humerus (upper arm bone) , initial encounter. Imaging Test: X-ray Humerus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 2 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 right 2 views; Application long arm splint and Orthopedic surgery referral. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's x-ray patient report dated 12/16/23 indicated Procedure: Right Humerus, 2+ views; Findings: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Rest of the right humerus show normal alignment. The bones show normal architecture. Degenerative changes were seen at the few joints. Rest of the articular margins and joint space of various joints appear normal. There was no radiological evidence of any loose bodies. There was no evidence of any osteomyelitis or sequestrum. No soft tissue calcification was seen. Impression: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Residents Affected - Few Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 11:09am; Completed by ADON G: COVID Booster given in Left deltoid, tolerated well, with no redness or swelling noted. -On 12/15/23 at 9:23pm; Completed by LVN E: LATE ENTRY - Called to Resident #1's room by care by staff. Resident #1 complaining her right arm was hurting and was holding that arm across her chest. No bruising, redness or swelling noted on arm. No obvious deformity or protrusions. Resident #1 was able to grasp hands of nurse firmly. Noted gauze on center of arm where blood drawn done previously, asked Resident #1 if that was the area that was hurting, and she replied yes then said no I'm not sure. Resident #1 was cursing staff to leave her alone. Will report to AM nurse in report to monitor. -On 12/16/23 at 1:31pm; Completed by LVN B: Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and that behavior was very unlike Resident #1. -On 12/16/23 at 4:32pm; Completed by LVN B: Resident #1 was transferred to a hospital on [DATE] 12:00am related to Resident #1 complaining of pain to right arm. Obtained portable x-ray which show a fractured humerus. -On 12/16/23 at 9:07pm; Completed by LVN E: Resident #1 returned from the ER. Sling to right arm in place, continue all previous orders and follow up with orthopedic doctor. During an observation on 12/30/23 at 1:55 p.m., Resident #1 was not interviewable. She was not able to answer or understand questions asked at that time. Resident #1 was well groomed, no odors, and did not appear distressed. Resident #1 was lying in bed resting with right arm was in a sling and propped on pillows. During an interview on 12/30/23 at 12:56 p.m., LVN B said she worked the 6am to 6pm shift, and she could not recall if the incident occurred on Saturday or Sunday, but CNA C came to her regarding Resident #1 favoring her right arm and would curse if anyone touched her which was not like Resident #1 to curse. She said Resident #1 had mentioned earlier (after breakfast, but before Lunch) that her arm was hurting, but LVN B said she assumed it was due to Resident #1 had received a COVID booster shot a few days before and that was the reason Resident #1's arm was sore. LVN B said Resident #1's right arm looked swollen compared to her left arm, which prompted her to go back and review Resident #1's COVID assessment to verify which arm Resident #1 received her booster shot and that was when she saw the booster was administered in Resident #1's left arm. LVN B said she called for an x-ray, and notified the MD, Resident #1's family member, and the DON. LVN B said the x-ray technician called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 3 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her into Resident #1's room to view the x-ray and she said it was visible that Resident #1's arm was broken. LVN B said she sent Resident #1 to the ER for further evaluation and treatment. LVN B said she did not know how Resident #1's arm was fractured, possibly from Hoyer transfer but Resident #1 had not been transferred that day. During an interview on 12/30/23 at 1:17 p.m., CNA C said the morning of the incident, during the morning report she overheard the night nurse tell LVN B that Resident #1 had a booster shot and was complaining of arm pain. CNA C said whenever she made her first round (could not recall time) she observed Resident #1 holding her right arm, but she did not think too much of it because of what the night nurse had said during her report. CNA C said during her second round (did not recall time) Resident #1 was not wet, so she did not touch her arm. She said during her third round (did not recall time) Resident #1 was wet and she noticed Resident #1 was still holding her right arm. CNA C said CNA F asked her why Resident #1's right arm was hurting, CNA C said she explained that Resident #1's arm was hurting possibly due to booster shot she received a few days prior. She said CNA F asked Resident #1 location of pain, and Resident #1 pointed to location, she said CNA F touched area and Resident #1 yelled out in pain, so CNA F and CNA C propped arm and notified LVN B. CNA C said Resident #1 cursed at them and that was unlike her to curse because normally Resident #1 was cool, calm, and collected and gave them no issues. During an interview on 12/30/23 at 2:10 p.m., CNA D said on 12/15/23 around 7:00pm Resident #1's roommate asked for patient care and when she went to do patient care on the roommate, Resident #1 voiced pain and grabbed her arm. CNA D said she immediately notified LVN E and LVN E assessed Resident #1. She said she observed LVN E bend Resident #1's arm up and down, and Resident #1 squeezed LVN E' s hand. CNA D said Resident #1 did not voice being in pain when she performed patient care after LVN E's assessment. During an interview on 12/30/23 at 6:24 p.m., LVN E said she worked the 6pm to 6am shift and on 12/15/23. LVN E said after the CNAs first round the CNAs told her Resident #1 complained of arm pain and was holding her arm to her chest. LVN E said she observed Resident #1 holding her arm, and saw a gauze from the booster shot, and Resident #1 could not say exactly where her arm was hurting. LVN E said she did range of motion on Resident #1, with no issues. LVN E said she did not administer Resident #1 PRN pain medications because she did not feel pain medicine was needed. LVN E said she needed more facial grimacing . She said it was not normal for Resident #1 to hold her arm or complain of pain but during the rest of her shift Resident #1 did not complain of pain so did not think much of it. LVN E said she did not do any follow up interventions after her initial assessment, but she did verbally report to LVN B and documented on the 24-hour change of condition form to monitor Resident #1 because she complained of arm pain. During an interview on 12/30/23 at 4:23 p.m., the DON said staff did not document pain assessment on Resident #1 and she did an Inservice on pain management. She said Resident #1 had an order for PRN pain medication and no pain medication was given when Resident #1 complained of arm pain on 12/15/23 or on 12/16/23. The DON said Resident #1 was not cognitive enough to know she needed pain medication; therefore, pain medication should had been given whenever Resident #1 was complaining or showing signs of being in pain. She said the pain scale was not required if PRN pain medication was not given, because nurses only documented pain level if pain medications were given. The DON said the nurses should have notified the physician with any change of condition, but didn't; she did an in-service on 1-17-24 Topic, Notify the physician with any change of condition (SBAR). During an interview via phone on 1/8/24 at 8:56 a.m., CNA F said on 12/16/23 she worked the 6am-6pm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 4 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few shift on the 100 Hall. She said she assisted CNA C with the 200 Hall to do patient care with Resident #1 around 9:00am and during patient care Resident #1 told them that her arm was hurting and pointed at her right arm. CNA F said they told LVN B and LVN B explained to them that LVN E told her during morning report that Resident #1 started complaining of arm pain during the 6pm to 6am shift on 12/15/23 and was possibly due to lab drawn a few days prior. CNA F said she did see Resident #1 had gauze on her right hand and did not think anything of it after LVN B told them Resident #1 was sore from having blood drawn. CNA F said during her second round after lunch around 1pm she assisted CNA C with patient care on Resident #1 and when they rolled Resident #1 during patient care Resident #1 started cursing at them and calling them the B-word which was not like Resident #1, and she knew something was wrong. CNA F said after they finished patient care, they notified LVN B again that something was seriously wrong for her to react like that. CNA F said Resident #1 was not interviewable, and Resident #1 was able to answer questions, but her responses were random and often did not make sense. CNA F said Resident #1 did not normally complain of pain and was not cognitive enough to ask for pain medication, and she did not know if Resident #1 was given pain medication. During an interview via phone on 1/8/24 at 9:29 a.m., ADON G said she administered Resident #1's COVID booster shot on 12/13/23 and Resident #1 was not complaining of pain at that time. ADON G said her last time seeing Resident #1 was on 12/14/23 before she was on leave for the next three days, but on 12/14/23 it was after lunch and Resident #1 was up in her wheelchair outside her room on the 200 Hall, and she remembered seeing Resident #1's hands prayer style and she was resting her chin. ADON G said Resident #1 did not appear in pain during that time. ADON G said most residents had PRN pain meds and if a resident was complaining of pain, then nurses can give pain medications. ADON G said Resident #1 was non interviewable and did not normally complain of pain, she said Resident #1 should had been given pain medicine if she was showing signs and voicing pain. During an interview on 1/17/24 at 4:09 p.m., CNA H said on 12/15/23, she was walking down Hall 200 coming from her break and was going back to Hall 400 and saw CNA D standing outside Resident #1's door. CNA H said CNA D asked for someone to go get the nurse and CNA J left to get LVN E. CNA H said she was not involved much, and personally did not hear Resident #1 say she was hurting but she did see LVN E raise Resident #1's arm and ask Resident #1 if that hurt and Resident #1 said No. During an interview on 1/18/24 at 7:12 p.m., CNA J said on 12/15/23 around 9:15pm, she was working on hall 100 when she heard a call light on hall 200 and whenever she looked down hall 200 CNA D was coming out of Resident #1's room. She said CNA D motioned for her to come over and CNA D told her Resident #1 was saying her arm was broke and for CNA J to go get LVN E. CNA J said she left to go look for LVN E, and then she returned with LVN E to Resident #1's room. CNA J said CNA D and CNA H were both in Resident #1's room waiting for LVN E and Resident #1 was in bed holding her right arm. She said LVN E asked Resident #1 what was wrong, and she heard Resident #1 say my arm hurt, it's broke and was moaning ow, ow. CNA J said LVN E touched Resident #1's right arm and Resident #1 said it hurts. She said LVN E looked over at them and said Resident #1 had lab drawn earlier, and then LVN went to go verify in Resident #1's chart. CNA J said she returned to Resident #1's room around 5:00am to assist CNA D with rotating Resident #1 and Resident #1 was saying Oh my arm hurts, hurts so bad. CNA J said she made the comment to CNA D Are they not going to send Resident #1 out or get an x-ray because Resident #1 appeared to be in a lot of pain. CNA J said they did mention to LVN E that Resident #1 was still complaining of arm pain. Record review of revised pain management/assessment scaled policy dated 5/25/2016 indicated Pain is a subjective sensation `of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: Complaints of pain will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 5 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1) Residents identifies pain characteristics. 2) Resident articulates factors that intensify pain. 3) Resident expresses a feeling of comfort and relief from pain. 4) Resident states and carries out appropriate pain interventions from pain relief. 5) Cognitively impaired residents will demonstrate actions of pain relief. Procedures: 1) Assess resident's physical symptoms of pain, physical complaints, and daily activities. Plain questions based on a resident communication ability were included in the Admission/readmission and weekly nursing summary. If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAIN AD assessment. 2) Perform comfort measures to promote relaxation. 3) Plan activities with the resident to provide distraction, such as reading, craft, television, or visits, to help resident focus on non-pain related matters. 4) Manipulate the environment to promote periods of uninterrupted rest as much as possible. This promotes health, well-being, and increased energy level important to pain relief. 5) Apply heat or cold as ordered (specify) to minimize or relieve pain. 6) Help resident into a comfortable position and use pillows to splint or support painful area, as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 7) Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8) Instruct resident in use of relaxation techniques. 9) Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. 10) Assist the resident in maintaining a pain management and rest schedule, exercise program and medication regimen. 11) Encourage self-care activities. 12) Talk with the resident about pain and assess for pain relief after interventions. 13) Monitor for effectiveness of pain interventions. 14) The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plan will be maintained for the management of the resident's pain. Record review of revised notifying the physician of change in status policy dated 03/11/13 indicated The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to notify the MD/MP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on next workday notification of the physician. 1)The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2) Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3) The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record .6) The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide and nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7) The nurse will document all attempts to contact the physician, all attempts to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 6 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions. Level of Harm - Immediate jeopardy to resident health or safety On 01/17/2024 at 4:00p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. Residents Affected - Few The Plan of Removal (POR) was accepted on 1/18/24 at 11:45am and indicated the following: Plan of Removal - F697 Pain Management On January 17, 2024, the facility learned that an IJ was being called due to F697 Pain Management. The Facility failed to: -Adequately assess Resident #1 for pain and administer pain medications as ordered. Resident #1 did not receive as needed pain medications from 12/15/23-12/20/23. -Notify the physician when Resident #1 had a change in behavior and complained of pain. -Notify the Administrator when Resident #1 had a change in behavior and complained of pain -Follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. -Follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent residents from not receiving pain medications and a diminished quality of life, that could lead to serious injury, harm, or death. -As of 1/17/24 resident # 1 was assessed for pain by the DON. No complaints of pain or additional issues noted. Resident #1 has pain medication ordered. -All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 1/17/24. No additional residents were identified. -As of 1/17/24 the charge nurse B and charge nurse E were 1:1 in-serviced by the DON on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All charge nurses were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses including agency staff, new hires and PRN charge nurses not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse. -Administering pain medication for residents with signs and symptoms of pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 7 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All clinical staff were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topic below. All clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse -Pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) -Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. -Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The medical director was notified by the DON on 1/17/24 on the immediate jeopardy situation by the Administrator. An AD HOC QAPI meeting was held on 1/17/24 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. In attendance was the Administrator, DON, Regional Nurse, Medical Director, [NAME] President of Clinical Services, [NAME] President of Operations. On 01/18/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews and record reviews were conducted on 01/18/24 from 5:00 p.m. through 8:00 p.m. and included 5 LVNs, 6 CNAs, ADON, DON, and Regional Compliance Nurse. Staff were able to explain administering pain medication for residents with signs and symptoms of pain. Staff had knowledge on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff were able to explain pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Staff had knowledge on notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. All residents in the facility were assessed for any increased pain by the DON and Charge Nurses. This was verified by interview with DON and record review of audit sheets listing resident name and room number. In-Services addressed pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff was in-serviced on pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 8 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few clutching). Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The Charge Nurses was in-serviced on administering pain medication for residents with signs and symptoms of pain. Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. This was verified by record review of staff in-services signature sheets and staff interviews. The Director of Nursing / designee will educate all clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of the above in-services. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Compliance Nurse verified an Ad Hoc QAPI was conducted to discuss the immediate jeopardy concerning pain management and to develop the above-mentioned plan of care. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 9 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 1 facility self-reported incidents reviewed for reporting to the State Survey Agency. (Incident #471317) The facility failed to report an injury of unknown origin when Resident #1 was found to have a closed displaced oblique fracture of shaft of right humerus. This failure could place the residents at risk for increased risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet, printed on 12/20/23 indicated she was an 86- year -old female who admitted to facility on 2/25/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease a type of dementia that affects memory, thinking and behavior), cognitive communication deficit (defined as an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle wasting and atrophy in right and left shoulders (is the wasting or thinning of your muscle mass), and age related osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #1 has ability to understand others. She had Brief Interview for Mental Status (BIMS) score of 3, which indicated a severe cognitive impairment. Section J indicated Resident #1 does not receive scheduled pain medication and had not received PRN pain medication, did not receive non-medication intervention for pain and had not been in pain over the 5 previous days. Record review of Resident #1's care plan indicated the following: Focus: The resident has a potential for uncontrolled pain due to Fracture of Right Humerus. Date Initiated: 12/20/23; Goal: -The resident will not have an interruption in normal activities due to pain. - The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident will not have discomfort related to side effects of analgesia. Date Initiated: 12/20/23; Intervention:- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Ensure sling is in place to right arm. - Evaluate the effectiveness of pain interventions . Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 10 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM , withdrawal, or resistance to care. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 12/20/23. Record review of Resident #1's incident report dated 12/20/23 completed by LVN B indicated the incident happened in Resident #1's room. Nursing Description: Late Entry for 12/16/23 at 1:31pm Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to be hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and this behavior is very unlike resident. Resident Description: Resident #1 unable to give description. Immediate Action Taken: Order placed to obtain X-ray and called to get portable x-ray completed. Resident #1's family member notified, and NP notified. Injury Type: Fracture; Injury Location: Right upper arm. Record review of Resident #1's ER After Visit Summary dated 12/16/23 indicated the reason for visit: Arm Injury; Diagnosis: Closed displaced oblique fracture of shaft of right humerus, initial encounter. Imaging Test: X-ray Humerus right 2 views; Application long arm splint and Orthopedic surgery referral. Record review of Resident #1's x-ray patient report dated 12/16/23 indicated Procedure: Right Humerus, 2+ views; Findings: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Rest of the right humerus show normal alignment. The bones show normal architecture. Degenerative changes were seen at the few joints. Rest of the articular margins and joint space of various joints appear normal. There was no radiological evidence of any loose bodies. There was no evidence of any osteomyelitis or sequestrum. No soft tissue calcification was seen. Impression: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 11:09am; Completed by ADON G: COVID Booster given in Left deltoid, tolerated well, with no redness or swelling noted. -On 12/15/23 at 9:23pm; Completed by LVN E: LATE ENTRY - Called to Resident #1's room by care by staff. Resident #1 complaining her right arm was hurting and was holding that arm across her chest. No bruising, redness or swelling noted on arm. No obvious deformity or protrusions. Resident #1 was able to grasp hands of nurse firmly. Noted gauze on center of arm where blood drawn done previously, asked Resident #1 if that was the area that was hurting, and she replied yes then said no I'm not sure. Resident #1 was cursing staff to leave her alone. Will report to AM nurse in report to monitor. -On 12/16/23 at 1:31pm; Completed by LVN B: Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and that behavior was very unlike Resident #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 11 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 -On 12/16/23 at 4:32pm; Completed by LVN B: Resident #1 was transferred to a hospital on [DATE] 12:00am related to Resident #1 complaining of pain to right arm. Obtained portable x-ray which show a fractured humerus. -On 12/16/23 at 9:07pm; Completed by LVN E: Resident #1 returned from the ER. Sling to right arm in place, continue all previous orders and follow up with orthopedic doctor. Record review of intake worksheet for facility self-reported incident #471317 revealed it was received by HHSC on 12/17/23. During an observation on 12/30/23 at 1:55 p.m., Resident #1 was not interviewable. She was not able to answer or understand questions asked at that time. Resident #1 was well groomed, no odors, and did not appear distressed. Resident #1 was lying in bed resting with right arm in a sling and propped on pillows. During an interview on 12/30/23 at 12:56 p.m., LVN B said she worked the 6am to 6pm shift, and she could not recall if the incident occurred on Saturday or Sunday, but CNA C came to her regarding Resident #1 favoring her right arm and would curse if anyone touched her which was not like Resident #1 to curse. She said Resident #1 had mentioned earlier (after breakfast, but before Lunch) that her arm was hurting, but LVN B said she assumed it was due to Resident #1 had received a COVID booster shot a few days before and that was the reason Resident #1's arm was sore. LVN B said Resident #1's right arm looked swollen compared to her left arm, which prompted her to go back and review Resident #1's COVID assessment to verify which arm Resident #1 received her booster shot and that was when she saw the booster was administered in Resident #1's left arm. LVN B said she called for an x-ray, and notified the MD, Resident #1's family member, and the DON. LVN B said the x-ray technician called her into Resident #1's room to view the x-ray and she said it was visible that Resident #1's arm was broken. LVN B said she sent Resident #1 to the ER for further evaluation and treatment. LVN B said she did not know how Resident #1's arm was fractured, possibly from Hoyer transfer but Resident #1 had not been transferred that day. During an interview on 12/30/23 at 1:17 p.m., CNA C said the morning of the incident, during the morning report, she overheard the night nurse tell LVN B that Resident #1 had a booster shot and was complaining of arm pain. CNA C said whenever she made her first round (could not recall time) she observed Resident #1 holding her right arm, but she did not think too much of it because of what the night nurse had said during her report. CNA C said during her second round (did not recall time) Resident #1 was not wet, so she did not touch her arm. She said during her third round (did not recall time) Resident #1 was wet and she noticed Resident #1 was still holding her right arm. CNA C said CNA F asked her why Resident #1's right arm was hurting, CNA C said she explained that Resident #1's arm was hurting possibly due to booster shot she received a few days prior. She said CNA F asked Resident #1 location of pain, and Resident #1 pointed to location, she said CNA F touched area and Resident #1 yelled out in pain, so CNA F and CNA C propped arm and notified LVN B. CNA C said Resident #1 cursed at them and that was unlike her to curse because normally Resident #1 was cool, calm, and collected and gave them no issues. During an interview on 12/30/23 at 2:10 p.m., CNA D said on 12/15/23 around 7:00pm Resident #1's roommate asked for patient care and when she went to do patient care on the roommate, Resident #1 voiced pain and grabbed her arm. CNA D said she immediately notified LVN E and LVN E assessed Resident #1. She said she observed LVN E bend Resident #1's arm up and down, and Resident #1 squeezed LVN E' s hand. CNA D said Resident #1 did not voice being in pain when she performed patient care after LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 12 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 E's assessment. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/30/23 at 6:24 p.m., LVN E said she worked the 6pm to 6am shift and on 12/15/23. LVN E said after the CNAs first round the CNAs told her Resident #1 complained of arm pain and was holding her arm to her chest. LVN E said she observed Resident #1 holding her arm, and saw a gauze from the booster shot, and Resident #1 could not say exactly where her arm was hurting. LVN E said she did range of motion on Resident #1, with no issues. LVN E said she did not administer Resident #1 PRN pain medications because she did not feel pain medicine was needed. LVN E said she needed more facial grimacing . She said it was not normal for Resident #1 to hold her arm or complain of pain but during the rest of her shift Resident #1 did not complain of pain so did not think much of it. LVN E said she did not do any follow up interventions after her initial assessment, but she did verbally report to LVN B and documented on the 24-hour change of condition form to monitor Resident #1 because she complained of arm pain. Residents Affected - Few During an interview on 12/30/23 at 4:23 p.m., the DON said staff did not document pain assessment on Resident #1 and she did an Inservice on pain management. She said Resident #1 had an order for PRN pain medication and no pain medication was given when Resident #1 complained of arm pain on 12/15/23 or on 12/16/23. The DON said Resident #1 was not cognitive enough to know she needed pain medication; therefore, pain medication should had been given whenever Resident #1 was complaining or showing signs of being in pain. She said the pain scale was not required if PRN pain medication was not given, because nurses only documented pain level if pain medications were given. During an interview via phone on 1/8/24 at 8:56 a.m., CNA F said on 12/16/23 she worked the 6am-6pm shift on the 100 Hall. She said she assisted CNA C with the 200 Hall to do patient care with Resident #1 around 9:00am and during patient care Resident #1 told them that her arm was hurting and pointed at her right arm. CNA F said they told LVN B and LVN B explained to them that LVN E told her during morning report that Resident #1 started complaining of arm pain during the 6pm to 6am shift on 12/15/23 and was possibly due to lab drawn a few days prior. CNA F said she did see Resident #1 had gauze on her right hand and did not think anything of it after LVN B told them Resident #1 was sore from having blood drawn. CNA F said during her second round after lunch around 1pm she assisted CNA C with patient care on Resident #1 and when they rolled Resident #1 during patient care Resident #1 started cursing at them and calling them the B-word which was not like Resident #1, and she knew something was wrong. CNA F said after they finished patient care they notified LVN B again that something was seriously wrong for her to react like that. CNA F said Resident #1 was not interviewable, and Resident #1 was able to answer questions, but her responses were random and often did not make sense. CNA F said Resident #1 did not normally complain of pain and was not cognitive enough to ask for pain medication, and she did not know if Resident #1 was given pain medication. During an interview via phone on 1/8/24 at 9:29 a.m., ADON G said she administered Resident #1's COVID booster shot on 12/13/23 and Resident #1 was not complaining of pain at that time. ADON G said her last time seeing Resident #1 was on 12/14/23 before she was on leave for the next three days, but on 12/14/23 it was after lunch and Resident #1 was up in her wheelchair outside her room on the 200 Hall, and she remembered seeing Resident #1's hands prayer style and she was resting her chin. ADON G said Resident #1 did not appear in pain during that time. ADON G said most residents had PRN pain meds and if a resident was complaining of pain, then nurses can give pain medications. ADON G said Resident #1 was non interviewable and did not normally complain of pain, she said Resident #1 should had been given pain medicine if she was showing signs and voicing pain. During an interview on 1/17/24 at 4:09 p.m., CNA H said on 12/15/23 she was walking down Hall 200 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 13 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 coming from her break and was going back to Hall 400 and saw CNA D standing outside Resident #1's door. CNA H said CNA D asked for someone to go get the nurse and CNA J left to get LVN E. CNA H said she was not involved much, and personally did not hear Resident #1 say she was hurting but she did see LVN E raise Resident #1's arm and ask Resident #1 if that hurt and Resident #1 said No. During an interview on 1/18/24 at 7:12 p.m., CNA J said on 12/15/23 around 9:15pm she was working on hall 100 when she heard a call light on hall 200 and whenever she looked down hall 200 CNA D was coming out of Resident #1's room. She said CNA D motioned for her to come over and CNA D told her Resident #1 was saying her arm was broke and for CNA J to go get LVN E. CNA J said she left to go look for LVN E, and then she returned with LVN E to Resident #1's room. CNA J said CNA D and CNA H were both in Resident #1's room waiting for LVN E and Resident #1 was in bed holding her right arm. She said LVN E asked Resident #1 what was wrong, and she heard Resident #1 say my arm hurt, it's broke and was moaning ow, ow. CNA J said LVN E touched Resident #1's right arm and Resident #1 said it hurts. She said LVN E looked over at them and said Resident #1 had lab drawn earlier, and then LVN went to go verify in Resident #1's chart. CNA J said she returned to Resident #1's room around 5:00am to assist CNA D with rotating Resident #1 and Resident #1 was saying Oh my arm hurts, hurts so bad. CNA J said she made the comment to CNA D Are they not going to send Resident #1 out or get an x-ray because Resident #1 appeared to be in a lot of pain. CNA J said they did mention to LVN E that Resident #1 was still complaining of arm pain. During an interview on 1/18/24 at 6:40 p.m., LVN E said on 12/16/23 she worked the 6pm to 6am shift, and Resident #1 had already been sent out to the ER during the previous shift, and Resident #1 returned from the ER during her shift. She said Resident #1's x-ray Final Report was faxed to facility on 12/16/23 during her shift, and she put the paperwork in the DON box. LVN E said she did not call or notify the DON or the Administrator whenever Resident #1 returned from the facility nor did she notified the DON or the Administrator when the Final Report confirming the fracture was received. She said she thought LVN B had already notified the DON and Administrator regarding Resident #1's preliminary findings and assumed that was the reason Resident #1 was sent to the ER for evaluation in the first place, and therefore it was no need for her to notify everyone again because LVN B had already done that. During an interview via phone on 1/17/24 at 2:27 p.m., the DON said LVN B did notify her on 12/16/23 regarding Resident #1 needing a STAT x-ray and was sent an unclear picture of Resident #1's x-ray but she could not see the picture good on her phone to verify it was a fracture and was aware Resident #1 was sent to ER for further evaluation. The DON said LVN E did not notify her after Resident #1 returned from the hospital on [DATE] nor of the final x-ray results findings. She said the following morning, on 12/17/23, she reviewed Resident #1's chart and the nurse 24-hour report regarding Resident #1's ER notes and the only notes she found on chart was Resident #1 returned to facility with a sling and referral for orthopedic, no new orders. The DON said it was poor documentation, and she had to ask LVN E if Resident #1 had a fracture. During an interview on 1/17/24 at 1:23 p.m., the Administrator said he was the Abuse Coordinator, and he followed the facility's abuse policy and the State regulations. He said any injury of unknown origin, and if the resident was not cognitively aware, and depending on the type of injury would determine if the incident needed to be called into the State. The Administrator said injuries with major injuries needed to be reported within two hours to the state. He said regarding Resident #1's incident #471317 he reported the incident to the state on 12/17/23, Sunday morning at 11:06am. The Administrator said the facility first learned of the incident regarding Resident #1 having a possible fracture was on 12/16/23 at 4:15pm and Resident #1 was sent to the ER around 4:30pm and returned to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 14 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 facility 9:07pm; however, he was not notified of the of the final x-ray results until the next day on 12/17/23 Sunday morning, and that was when he called it in the state. He said he expected for the staff to have notified either himself the Administrator and/or the DON on 12/16/23 whenever they received the final x-ray results revealing Resident #1 had a fracture, because he had two-hour window to report to the state regarding the findings of Resident #1's major injury and he was not notified, said he was not sure if the DON was notified. Record review of revised abuse policy dated 3/29/18 revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is no limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: 12) Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not to be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time . E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected case of abuse, neglect or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b) If the allegation does not involve abuse or serious bodily injury, the report must be made with 24 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 15 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, for 1 of 7 residents (Resident #1) reviewed for pain management. Residents Affected - Few 1. Facility failed to ensure Resident #1 was adequately assess for pain and administer pain medications as ordered from 12/15/23-12/20/23. 2. Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. 3. Facility failed to ensure the Administrator was notified when Resident #1 had a change in behavior and complained of pain 4. Facility failed to follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. 5. Facility failed to follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. These failures could place residents at risk of not receiving pain medications and a diminished quality of life. Findings included: Record review of Resident #1's face sheet, printed on 12/20/23 indicated she was an [AGE] year old female who admitted to facility on 2/25/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease a type of dementia that affects memory, thinking and behavior), cognitive communication deficit (defined as an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle wasting and atrophy in right and left shoulders (is the wasting or thinning of your muscle mass), and age related osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #1 has ability to understand others. She had Brief Interview for Mental Status (BIMS) score of 3, which indicated a severe cognitive impairment. Section J indicated Resident #1 does not receive scheduled pain medication and had not received PRN pain medication, did not receive non-medication intervention for pain and had not been in pain over the 5 previous days. Record review of Resident #1's care plan indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 16 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Focus: The resident has a potential for uncontrolled pain due to Fracture of Right Humerus. Date Initiated: 12/20/23; Goal: -The resident will not have an interruption in normal activities due to pain. - The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident will not have discomfort related to side effects of analgesia. Date Initiated: 12/20/23; Intervention:- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Ensure sling is in place to right arm. - Evaluate the effectiveness of pain interventions . Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM , withdrawal, or resistance to care. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 12/20/23. Focus: The resident has an ADL Self Care Performance Deficit. Date Initiated: 03/01/23; Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score). Revised on: 11/13/23; Intervention: Required staff x1 assist with Bathing, Bed Mobility, Dressing, and Toilet use. Resident #1 required a lift for all Transfers. Revised on: 03/08/22. Record review of Resident #1's physician order dated 12/20/23 revealed Tramadol Tablet 50mg - give one tablet by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Tylenol with Codeine #3 Tablet 300-30mg (Acetaminophen-Codeine) - give two tablets by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Record review of Resident #1's Treatment Administration Record printed on 12/20/23 revealed Tramadol and Tylenol PRN pain medications were not given from 12/01/23 to 12/20/23; and no pain level was documented from 12/01/23 to 12/20/23. The page was blank. Record review of Resident #1's incident report dated 12/20/23 completed by LVN B indicated the incident happened in Resident #1's room. Nursing Description: Late Entry for 12/16/23 at 1:31pm Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to be hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and this behavior is very unlike resident. Resident Description: Resident #1 unable to give description. Immediate Action Taken: Order placed to obtain X-ray and called to get portable x-ray completed. Resident #1's family member notified, and NP notified. Injury Type: Fracture; Injury Location: Right upper arm. Record review of Resident #1's ER After Visit Summary dated 12/16/23 indicated the reason for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 17 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few visit: Arm Injury; Diagnosis: Closed displaced oblique fracture (occur when your bone is broken at an angle) of shaft of right humerus (upper arm bone) , initial encounter. Imaging Test: X-ray Humerus right 2 views; Application long arm splint and Orthopedic surgery referral. Record review of Resident #1's x-ray patient report dated 12/16/23 indicated Procedure: Right Humerus, 2+ views; Findings: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Rest of the right humerus show normal alignment. The bones show normal architecture. Degenerative changes were seen at the few joints. Rest of the articular margins and joint space of various joints appear normal. There was no radiological evidence of any loose bodies. There was no evidence of any osteomyelitis or sequestrum. No soft tissue calcification was seen. Impression: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 11:09am; Completed by ADON G: COVID Booster given in Left deltoid, tolerated well, with no redness or swelling noted. -On 12/15/23 at 9:23pm; Completed by LVN E: LATE ENTRY - Called to Resident #1's room by care by staff. Resident #1 complaining her right arm was hurting and was holding that arm across her chest. No bruising, redness or swelling noted on arm. No obvious deformity or protrusions. Resident #1 was able to grasp hands of nurse firmly. Noted gauze on center of arm where blood drawn done previously, asked Resident #1 if that was the area that was hurting, and she replied yes then said no I'm not sure. Resident #1 was cursing staff to leave her alone. Will report to AM nurse in report to monitor. -On 12/16/23 at 1:31pm; Completed by LVN B: Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and that behavior was very unlike Resident #1. -On 12/16/23 at 4:32pm; Completed by LVN B: Resident #1 was transferred to a hospital on [DATE] 12:00am related to Resident #1 complaining of pain to right arm. Obtained portable x-ray which show a fractured humerus. -On 12/16/23 at 9:07pm; Completed by LVN E: Resident #1 returned from the ER. Sling to right arm in place, continue all previous orders and follow up with orthopedic doctor. During an observation on 12/30/23 at 1:55 p.m., Resident #1 was not interviewable. She was not able to answer or understand questions asked at that time. Resident #1 was well groomed, no odors, and did not appear distressed. Resident #1 was lying in bed resting with right arm was in a sling and propped on pillows. During an interview on 12/30/23 at 12:56 p.m., LVN B said she worked the 6am to 6pm shift, and she could not recall if the incident occurred on Saturday or Sunday, but CNA C came to her regarding Resident #1 favoring her right arm and would curse if anyone touched her which was not like Resident #1 to curse. She said Resident #1 had mentioned earlier (after breakfast, but before Lunch) that her arm was hurting, but LVN B said she assumed it was due to Resident #1 had received a COVID booster shot a few days before and that was the reason Resident #1's arm was sore. LVN B said Resident #1's right arm looked swollen compared to her left arm, which prompted her to go back and review Resident #1's COVID assessment to verify which arm Resident #1 received her booster shot and that was when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 18 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety saw the booster was administered in Resident #1's left arm. LVN B said she called for an x-ray, and notified the MD, Resident #1's family member, and the DON. LVN B said the x-ray technician called her into Resident #1's room to view the x-ray and she said it was visible that Resident #1's arm was broken. LVN B said she sent Resident #1 to the ER for further evaluation and treatment. LVN B said she did not know how Resident #1's arm was fractured, possibly from Hoyer transfer but Resident #1 had not been transferred that day. Residents Affected - Few During an interview on 12/30/23 at 1:17 p.m., CNA C said the morning of the incident, during the morning report she overheard the night nurse tell LVN B that Resident #1 had a booster shot and was complaining of arm pain. CNA C said whenever she made her first round (could not recall time) she observed Resident #1 holding her right arm, but she did not think too much of it because of what the night nurse had said during her report. CNA C said during her second round (did not recall time) Resident #1 was not wet, so she did not touch her arm. She said during her third round (did not recall time) Resident #1 was wet and she noticed Resident #1 was still holding her right arm. CNA C said CNA F asked her why Resident #1's right arm was hurting, CNA C said she explained that Resident #1's arm was hurting possibly due to booster shot she received a few days prior. She said CNA F asked Resident #1 location of pain, and Resident #1 pointed to location, she said CNA F touched area and Resident #1 yelled out in pain, so CNA F and CNA C propped arm and notified LVN B. CNA C said Resident #1 cursed at them and that was unlike her to curse because normally Resident #1 was cool, calm, and collected and gave them no issues. During an interview on 12/30/23 at 2:10 p.m., CNA D said on 12/15/23 around 7:00pm Resident #1's roommate asked for patient care and when she went to do patient care on the roommate, Resident #1 voiced pain and grabbed her arm. CNA D said she immediately notified LVN E and LVN E assessed Resident #1. She said she observed LVN E bend Resident #1's arm up and down, and Resident #1 squeezed LVN E' s hand. CNA D said Resident #1 did not voice being in pain when she performed patient care after LVN E's assessment. During an interview on 12/30/23 at 6:24 p.m., LVN E said she worked the 6pm to 6am shift and on 12/15/23. LVN E said after the CNAs first round the CNAs told her Resident #1 complained of arm pain and was holding her arm to her chest. LVN E said she observed Resident #1 holding her arm, and saw a gauze from the booster shot, and Resident #1 could not say exactly where her arm was hurting. LVN E said she did range of motion on Resident #1, with no issues. LVN E said she did not administer Resident #1 PRN pain medications because she did not feel pain medicine was needed. LVN E said she needed more facial grimacing . She said it was not normal for Resident #1 to hold her arm or complain of pain but during the rest of her shift Resident #1 did not complain of pain so did not think much of it. LVN E said she did not do any follow up interventions after her initial assessment, but she did verbally report to LVN B and documented on the 24-hour change of condition form to monitor Resident #1 because she complained of arm pain. During an interview on 12/30/23 at 4:23 p.m., the DON said staff did not document pain assessment on Resident #1 and she did an Inservice on pain management. She said Resident #1 had an order for PRN pain medication and no pain medication was given when Resident #1 complained of arm pain on 12/15/23 or on 12/16/23. The DON said Resident #1 was not cognitive enough to know she needed pain medication; therefore, pain medication should had been given whenever Resident #1 was complaining or showing signs of being in pain. She said the pain scale was not required if PRN pain medication was not given, because nurses only documented pain level if pain medications were given. During an interview via phone on 1/8/24 at 8:56 a.m., CNA F said on 12/16/23 she worked the 6am-6pm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 19 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few shift on the 100 Hall. She said she assisted CNA C with the 200 Hall to do patient care with Resident #1 around 9:00am and during patient care Resident #1 told them that her arm was hurting and pointed at her right arm. CNA F said they told LVN B and LVN B explained to them that LVN E told her during morning report that Resident #1 started complaining of arm pain during the 6pm to 6am shift on 12/15/23 and was possibly due to lab drawn a few days prior. CNA F said she did see Resident #1 had gauze on her right hand and did not think anything of it after LVN B told them Resident #1 was sore from having blood drawn. CNA F said during her second round after lunch around 1pm she assisted CNA C with patient care on Resident #1 and when they rolled Resident #1 during patient care Resident #1 started cursing at them and calling them the B-word which was not like Resident #1, and she knew something was wrong. CNA F said after they finished patient care, they notified LVN B again that something was seriously wrong for her to react like that. CNA F said Resident #1 was not interviewable, and Resident #1 was able to answer questions, but her responses were random and often did not make sense. CNA F said Resident #1 did not normally complain of pain and was not cognitive enough to ask for pain medication, and she did not know if Resident #1 was given pain medication. During an interview via phone on 1/8/24 at 9:29 a.m., ADON G said she administered Resident #1's COVID booster shot on 12/13/23 and Resident #1 was not complaining of pain at that time. ADON G said her last time seeing Resident #1 was on 12/14/23 before she was on leave for the next three days, but on 12/14/23 it was after lunch and Resident #1 was up in her wheelchair outside her room on the 200 Hall, and she remembered seeing Resident #1's hands prayer style and she was resting her chin. ADON G said Resident #1 did not appear in pain during that time. ADON G said most residents had PRN pain meds and if a resident was complaining of pain, then nurses can give pain medications. ADON G said Resident #1 was non interviewable and did not normally complain of pain, she said Resident #1 should had been given pain medicine if she was showing signs and voicing pain. During an interview on 1/17/24 at 4:09 p.m., CNA H said on 12/15/23, she was walking down Hall 200 coming from her break and was going back to Hall 400 and saw CNA D standing outside Resident #1's door. CNA H said CNA D asked for someone to go get the nurse and CNA J left to get LVN E. CNA H said she was not involved much, and personally did not hear Resident #1 say she was hurting but she did see LVN E raise Resident #1's arm and ask Resident #1 if that hurt and Resident #1 said No. During an interview on 1/18/24 at 7:12 p.m., CNA J said on 12/15/23 around 9:15pm, she was working on hall 100 when she heard a call light on hall 200 and whenever she looked down hall 200 CNA D was coming out of Resident #1's room. She said CNA D motioned for her to come over and CNA D told her Resident #1 was saying her arm was broke and for CNA J to go get LVN E. CNA J said she left to go look for LVN E, and then she returned with LVN E to Resident #1's room. CNA J said CNA D and CNA H were both in Resident #1's room waiting for LVN E and Resident #1 was in bed holding her right arm. She said LVN E asked Resident #1 what was wrong, and she heard Resident #1 say my arm hurt, it's broke and was moaning ow, ow. CNA J said LVN E touched Resident #1's right arm and Resident #1 said it hurts. She said LVN E looked over at them and said Resident #1 had lab drawn earlier, and then LVN went to go verify in Resident #1's chart. CNA J said she returned to Resident #1's room around 5:00am to assist CNA D with rotating Resident #1 and Resident #1 was saying Oh my arm hurts, hurts so bad. CNA J said she made the comment to CNA D Are they not going to send Resident #1 out or get an x-ray because Resident #1 appeared to be in a lot of pain. CNA J said they did mention to LVN E that Resident #1 was still complaining of arm pain. Record review of revised pain management/assessment scaled policy dated 5/25/2016 indicated Pain is a subjective sensation `of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: Complaints of pain will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 20 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1) Residents identifies pain characteristics. 2) Resident articulates factors that intensify pain. 3) Resident expresses a feeling of comfort and relief from pain. 4) Resident states and carries out appropriate pain interventions from pain relief. 5) Cognitively impaired residents will demonstrate actions of pain relief. Procedures: 1) Assess resident's physical symptoms of pain, physical complaints, and daily activities. Plain questions based on a resident communication ability were included in the Admission/readmission and weekly nursing summary. If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAIN AD assessment. 2) Perform comfort measures to promote relaxation. 3) Plan activities with the resident to provide distraction, such as reading, craft, television, or visits, to help resident focus on non-pain related matters. 4) Manipulate the environment to promote periods of uninterrupted rest as much as possible. This promotes health, well-being, and increased energy level important to pain relief. 5) Apply heat or cold as ordered (specify) to minimize or relieve pain. 6) Help resident into a comfortable position and use pillows to splint or support painful area, as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 7) Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8) Instruct resident in use of relaxation techniques. 9) Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. 10) Assist the resident in maintaining a pain management and rest schedule, exercise program and medication regimen. 11) Encourage self-care activities. 12) Talk with the resident about pain and assess for pain relief after interventions. 13) Monitor for effectiveness of pain interventions. 14) The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plan will be maintained for the management of the resident's pain. On 01/17/2024 at 4:00p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The Plan of Removal (POR) was accepted on 1/18/24 at 11:45am and indicated the following: Plan of Removal - F697 Pain Management On January 17, 2024, the facility learned that an IJ was being called due to F697 Pain Management. The Facility failed to: -Adequately assess Resident #1 for pain and administer pain medications as ordered. Resident #1 did not receive as needed pain medications from 12/15/23-12/20/23. -Notify the physician when Resident #1 had a change in behavior and complained of pain. -Notify the Administrator when Resident #1 had a change in behavior and complained of pain -Follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 21 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety -Follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent residents from not receiving pain medications and a diminished quality of life, that could lead to serious injury, harm, or death. Residents Affected - Few -As of 1/17/24 resident # 1 was assessed for pain by the DON. No complaints of pain or additional issues noted. Resident #1 has pain medication ordered. -All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 1/17/24. No additional residents were identified. -As of 1/17/24 the charge nurse B and charge nurse E were 1:1 in-serviced by the DON on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All charge nurses were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses including agency staff, new hires and PRN charge nurses not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse. -Administering pain medication for residents with signs and symptoms of pain. -Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All clinical staff were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topic below. All clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse -Pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) -Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. -Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The medical director was notified by the DON on 1/17/24 on the immediate jeopardy situation by the Administrator. An AD HOC QAPI meeting was held on 1/17/24 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. In attendance was the Administrator, DON, Regional Nurse, Medical Director, [NAME] President of Clinical Services, [NAME] President of Operations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 22 of 23 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 675183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Oaks Health and Rehabilitation Center 1123 N Bolton St Jacksonville, TX 75766 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 01/18/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews and record reviews were conducted on 01/18/24 from 5:00 p.m. through 8:00 p.m. and included 5 LVNs, 6 CNAs, ADON, DON, and Regional Compliance Nurse. Staff were able to explain administering pain medication for residents with signs and symptoms of pain. Staff had knowledge on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff were able to explain pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Staff had knowledge on notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. All residents in the facility were assessed for any increased pain by the DON and Charge Nurses. This was verified by interview with DON and record review of audit sheets listing resident name and room number. In-Services addressed pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff was in-serviced on pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The Charge Nurses was in-serviced on administering pain medication for residents with signs and symptoms of pain. Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. This was verified by record review of staff in-services signature sheets and staff interviews. The Director of Nursing / designee will educate all clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of the above in-services. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Compliance Nurse verified an Ad Hoc QAPI was conducted to discuss the immediate jeopardy concerning pain management and to develop the above-mentioned plan of care. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675183 If continuation sheet Page 23 of 23