Inspection·January 4, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .2143 [8:43 p.m.] .called to room by resident's wife, she stated that resident vomited, and she believes that he had aspirated. O2 saturation fluctuating between 90-94 % O2 at 3l per hour, RT suctioned resident's trach, wife insisting that resident be sent to hospital. Called EMS for transport, went to notify resident and wife that EMS was in route to transport, resident requested speaking valve, resident reported to this LVN, 'I'm not sick, it's her (pointing to wife) she's doing this to me' resident began looking at wife and stating, ' Quit lying, tell them what you're doing to me.' Staff stayed in room with resident, this LVN notified Administrator of resident statement, when EMS arrived to transport, notified lead EMT of resident's statement as well, resident transported to [hospital] at 2230 [9:30 p.m.] . In an interview with Agency LVN A on 01/03/24 at 3:45 p.m., she stated she had come on duty on 11/24/23 at 6:00 p.m. She stated Resident #1 required frequent suctioning and the Respiratory Therapist was working with him a lot during the shift. She stated Resident #1's family member asked about sending him to the hospital, but stated once they suctioned the resident his O2 sats were back in the normal range. She stated about 2 hours into her shift the family member called her to the room and reported Resident #1 had thrown up and she insisted he go to the hospital. Agency LVN A stated she had not seen any evidence the resident had thrown up. She stated she called Respiratory back in to suction the resident while she called for EMS since the family member insisted he go to the hospital. She stated when she returned to the room was when Resident #1 made the statements about his family member making him sick. She stated the family member kept talking over him. She stated the family member then stepped out of the room and she asked the resident what exactly the family member was doing to him, and he just kept saying ask her. She stated she had a staff member stay in the room with the resident until EMS arrived and she reported to them as well as called the hospital and told them what the resident had alleged. She stated she also contacted the Administrator and reported the allegation to her. She stated she treated the situation as an abuse allegation and reported it to the Abuse coordinator. In an interview with the Director of Operations on 01/03/24 at 4:00 p.m., he stated he was notified on 11/25/23 by the previous Assistant Administrator of the incident that had occurred on 11/24/23. He stated he was told by the Assistant Administrator the resident would not be returning to the facility. He stated he instructed her to report the incident to APS since the resident was no longer in the facility and it involved an allegation toward the family member. He stated he was informed today (01/03/24) by the SW that APS called her back in November 2023 and closed out the case and was told the facility needed to report the incident to the State Survey Agency. He stated had he been informed; he would have reported the incident to the State Survey Agency. He stated their policy required them to follow the Reporting guidelines so an allegation of abuse should had been reported within 2 hours. He stated the previous Assistant Administrator was responsible for reporting. He stated the Assistant Administrator had since been let go. In an interview with the Social Worker on 01/04/24 at 9:05 a.m., she stated she was first informed about the incident involving Resident #1 on 11/25/23. She stated the previous Assistant Administrator instructed her to notify APS of the allegation since the resident was no longer in the facility. She stated she reported the incident online and received a confirmation E-mail from APS the report was received. She stated sometime in the middle of the next week (11/27/23-12/01/23) she received a call from an APS worker ( name unknown) who stated the case had been closed and the facility needed to report the incident to the State Survey Agency. She stated she informed the Assistant Administrator of what the APS worker had said. She stated she was not sure what the previous Assistant Administrator had done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 2 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the previous Assistant Administrator on 01/04/24 at 1:25 p.m., she stated she had worked at the facility from July 2023 through 12/19/23 when she was terminated. She stated she recalled the incident with Resident #1 and stated Agency LVN A called and reported the incident to her on 11/24/23. She stated she did not call in the allegation to the State Survey Agency. She stated she reached out to the Director of Operations the next day, and he told her he did not think it was a reportable incident, but she stated she felt something needed to be done, so she instructed the Social Worker to call and report it to APS. She stated the Social Worker did come to her the next week and told her APS closed out the case and said the facility needed to report the incident to the State Survey Agency. She stated she thought she reported this to the Director of Operations. She stated at the time a lot her responsibility's had been removed from her and were being done by the Director of Operations and the DON. She stated, once again she did not report the incident to the State Survey Agency. In a follow up interview with the Director of Operations on 01/04/24 at 2:40 p.m., he stated the previous Assistant Administrator was the designated Abuse Coordinator during the time the incident on 11/24/23 occurred. He stated anytime there was a change of Abuse Coordinator, the staff were informed, and postings were placed in numerous locations throughout the facility with the name of the coordinator and their contact number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 3 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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 and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services were state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of seven residents (Resident #1) reviewed for abuse and neglect. The facility failed to report an allegation of abuse to the state survey agency when Resident #1's stated his spouse was making him sick on 11/24/23 within the 2-hour time frame. This failure could place residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin. Findings include: Record review of Resident #1's admission MDS assessment , dated 11/24/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included heart failure, seizure disorder (burst of uncontrolled electrical activity between brain cells that causes abnormalities in muscle tone or movements), and respiratory failure. Resident #1 was able to make himself understood and understood others. Resident #1's brief interview for mental status had not been completed at the time of the assessment. Resident #1 had a feeding tube and received 51 % of intake by artificial means, was oxygen dependent with a tracheostomy ( an opening in the windpipe to help air and oxygen reach the lungs) and was on mechanical ventilation. Record review of Resident #1's 48-hour care plan, dated 11/24/23, reflected The resident requires tube feedings .Interventions .Provide local care to G-tube site as ordered .The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders .The resident has a tracheostomy .Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia .Provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency Record review of Resident #1's progress note, written by Agency LVN A, dated 11/24/23 reflected .2143 [8:43 p.m.] .called to room by resident's wife, she stated that resident vomited, and she believes that he had aspirated. O2 sats fluctuating between 90-94 % O2 at 3l per hour, RT suctioned resident's trach, wife insisting that resident be sent to hospital. Called EMS for transport, went to notify resident and wife that EMS was in route to transport, resident requested speaking valve, resident reported to this LVN, ' I'm not sick, it's her (pointing to wife) she's doing this to me' resident began looking at wife and stating, 'Quit lying, tell them what you're doing to me.' Staff stayed in room with resident, this LVN notified Administrator of resident statement, when EMS arrived to transport, notified lead EMT of resident's statement as well, resident transported to [hospital] at 2230 [9:30 p.m. In an interview with Agency LVN A on 01/03/24 at 3:45 p.m. she stated she had come on duty on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 4 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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 11/24/23 at 6:00 p.m. She stated Resident #1 was requiring frequent suctioning and the Respiratory Therapist had been working with him a lot during the shift. She stated Resident #1's wife was asking about sending him to the hospital, but stated once they suctioned the resident his O2 sats were back in the normal range. She stated about 2 hours into her shift the wife called her to the room and reported that Resident #1 had thrown up and she was insisting that he go to the hospital. Agency LVN A stated she had not seen any evidence that the resident had thrown up. She stated she called Respiratory back in to suction the resident while she called for EMS since the wife was insisting, he go to the hospital. She stated when she returned to the room is when Resident #1 made the statements about his wife making him sick. She stated the wife kept talking over him. She stated the wife then stepped out of the room and she asked the resident what exactly the wife was doing to him, and he just kept saying ask her. She stated she had a staff member stay in the room with the resident until EMS arrived and she reported to them as well as calling the hospital and telling them what the resident had alleged. She stated she also contacted the Administrator and reported the allegation to her. She stated she treated the situation as an abuse allegation and reported it to the Abuse coordinator. In an interview with the Director of Operations on 01/03/24 at 4:00 p.m. he stated he was notified on 11/25/23 by the previous Assistant Administrator of the incident that had occurred on 11/24/23. He stated he had been told by the Assistant Administrator the resident would not be returning to the facility. He stated he instructed her to report the incident to APS since the resident was no longer in the facility and it involved an allegation toward the wife. He stated he was informed today (01/03/24) by the SW that APS had called her back in November 2023 and had closed out the case and was told the facility needed to report the incident to the State. He stated had he been informed; he would have reported the incident to the State. He stated their policy required them to follow the Reporting guidelines so an allegation of abuse should had been reported within 2 hours. He stated the previous Assistant Administrator was responsible for reporting. He stated the Assistant Administrator had since been let go. In an interview with the Social Worker on 01/04/24 at 9:05 a.m. she stated she was first informed about the incident involving Resident #1 on 11/25/23. She stated the previous Assistant Administrator instructed her to notify APS of the allegation since the resident was no longer in the facility. She stated she reported the incident online and received a confirmation E-mail from APS the report had been received. She stated sometime in the middle of the next week (11/27/23-12/01/23) she received a call from an APS worker ( name unknown) the case had been closed and the facility needed to report the incident to the State. She stated she informed the Assistant Administrator of what the APS worker had said. She stated she was not sure what the previous Assistant Administrator had done. In an interview with the previous Assistant Administrator on 01/04/24 at 1:25 p.m. she stated she had worked at the facility from July 2023 through 12/19/23 when she was terminated. She stated she recalled the incident with Resident #1 and stated Agency LVN A had called and reported the incident to her on 11/24/23. She stated she did not call in the allegation to the State. She stated she had reached out to the Director of Operations the next day, and he told her he did not think it was a reportable incident, but she stated she felt something needed to be done, so she instructed the Social Worker to call and report it to APS. She stated the Social Worker did come to her the next week and told her APS had closed out the case and told us we needed to report the incident to the State. She stated she thinks she reported this to the Director of Operations. She stated at the time a lot her responsibility's had been removed from her and were being done by the Director of Operations and the DON. She stated, once again she did not report the incident to the State. In a follow up interview with the Director of Operations on 01/04/24 at 2:40 p.m. he stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 5 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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 FORM CMS-2567 (02/99) Previous Versions Obsolete previous Assistant Administrator was the designated Abuse Coordinator during the time the incident on 11/24/23 had occurred. He stated anytime there is a change of Abuse Coordinator the staff were informed, and posting were placed in numerous locations throughout the facility with the name of the coordinator and their contact number. Record review of the facility's policy titled, Abuse, Neglect, Molestation and Misappropriation, revised November 2022, reflected, .All allegations of abuse along with injuries of unknown origin are reported immediately to the charge nurse and /or administrator of the facility along with other officials in accordance with State law through established guidelines .The Administrator and/or DON .will notify state agencies according to their state reporting guidelines .All allegations are to be reported withing the timeframe allotted by the appropriate state agency . Event ID: Facility ID: 675212 If continuation sheet Page 6 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for one of three residents (Resident #1) reviewed for admission Physician Orders. Residents Affected - Few 1. The facility failed to have Physician orders to check residual prior to medication administration. 2. The facility failed to have physician ordered which indicated the proper use of Resident #1's Gastrojejunostomy tube for feeding and medication administration upon his admission to the facility on [DATE]. These failures could place residents at risk of nausea, vomiting and diarrhea. Findings include: Record review of Resident #1's admission MDS assessment, dated 11/24/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included heart failure, seizure disorder (burst of uncontrolled electrical activity between brain cells that causes abnormalities in muscle tone or movements), and respiratory failure. Resident #1 was able to make himself understood and understood others. Resident #1's brief interview for mental status had not been completed at the time of the assessment. Resident #1 had a feeding tube and received 51 % of intake by artificial means, was oxygen dependent with a tracheostomy ( an opening in the windpipe to help air and oxygen reach the lungs) and was on mechanical ventilation. Record review of Resident #1's 48-hour care plan, dated 11/24/23, revealed The resident requires tube feedings .Interventions .Provide local care to G-tube site as ordered .The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders .The resident has a tracheostomy .Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia (slow heart rate) .Provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency Record review of Resident #1 progress note, written by LVN B on 11/22/23, reflected Arriving via ambulance after discharge from [hospital] status post Aortic Valve Repair (heart valve), R Hemothorax (collection of blood between the chest wall and lung), CVA (stroke), Septicemia (blood poison), respiratory failure .G/J tube (a soft narrow tube that enters the stomach in the upper part of the abdomen and threaded into the small intestine. The gastric port sits in the stomach and is used to vent air and give medications. The jejunal port sits in the small intestines and is used for feeding) site with some redness, Glucerna 1.5 started at 80cc/Hour Record review of Resident #1's Physician Order Summary, dated from 01/03/24, reflected an admission date of 11/22/23. The orders reflected, .Glucerna 1.5 at 80 ml/hour every shift Resident may be disconnected from feeding for activities, ADLS, therapy and quality of life with a start date of 11/22/23 The order did not indicate which port of the G/J tube the feeding was to be administered. Record review of the physician's orders did not include to check for residual (amount remaining) prior to administration of medication through the gastric port, or how much residual required physician notification and when to hold the medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 7 of 8 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the hospital discharge orders, dated 11/21/23, for Resident #1 reflected, Continue current Tube Feeding regimen: Promote (high protein supplement) at 80 ml/hr x 22 hours via J-tube water flushes per MD discretion In an interview with LVN C on 01/03/24 at 12:15 p.m. revealed she was the nurse who admitted Resident #1 on 11/22/23. She stated the admitting nurse was responsible for entering all the admission orders on any new admission. She stated they utilized the hospital discharge orders for their admitting orders, and if there was anything that needed clarifying they would contact the facility physician to obtain orders. She stated Resident #1 admitted with a G/J tube which was a specialty tube that had two separate ports. She stated the J tube was for feedings and the G tube was for medication administration. She stated they also had a standing protocol to check for residual prior to administering any medications. She stated the protocol was to hold medications for any residual over 100 ml and she stated she somehow missed putting it in the orders. She stated the G/J tube orders should have been specified on the orders as well to ensure the feedings were provided through the correct port. She stated failing to connect it to the J tube might cause some nausea. She stated she had no excuses, and stated she remembered having two admissions that day around the same time and guessed she just overlooked it. In an interview with the DON on 01/03/24 at 02:35 p.m., she stated all the nursing staff who were assigned to the ventilator hall had specialized training. She stated most of those residents had g-tubes and the nursing staff knew to always check residual prior to giving medications. She stated that was just standard nursing care. She stated however admission orders needed to be specific and indicate how much residual required physician notifications and when to hold the medications. She stated a specialty tube such a G/J tube should also have specified orders on which port to use for the feedings and which for the medications. She stated any concern or questions should be clarified with the physician. She stated failing to have specific orders for proper care of the G/J tube could result in tube occlusion, nausea and vomiting for the resident. Record review of the facility's policy titled, Enteral Feedings- Safety Precautions, dated November 2018, reflected, To ensure the safe administration of enteral nutrition .check the following information .Route of delivery .access site .Method (Pump, gravity, syringe) and Rate of administration (ml/hour) .Check enteral tube placement every 4 hours and prior to feeding or administration of medication .Check gastric residual volume as ordered FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 8 of 8