Inspection·January 31, 2024

F 0689 Review of Resident #1's progress notes, dated 01/30/2024, revealed: Level of Harm - Immediate jeopardy to resident health or safety -nursing progress note text on 01/15/2024 at 11:45 (11:45 a.m.), CNA (CNA A) attempted to transfer by sba (stand by assist). Resident unable to moved left leg due to increase weakness, to complete transfer. CNA (CNA A) lower resident to floor to prevent resident from falling. Residents Affected - Few -nursing progress note text on 01/15/2024 at 11:52 (11:52 a.m.), notify NP of incident, gave orders to continue monitoring and for pain medication. -nursing progress note text on 01/15/2024 at 12:00 (12:00 p.m.), Resident (Resident #1) given Tramadol 50mg (milligram) tab po (by mouth) for pain to left knee. Review of Resident #1's Event Nurses' Note-Fall, dated 01/15/2024 at 11:38 (11:38 a.m.), revealed LVN A's documentation: Location occurred: Resident room. Unwitnessed or hit head? none of the above Fall: legs gave out Injury -nursing progress note text on 01/16/2024 at 09:30 (09:30 a.m.), notify NP of changes of left ankle and receive order for Xray. Review of Resident #1's x-ray results, date of service 01/16/2024, revealed an impression: 1.Mildly displaced fracture of distal shaft of the left tibula bone. Review of Resident #1's progress notes, dated 01/30/2024, revealed: -Transfer notification on 01/16/2024 at 22:09 (10:09 p.m.) Resident #1 transferred to hospital on [DATE] 10:00 PM related to Fx (fracture) of L (left) Leg. Review of the facility's reported incident investigation's interviews, dated 01/17/2024, revealed CNA A statement, I went into resident (Resident #1) room to ask and check on her to see if she was going to get up and she told me yes cause she had to do therapy. CNA A added, I sit her on side of the bed put her chair next to the bed put her walker in front of her gave her a few minutes to rest on the side of the bed so then she say she was ready so she stood up with her walker the (then) she stated to pivot around to get in the chair she said let her sit back down on the bed so she got up off the bed again and started to pivot toward the chair and then (then) she said she couldn't so I told her to sit back down on the bed and she said lets gone and get in the chair so she started pivoting back so that's when her left knee started buckling and she started going down so I told her I'm going to lower her to the floor. CNA added, I saw PT (PT A) told her I needing her in (Resident #1's) room went and got the Mechanical lift from CNA B told LVN B I need her in resident #1's room so we put her back in the chair with the Mechanical lift. Review of the facility's reported incident investigation's interviews, no date, revealed PT A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 2 of 7 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few statement, I (PT A) did not personally see the fall; however I was walking down the hall when CNA (CNA A) asked me to help her get resident (Resident #1) off the floor. While CNA A went to get the Mechanical and tell the nurse, I saw with Resident #1. I put a pillow under her head and she began to cry and tell me her L (left) leg hurt, I asked her to move both LE (lower extremities) and was able to move her LE within patient functional limitations. CNA A and CNA B returned with the Mechanical lift and all 3 of use assisted Resident #1 back into her wheelchair with the Mechanical lift. CNA A told me the nurse was on the way and I left the room with Resident #1 calmed down, laughing, and safely in her chair. Interview on 01/30/2024 at 11:52 a.m., CNA B stated she was called for help by CNA A, and we (CNA A, PT A) helped her get up off the floor with the Mechanical lift on to her wheelchair. CNA B stated she was not sure that Resident #1 was assessed by a nurse before transferring Resident #1. CNA B assumed Resident #1 was because CNA A informed her a nurse was called. CNA B stated staff were not supposed to move a resident before a nurse assessment. CNA B stated it is important to review a resident's [NAME] to ensure the proper way and the needs to transfer all residents, and that there are always two or more staff assisting in a Mechanical lift transfer for a safe transfer. Interview on 01/30/2024 at 12:48 p.m., LVN A stated she remembers performing an assessment on Resident #1; pain was found in Resident #1's left knee. During the assessment, there was no swelling, redness, discoloration to her left lower extremity. LVN A stated Resident #1 was not on the floor during the assessment and confirmed Resident #1 was on her wheelchair. LVN A stated she did not see the fall. LVN A stated that it was listed as an assisted and witnessed fall. she is assuming why staff moved Resident #1. LVN A stated staff should wait for a nurse assessment before moving any residents after falls. LVN A stated staff follow the information listed in the resident's [NAME], and staff should review the [NAME] before care and transfers, to ensure safety. LVN A stated the resident's conditions change, and we update the [NAME] and care plan to reflect up to date care for residents. Interview on 01/30/2024 at 01:07 p.m., PT A stated she is the director of Physical Therapy. PT A stated that Resident #1 is a two-person transfer using a Mechanical lift. PT A stated on 01/15/2024, she was on the hall, then CNA A walked out of Resident #1's room and asked for assistance because Resident #1 was on the floor. PT A stated she walked in the room and saw Resident #1 on the floor and got down to her level and asked questions about range of motion and pain, CNA A and CNA B walked in the room with the Mechanical lift, and all three staff assisted Resident #1 from the floor to her wheelchair. PT A stated she does not do pain assessments; she does therapy assessments. During a phone Interview on 01/30/2024 at 01:14 p.m., CNA A confirmed Resident #1's assisted fall on 01/15/2024. CNA A stated she checked Resident #1 that day, and the resident asked to transfer to her wheelchair. During the transfer Resident #1's knee gave out. CNA A was behind Resident #1, supported her back, assisted Resident #1 to the floor, and laid Resident #1 on her back. CNA A stated Resident #1 is a two person transfer with a Mechanical lift. CNA A stated she was, just trying to help her (Resident #1). CNA A stated that staff must check all residents' [NAME] to confirm proper care. CNA A stated that staff are not supposed to move residents after falls, and that a nurse must assess the residents first after falls. Phone Interview on 01/30/2024 at 01:54 p.m., the MD recalls receiving information of the incident on Resident #1 on 01/15/2024.MD stated that this is an acute fracture to Resident #1's left tibia. MD stated that if he had to assume when the fracture occurred it more than likely occurred during the time when Resident #1 was assisted to the floor or prior to Resident #1 being assisted. MD explained that Resident #1's diagnoses with a combination of morbid obesity and osteoporosis could have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 3 of 7 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 contributing factors. Level of Harm - Immediate jeopardy to resident health or safety Interview on 01/30/2024 at 01:47 p.m., the ADON stated that the [NAME] must be followed from all staff to ensure proper care for residents. If not, they can drop the resident, or an accident can occur. ADON confirmed that there must be two people for all Mechanical lift transfers. ADON stated assessments are followed after all falls, and that assisted falls have the same procedure as witnessed falls and unwitnessed falls. ADON added there is no difference between a fall and an assisted fall. Residents Affected - Few Interview on 01/30/2024 at 02:34 p.m., DON stated that staff have been in-serviced to always check residents' [NAME], how to use the [NAME] and find information on transfers and safety, follow residents' orders, abuse and neglect, safe transfers and mechanical lift use. DON stated that CNA A has been in-serviced one on one and had to demonstrate how to use the Resident [NAME], how to find information, safe transfers, and had to demonstrate a Mechanical lift transfer safely with another staff. DON stated there is a difference between an assisted fall and unwitnessed or witnessed fall. DON stated a fall is a resident losing balance, while an assisted fall is staff guiding a resident to the floor. DON stated nursing assessments are important to gather medical details on the resident and how the fall occurred so there can be a plan of treatment and so interventions can be created. DON stated that an assessment before moving a resident is important because if staff move a resident after a fall, and before being assessed, we do not know what kind of injury occurred. and the DON said that moving a resident can cause bigger issues, because we don't know what kind of injury we are dealing with. Interview on 01/30/2024 at 02:36 p.m., LVN B stated she was not there to witness the fall, she had just started her shift, and she did not do the fall assessment after the incident. LVN B stated she performed the follow up fall assessments for Resident #1. LVN B stated staff must follow the proper way to transfer. She stated that information is listed in a resident's [NAME]. LVN B stated that when a resident falls, nursing performs assessments, check for injuries, pain, swelling, bleeding, or apparent injuries, check the surroundings, and detail information on the fall. LVN B stated the risk of moving residents before a nursing assessment are bad. She stated they (residents) should not be moved until they are assessed because moving a resident might cause more harm. Review of the facility's Hydraulic Lift policy, no date, reflected the hydraulic list is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer recommendations. Review of the facility's Employee Disciplinary Report Action Request, dated 01/18/2024, reflected Specific Reason for requesting Disciplinary Action for CNA A-improper transfer of a resident. Request for the facility' policies for care plans and nursing assessments were not given before exit. The ADM was notified on 01/30/2024 on 01/30/2024 at 06:16 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 01/31/2024 at 12:35 p.m., and included: Plan of Removal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 4 of 7 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Problem: F689 Free from Accidents/Hazards Level of Harm - Immediate jeopardy to resident health or safety Interventions: Residents Affected - Few o On 1/30/24, CNA was in-serviced 1:1 by the DON on the following: Following the [NAME] for all transfers with return demonstration. o [mechanical lift] transfers with return demonstration. o Abuse and Neglect. o Fall Prevention On 1/30/24 CNA and Director of Rehab were in-serviced 1:1 by the DON on not to move or transfer a resident after a fall until a nurse performs an assessment. On 1/30/24, all residents in the facility were assessed and evaluated for transfer assistance by the DON and Director of Rehab. On 1/30/24, all resident care plans reviewed for accuracy of transfer assistance by DON and MDS Coordinator. No issues were identified. On 1/30/24 the Facility initiated our second round of mechanical lift training and check offs. All nursing staff will be checked off again prior to the start of their next shift. Training and checks will be completed by DON/ADON/and Director of Rehab. The medical director was notified by the administrator on 1/30/24 at 7:00pm. Ad hoc QAPI was held with the Medical Director and facility interdisciplinary team on 1/30/24. In-services: The Administrator, DON, and ADON were in-serviced 1:1 on the following topics below on 1/30/24 by the Regional Compliance Nurse. The DON and ADON then in-serviced all nursing staff present on the follow topics below as of 1/30/24. All staff not present will not be allowed to assume their duties until in-serviced. All new hires will be in-service on their date of hire, during facility orientation. Admin and DON will complete the in-services and monitor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 5 of 7 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Abuse and neglect policy. Level of Harm - Immediate jeopardy to resident health or safety Hydraulic lift policy with return demonstration. Residents Affected - Few Fall Prevention Policy. How to use the [NAME] in PCC to determine the transfer status of a resident with return demonstration. Do not move or transfer a resident after a fall until assessed by nurse for injury. The Survey Team monitored the Plan of Removal on 01/31/2024: Observation on 01/31/2024 at 12:53 p.m., revealed signage at the clock in station stating, All Staff, clock in and go directly to DON office. Observation on 01/31/2024 from 12:57 p.m. to 02:15 p.m., revealed CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F demonstrated [NAME] use, and how to find information for a proper and safe transfer. Observation on 01/31/2024, revealed CNA B and CNA C demonstrated a Mechanical lift transfer with two persons assist. Interviews on 01/31/2024 from 12:57 p.m. to 02:15 p.m., revealed CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F confirmed and stated in-services were completed from 01/30/2024 to 01/31/2024 on topics of [NAME] Use, Mechanical lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. Interviews and record reviews on 01/31/2024 from 01:28 p.m. to 02:48 p.m. ADM, DON, ADON, LVN A, and LVN B confirmed and stated in-services were completed from 01/30/2024 to 01/31/2024 on topics of [NAME] Use, Mechanical lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. Interview on 01/31/2024 on 01:51 p.m., Corporate Registered Nurse and DON stated staff not present, such as PRN or staff on leave, will not be allowed to assume their duties until in-serviced. All new hires will be in-service on their date of hire, during facility orientation. Admin and DON will complete the in-services and monitor. Interview on 01/31/2024 on 03:34 p.m., DON stated CNA a was in-serviced one-on-one on topics of Following the [NAME] for all transfers with return demonstration, Mechanical lift transfers with return demonstration, Abuse and Neglect and fall prevention. DON stated that CNA A and PT A were in-serviced one-on-one on the topic of not to move or transfer a resident after a fall until a nurse performs an assessment. Record review on 01/31/2024, reflected Ad hoc QAPI meeting occurred, no date, on 01/30/2024 with ADM, MD (by phone), DON, Assistant Director of Operations, and Corporate Registered Nurse. Record review on 01/31/2024, reflected one on one in-services completed on CNA A on the topics of [NAME] Use, Mechanical lift Lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 6 of 7 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review on 01/31/2024, reflected one on one in-services completed on PT A on the topic of not to move or transfer a resident after a fall until a nurse performs an assessment. The ADM was notified on 01/31/2024 at 04:17 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 01/31/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675210 If continuation sheet Page 7 of 7