Inspection·March 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 02/26/2023 at 10:45 AM, Resident #56 was walking down the hallway, into the dining room, holding onto the back of a wheelchair. Resident #56 had a shuffled gait and walked at a fast pace. Resident #56's pants had slipped down below her buttocks exposing her brief. During an interview on 02/26/2023 at 11:06 AM, Resident #56 was non-interviewable as evidenced by confused conversation. During an observation on 02/26/2023 at 11:16 AM, Resident #56 was walking down the hallway, into the dining room, holding onto the back of a wheelchair. Resident #56 had a shuffled gait and walked at a fast pace. Resident #56's pants had slipped down below her buttocks exposing her brief. During an observation on 02/26/2023 at 12:20 PM, Resident #56 was walking down the hallway, into the dining room, holding onto the back of a wheelchair. Resident #56 had a shuffled gait and walked at a fast pace. Resident #56's pants had slipped down below her buttocks exposing her brief. 2. Record review of Resident #36's face sheet, dated 03/01/2023, revealed Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of vascular dementia, severe, without behavioral disturbance (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain). Record review of the MDS assessment, dated 01/16/2023, revealed Resident #36 had clear speech and was understood by staff. The MDS revealed Resident #36 was able to understand others. The MDS revealed Resident #36 had poor long-term and short-term memory. The MDS revealed Resident #36 was only able to recall the location of her room and had severely impaired decision-making skills. The MDS revealed no behaviors or refusal of care during the look-back period. The MDS revealed Resident #36 required extensive assistance with one staff assist with eating. Record review of the comprehensive care plan, initiated on 05/15/2017, revealed Resident #36 had an ADL self-care performance deficit. The interventions revealed Resident #36 required a one person staff participation to eat. During a dining observation on 02/26/2023 at 12:34 PM, MA G was standing near Resident #36 and asked, Is she a feeder? During an interview on 02/26/2023 at 11:01 AM, Resident #36 was non-interviewable as evidenced by confused conversation. 3. Record review of Resident #58's face sheet, dated 03/01/2023, revealed Resident #58 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of vascular dementia, severe, without behavioral disturbance (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain). Record review of the MDS assessment, dated 11/17/2022, revealed Resident #58 had clear speech and was understood by staff. The MDS revealed Resident #58 was able to understand others. The MDS revealed Resident #58 was unable to complete the BIMS interview, which indicated cognitive impairment. The MDS revealed Resident #58 had no behaviors or refusal of care during the look-back period. The MDS revealed Resident #58 required limited one-person assistance with eating. During a dining observation on 02/26/2023 at 8:53 AM, CNA L was standing up while feeding Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 2 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0550 #58. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/26/2023 at 9:06 AM, CNA L stated she normally fed residents while standing. CNA L stated she was scheduled to work during the weekends. CNA L stated she was feeding Resident #58 while standing because she had no chairs to sit in while in the dining room. CNA L further stated she had multiple residents to feed and was unable to sit with only one. CNA L stated Resident #58 would have liked and responded better if she was sitting while feeding him. CNA L stated feeding Resident #58 while standing could have been embarrassing. Residents Affected - Some During an interview on 02/26/2023 at 11:02 AM, Resident #58 was non-interviewable as evidenced by confused conversation. During an interview to obtain more information on 03/01/2023 at 4:02 PM, CNA L did not answer the telephone and a brief message was left. CNA L did not return the call upon exit of the facility. During an interview on 03/01/2023 at 4:09 PM, LVN H did not answer the telephone and a brief message was left. LVN H did not return the call upon exit of the facility. During an interview 03/01/2023 at 4:16 PM, CNA Q stated it was not appropriate for Resident #56 to wear ill-fitting pants. CNA Q stated if her pants were too big, CNAs should have assisted Resident #56 with changing her pants. CNA Q stated allowing Resident #56 to wear ill-fitting pants was a dignity issue and could have been embarrassing to Resident #56. CNA Q stated it was not appropriate to refer to residents as feeders. CNA Q stated it was important to refer to residents respectfully to maintain the resident's dignity. During an interview on 03/01/2023 at 4:32 PM, LVN M stated ill-fitting pants should have been addressed by the facility staff. LVN M stated pants that were too big and exposed Resident #56's brief could have been embarrassing. LVN M stated staff should not feed residents while standing or refer to residents as feeders. LVN M stated it was important to treat residents with dignity and respect. During an interview on 03/01/2023 at 4:38 PM, MA G stated she referred to Resident #36 as a feeder because she had not worked in the secured unit for a while, and she was unsure if Resident #36 needed to be fed. MA G stated it was not appropriate to use the term feeder when referring to a resident. MA G stated using the term feeder was a lack of dignity and could have been embarrassing to Resident #36. During an interview on 03/01/2023 at 5:39 PM, the DON stated she expected staff to ensure residents wore well-fitted clothing, were not referred to as feeders, and were not fed by staff who were standing up. The DON stated it could have been embarrassing to the residents and it was important to ensure residents maintained their dignity and respect. During an interview on 03/01/2023 at 6:14 PM, the ADM stated he expected staff to treat residents with dignity and respect. The ADM stated it was important to treat the residents with dignity and respect because staff would want to have been treated with dignity and respect. Record review of the Resident Rights policy, last revised in 08/2020, revealed Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 3 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life and privacy and confidentiality of the medical records for 2 of 19 residents reviewed for resident rights. (Resident #27 and Resident #42) Residents Affected - Few 1. The facility failed to ensure LVN O closed the EMAR of Resident #42 before entering her room to provide a blood glucose check and administer insulin. 2. The facility failed to ensure CNA U and CNA V provided privacy to Resident #27 while providing incontinent care. This failure could place residents at risk for a violation of resident's rights, diminished quality of life, and loss of dignity or self-worth. The findings included: 1. Record review of Resident #42's face sheet, dated 03/01/2023, revealed Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of systemic lupus erythematosus or SLE (autoimmune disease, with systemic manifestations including skin rash, erosion of joints or even kidney failure), type 2 diabetes mellitus without complications (high blood sugar), and mild cognitive impairment (condition where memory or thinking skills are worse than normal for one's age, but not severe enough to affect daily life). Record review of the order summary report, dated 03/01/2023, revealed Resident #42 had an order, which started on 08/05/2022, for Novolog (insulin, used to lower blood sugar) per sliding scale (scale used to determine how much insulin should be given based on the blood sugar). Record review of the MDS assessment, dated 01/07/2023, revealed Resident #42 had clear speech and was understood by staff. The MDS revealed Resident #42 was able to understand others. The MDS revealed Resident #42 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #42 received insulin injections 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, last reviewed on 01/18/2023, revealed Resident #42 had diabetes mellitus and required insulin injections. During an observation on 02/27/2023 between 11:18 AM - 11:42 PM, LVN O took her nursing cart and laptop to the hallway outside of Resident #42's room. LVN O obtained Resident #42's blood sugar and entered the amount into her EMAR. LVN O drew up her insulin and checked it against the EMAR to ensure the amount of insulin was correct. LVN O then went into Resident #42's room to administer the insulin leaving the EMAR screen open on her cart in the hallway that was visible to staff members walking by. During an interview on 03/01/2023 at 1:32 PM, LVN O stated she had only worked at the facility for a few days. LVN O stated she should not have left her EMAR screen open. LVN O stated she was nervous because state was in the building. LVN O stated it was important to ensure EMAR information was hidden to ensure patient privacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 4 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/01/2023 at 5:58 PM, the DON stated she expected staff to ensure EMAR information was protected when they were away from their carts. The DON stated privacy was monitored by education and frequent rounding. The DON stated it was important to ensure EMAR information was hidden to ensure the residents' privacy. During an interview on 03/01/2023 at 6:24 PM, the ADM stated he expected staff to ensure EMAR information was protected while on the nurse carts. The ADM stated nurse management was responsible for ensuring patient privacy was protected. The ADM stated it was important to ensure EMAR information was hidden to respect the resident's privacy and confidentiality. 2. Record review of Resident #27's face sheet, dated 3/01/2023, revealed an [AGE] year old male, initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included dementia in other diseases classified elsewhere, severe, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors), unspecified atrial fibrillation (irregular, often rapid heart rate), and acute on chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation). Record review of the MDS assessment, dated 02/07/2023, revealed Resident #27 was understood and sometimes understood others. The MDS assessment revealed Resident #27 had a BIMS score of 01, indicating Resident #27's cognition was severely impaired. The MDS assessment revealed Resident #27 required extensive assistance with bed mobility, transfer, walk in room, walk in corridor, locomotion on unit and locomotion off unit, dressing, eating, toilet use, and personal hygiene. Record review of an undated care plan revealed, Resident #27 had an ADL self-care performance deficit and required limited assistance of 1 staff for toilet use, bed mobility, and personal hygiene. During an observation on 02/26/2023 at 11:10 AM, CNA U and CNA V were providing incontinent care on Resident #27 with the blinds to the window open exposing his buttocks and genital area. The outdoors and road were visible from his open blinds. During an interview on 02/26/2023 at 11:25 AM, CNA U stated she should have shut the blinds to the window while performing incontinent care. CNA U stated she did not realize the blinds were open. CNA U stated it was not ok for the blinds to the window to remain opened because it did not give Resident #27 the right for privacy, and it could make Resident #27 feel like he lost his dignity. During an interview on 02/26/2023 at 11:29 AM, CNA V stated the blinds to the window should have been closed while providing incontinent care for Resident #27. CNA V stated she did not close the blinds because she did not think to close them, and she overlooked it. CNA V stated it was important to close them for Resident #27's privacy, due to HIPAA (Health Insurance Portability and Accountability Act of 1996), and for dignity. CNA V stated it could make Resident #27 feel like it was messing with his dignity. During an attempted interview with Resident #27 on 02/27/2023 at 3:18 PM, indicated he was not interviewable. During an interview on 03/01/2023 at 10:04 AM, LVN S stated while providing incontinent care the CNAs should close the blinds to the window, close the door, and pull the curtains. LVN S stated while providing incontinent care it was important to provide privacy for the resident's dignity. LVN S stated the CNAs knew they were supposed to provide privacy while providing incontinent care. LVN S (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 5 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the DON provides education via in-services on providing privacy for the residents. LVN S stated not providing privacy during incontinent care could make the resident want to stay in the room if they were shy or modest because it could make them feel embarrassed. During an interview on 03/01/2023 at 1:37 PM, ADON K stated while providing incontinent care the CNAs should pull the curtains, close the blinds, and close the door to provide privacy for the residents. ADON K stated she did not have an answer as to who was responsible for ensuring the CNAs provided privacy for the residents. ADON K stated it was important to provide privacy for the resident's dignity. ADON K stated not providing privacy while providing incontinent care could make the residents feel shameful. During an interview on 03/01/2023 at 3:53 PM, ADON T stated while providing incontinent care the CNAs should close the curtain and the door and close the blinds. ADON T stated the CNAs should make sure everything is closed to provide privacy for the residents. ADON T stated nurse management did in-services on how to provide incontinent care and he tried to reinforce the education on this when he had an opportunity. ADON T stated it was important to provide privacy while providing incontinent care for the resident's privacy and safety. ADON T stated not providing privacy while providing incontinent care could make the residents feel like the staff did not care about them and everybody was seeing their private parts. During an interview on 03/01/2023 at 4:04 PM, the administrator stated he expected the CNAs to provide privacy for the residents. The administrator stated the CNAs should close the blinds on the window while providing incontinent care. The administrator stated it was the responsibility of the CNAs to ensure they were providing privacy for the residents. The administrator stated not closing the blinds to the window while providing incontinent care could be humiliating to the resident. During an interview on 03/01/23 at 4:30 PM, the DON stated the CNAs should provide privacy during incontinent care by closing the curtains, the doors, and the blinds on the window. The DON stated not closing the blinds when providing incontinent care was a dignity issue. The DON stated in services were done by nurse management to ensure the CNAs were providing privacy for the residents. Record review of the Resident Rights policy, dated 08/2020, revealed The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life . The policy further revealed I. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to a resident's right to: E. Privacy and confidentiality . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 6 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 secured unit observed for homelike environment. Residents Affected - Few The facility served 12 out of 12 residents in the dining room, on the secured unit, on a serving tray. The facility posted signs on the secured unit doors that stated, Elopement and Wandering in Seniors. These failures could result in resident having poor self-esteem and decreased quality of life. The findings included: During an observation on 02/26/2023 between 8:39 AM - 9:05 AM, 12 out of 12 residents were sitting in the dining room with their breakfast meal served on the serving tray. There were two signs noted on the secured unit doors which stated, Elopement and Wandering in Seniors and had a picture of an elderly lady holding a cane walking toward a door. During an interview on 03/01/2023 at 4:11 PM, CNA Q stated meals were not always passed on the serving trays. CNA Q stated she was unsure why meals would have been served on the serving trays. CNA Q stated the signs on the secured unit doors were kid-like. CNA Q stated providing meals on a serving tray and posting signs was a dignity issue and was intuitional-like and not homelike. During an interview on 03/01/2023 at 4:35 PM, LVN M stated meals were normally served on serving trays in the secured unit. LVN M stated he was unsure if meals should have been served on the serving trays. LVN M stated the signs on the doors could have been re-worded or could have been placed somewhere else. LVN M stated the failure to the residents for serving meals on the serving trays and having signage on the doors was lack of dignity to the residents and an un-homelike environment. During an interview on 03/01/2023 at 5:42 PM, the DON stated meals should not have been served on serving trays. The DON stated the signage should not have been posted on the doors to the secured unit. The DON stated meals served on serving trays and signage on the doors was monitored by education and constant rounding. The DON stated the failure to the residents was lack of dignity. During an interview on 03/01/2023 at 6:16 PM, the ADM stated he expected staff to ensure residents had a home-like environment. The ADM stated the importance of ensuring staff did not serve meals on serving trays and signage on the secured unit doors was to ensure the facility was non-institutional like and more home-like. Record review of the Resident Rooms and Environment policy, last revised on 08/2020, revealed The facility provides residents with a safe, clean, comfortable, and homelike environment. The policy further revealed VI. Facility staff work to minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting, including: C. institutional signage (for example, labeled storage closets and work rooms in common areas); and F. generic, mass produced bedding, drapes, and furniture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 7 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure an accurate MDS was completed for 2 of 19 residents (Residents #48 and #73) reviewed for MDS assessment accuracy. Residents Affected - Few 1. The facility failed to accurately document smoking for Resident #48 on the MDS assessment. 2. The facility failed to accurately document discharge status for Resident #73 on the MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #48's order summary report, dated 03/01/2023, indicated Resident #48 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), and schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood). Record review of Resident #48's annual MDS, dated [DATE], indicated Resident #48 understood others and made herself understood. The assessment indicated Resident #48 was cognitively intact with a BIMS score of 15. The assessment indicated Resident #48 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #48 did not use tobacco. Record review of Resident #48's undated care plan indicated Resident #48 chose to smoke periodically. The care plan interventions included, perform smoking assessment according to facility policy, and educate resident not to smoke with patch in place. Record review of an undated sheet titled Smoking List provided by the DON indicated Resident #48 was a smoker. Record review of a Safe Smoking Evaluation dated 01/22/2023 indicated Resident #48 was a smoker. During an observation on 02/27/2023 at 3:30 p.m., Resident #48 was observed smoking a black cigarette. During an observation on 02/28/2023 at 11:15 a.m., Resident #48 was observed smoking a black cigarette. 2. Record review of Resident #73's order summary report, dated 03/01/2023, indicated Resident #73 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #73's discharge MDS, dated [DATE], indicated Resident #73 was discharged to an acute hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 8 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a progress note dated 11/30/2022 indicated Resident #73 was discharged to another nursing facility. During an interview on 03/01/2023 at 1:36 p.m., the Regional MDS Nurse stated the MDS nurse had only been in the facility for a week. The Regional MDS nurse stated the MDS nurse was responsible for coding accurately. The Regional MDS nurse stated tobacco should have been coded on Resident #48 annual MDS. The Regional MDS nurse stated Resident #73 discharge assessment should have indicated she was discharged to another skilled nursing facility. The Regional MDS nurse stated she monitors a sample of assessments for accuracy during facility visits. The Regional MDS nurse stated the visits are usually 2-3 times a month or more. The Regional MDS nurse was unable to verify if Residents #48 and #73 were part of the resident sample she reviewed. The Regional MDS nurse stated these failures caused no harm to the residents. During an interview on 03/01/2023 at 4:23 p.m., the Regional MDS nurse stated there was not a policy and procedure regarding MDS assessment accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 9 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 3 of 19 residents (Resident #8, Resident #23, and Resident #44) reviewed for PASARR. The facility failed to coordinate IDT meetings to discuss specialized services with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #8 and Resident #44. The facility failed to ensure the correct PASARR Screening was submitted to the local authority for Resident #23 who had MI diagnosis upon admission. These failures could place residents with positive PASARR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 03/01/2023 revealed, Resident #8 was a [AGE] year old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of bipolar disorder, in partial remission, most recent episode depressed (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), vascular dementia, unspecified severity, without behavioral disturbance, mood disturbance, psychotic disturbance, mood disturbance, and anxiety (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain with no behaviors), and anxiety disorder, unspecified. Record review of the comprehensive MDS assessment dated [DATE] revealed, Resident #8 had serious mental illness. The MDS assessment revealed, Resident #8 was understood and understood others. The MDS assessment revealed, Resident #8 had a BIMS score of 05, indicating severe cognitive impairment. The MDS assessment in the section of psychiatric/mood disorder revealed, Resident #8 had diagnoses of bipolar disorder and anxiety disorder. Record review of an undated care plan revealed, Resident #8 had a psychosocial wellbeing problem related to bipolar disorder. The care plan for Resident #8 did not address PASARR coordination of services. Record review of Resident #8's PASARR Level 1 Screening completed on 01/21/2022 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. Record review of Resident #8's PASARR Evaluation dated 01/27/2022 revealed he had mood disorder (bipolar disorder, major depression, or other mood disorder). For Resident #8 the PASARR Evaluation question based on the QMHP assessment, does this individual meet the PASARR definition of mental illness was answered yes. Resident #8's PASARR Evaluation indicated the recommended services provided/coordinated by the local authority were routine case management. During an interview with the MDS corporate nurse on 02/28/2023 at 11:22 AM, records for the IDT meetings with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 10 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0644 were requested from the MDS corporate nurse and none were provided upon exit. Level of Harm - Minimal harm or potential for actual harm 2. Record review of a face sheet dated 03/01/2023 revealed, Resident #44 was a [AGE] year old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and unspecified mood affective disorder (severe disturbance in mood depression, anxiety, elation, and excitement accompanied by psychotic symptoms such as delusions, hallucinations). Residents Affected - Some Record review of the comprehensive MDS assessment dated [DATE] revealed, Resident #44 had serious mental illness. The MDS assessment revealed, Resident #44 was understood and understood others. The MDS assessment revealed, Resident #44 had a BIMS score of 00, indicating severe cognitive impairment. The MDS assessment in the section of psychiatric/mood disorder revealed, Resident #44 had diagnoses of anxiety disorder, depression, and bipolar disorder. Record review of the care plan last revised on 02/28/2023, indicated Resident #44 had a mood problem related to disease process and diagnoses of bipolar and mood affective. The care plan indicated Resident #44 was PASARR positive related to a severe mental illness, and the initial IDT was completed 02/28/2023 (IDT meeting occurred after surveyors entered facility), determined that Resident #44 no longer qualified for services related to primary diagnosis of dementia. Record review of Resident #44's PASARR Level 1 Screening completed on 10/21/2019 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. Record review of Resident #44's PASARR Evaluation dated 10/24/2019 revealed he had mood disorder (bipolar disorder, major depression, or other mood disorder). For Resident #44 the PASARR evaluation question based on the QMHP assessment, does this individual meet the PASARR definition of mental illness was answered yes. Resident #44's PASARR Evaluation indicated the recommended services provided/coordinated by local authority were routine case management. Record Review of the PCSP Form dated 02/10/2021 revealed there was an annual IDT/SPT meeting on 02/10/2021. The PCSP Form indicated Resident #44 expressed interest in services, but the IDT members were unsure if Resident #44 understood the services being offered, and that the nursing facility would follow up and determine if dementia was a primary diagnosis and would provide an update to the local mental health authority. During an interview with the MDS corporate nurse on 02/28/2023 at 11:25 AM, the MDS corporate nurse stated there were no IDT meetings with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #44 since the last meeting on 02/10/2021. The MDS corporate nurse stated she would check to see if a Form 1012 (form for Mental Illness/Dementia Resident Review) had been submitted for Resident #44. No Form 1012 was provided for Resident #44 upon exit. 3. Record review of a face sheet dated 03/01/2023, revealed Resident #23 was an [AGE] year old male admitted [DATE] with diagnoses including vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 11 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0644 Level of Harm - Minimal harm or potential for actual harm brain), unspecified psychosis not due to a substance or known physiological condition (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Residents Affected - Some Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #23 was usually understood and understood others. The MDS assessment revealed Resident #23's BIMS was a 03, indicating severe cognitive impairment. The MDS assessment indicated Resident #23 received antipsychotic medication 7 days in the past 7 days. The MDS indicated Resident #23 received antipsychotic medications on a routine basis only. Record review of the care plan last revised 01/18/2023, revealed Resident #23 had depression. Record review of the February 2023 MAR revealed, Resident #23 was receiving Seroquel tablet 25 mg (quetiapine fumarate) give 1 tablet by mouth two times a day for schizoaffective disorder with an order date of 03/16/2022. Record review of Resident #23's PASARR Level 1 Screening completed on 02/23/2022 indicated in section C0100 that there was no evidence or an indicator that this individual had mental illness. During an interview on 03/01/2023 at 10:20 AM, the corporate MDS nurse stated the MDS nurse was responsible for the PASARRs and for ensuring the IDT meetings happened. The corporate MDS nurse stated if a resident admitted to the facility with a negative PASARR screening and the MDS nurse found that the resident should have been positive, the MDS nurse should do a 1012 Form and contact the local authority. The corporate MDS nurse stated Resident #23 should have been identified as having a mental illness on his PASARR screening. The corporate MDS nurse was unable to explain why this was not addressed. The corporate MDS nurse stated the IDT meetings should be held yearly. The corporate MDS nurse stated for Resident #8 and Resident #44, she noticed their IDT meetings stopped in 2021 and that was when COVID happened, and she believed something happened in the system that caused it not to trigger the need for an IDT meeting for Resident #8 and Resident #44. The corporate MDS nurse stated it was important to coordinate services for PASARR so the residents could receive mental health services if they desired them. During an interview on 03/01/2023 at 4:22 PM, the administrator stated the MDS nurse, and the social worker were responsible for PASARR coordination. The administrator stated he expected the PASARR screenings to be accurate and expected the staff to coordinate IDT meetings. The administrator stated it was important that the PASARR screenings be accurate to help ensure the needs for the residents were met. The administrator stated it was important for the PASARR IDT meetings to be done so the needs of the residents were addressed. During an interview on 03/01/2023 at 4:43 PM, the DON stated she was not responsible for the PASARR program, and that the MDS nurse and social worker were responsible for the PASARR screenings and IDT meetings. The DON stated it was important for the PASARR screenings to be accurate and to coordinate the IDT meetings to see if the residents wanted any extra services. During an interview on 03/01/2023 at 5:28 PM, the policy regarding PASARR was requested from the administrator and was not provided upon exit of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 12 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 19 residents (Resident #4 and Resident #23) reviewed for care plans. The facility failed to develop and implement the comprehensive care plan from the triggered CAAs from the comprehensive MDS assessment for Resident #4 and Resident #23. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #4's face sheet, dated 02/27/2023, revealed Resident #4 was an [AGE] year-old male who admitted to the facility with diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and macular degeneration (causes blurred or reduced central vision, due to thinning of the macula, which is responsible for clear vision and direct line of site). Record review of comprehensive MDS assessment, dated 01/09/2023, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was sometimes able to understand others. The MDS revealed Resident #4 was unable to answer questions on the BIMS interview. The MDS revealed Resident #4 had disorganized thinking that fluctuated. The MDS revealed Resident #4 had delusion and wandering behavior. The MDS revealed Resident #4 should have been care planned for the following: cognitive loss or dementia, ADL function and rehabilitation potential, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, and psychotropic drug use. Record review of the comprehensive care plan, last revised on 01/18/2023, revealed no care plan developed or implemented for cognitive loss or dementia, ADL function and rehabilitation potential, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, or psychotropic drug use. During an interview on 03/01/2023 at 1:52 PM, the Regional MDS Nurse stated the MDS nurse was responsible for ensuring the CAA triggers were care planned. The Regional MDS Nurse stated the MDS nurse should have care planned the triggered CAAs from the comprehensive MDS assessment. The Regional MDS Nurse stated she expected the MDS Nurse at the facility to ensure the CAAs were care planned. The Regional MDS Nurse stated assessments were monitored by spot checks on a sample of residents. The Regional MDS Nurse stated she was unsure why the CAAs were not completed for Resident #4. The Regional MDS Nurse stated she did not believe there would have been any harm to Resident #4 for failure to care plan the CAA triggers. The Regional MDS Nurse stated the care plan was important for helping to assess the resident's needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 13 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/01/2023 at 6:26 PM with the DON. The policy for comprehensive care plans was requested and not provided upon exit of the facility. During an interview on 03/01/2023 at 6:28 PM, the ADM stated he expected the MDS nurses to ensure the CAAs were care planned. The ADM stated the importance of ensuring CAAs were care planned was to help staff with the delivery of care. 2. Record review of a face sheet dated 03/01/2023, revealed Resident #23 was an [AGE] year old male admitted [DATE] with diagnoses including vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), unspecified psychosis not due to a substance or known physiological condition (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #23 was usually understood and understood others. The MDS assessment revealed Resident #23's BIMS was a 03, indicating severe cognitive impairment. The MDS assessment indicated Resident #23 had no behaviors and did not reject care. The MDS assessment indicated Resident #23 required extensive assist with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. The MDS assessment indicated Resident #23 received antipsychotic medication 7 days in the past 7 days. The MDS indicated Resident #23 received antipsychotic medications on a routine basis only. The MDS assessment in the Care Area Assessment Summary indicated psychotropic drug use care area triggered and it would be included in the care plan. Record review of the February 2023 MAR revealed, Resident #23 was receiving Seroquel tablet 25 mg (quetiapine fumarate) give 1 tablet by mouth two times a day for schizoaffective disorder with an order date of 03/16/2022. Record review of the care plan last revised on 01/18/2023, revealed psychotropic drug use was not in the care plan. During an interview on 03/01/2023 at 10:35 AM, the MDS corporate nurse stated if something triggered in the care area assessment summary it should be included in the care plan. The MDS corporate nurse stated the MDS nurse was responsible for including Resident #23's psychotropic drug use in the care plan. The MDS corporate nurse stated the MDS nurse that should have included the psychotropic drug use in the care plan was no longer at the facility. The MDS corporate nurse stated it was important to include the triggered care areas in the care plan because it was part of the resident's record, and it should be accurate. During an interview on 03/01/2023 at 4:18 PM, the administrator stated the care plan was completed by the interdisciplinary team (nurses, social worker, and the MDS nurse). The administrator stated he expected the care areas that triggered be included in the care plan. The administrator stated this was important because it helped with the overall care of the residents. During an interview on 03/01/2023 at 4:33 PM, the DON stated she participated in completing the care plans along with nurse management and the MDS nurse. The DON stated if something triggered in the care area assessment that it should have been included in the care plan. The DON stated the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 14 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nurse was responsible for including the care areas that triggered in the care plan. The DON stated it was important to care plan care areas that triggered to ensure care pertaining to the residents was properly done. During an interview on 03/01/2023 at 5:28 PM, the policy regarding comprehensive care plans was requested from the administrator and was not provided upon exit of the facility. Event ID: Facility ID: 675367 If continuation sheet Page 15 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 19 residents reviewed for activities of daily living. (Resident #13 and Resident #60) Residents Affected - Few 1. The facility failed to ensure Resident #60 was toileted and provided with a clean brief. 2. The facility failed to provide facial hair removal/shaving for dependent female Resident #13. This failure could place residents who were dependent on staff to perform personal hygiene at risk or embarrassment, decreased self-esteem, or decreased quality of life. The findings included: 1. Record review of Resident #60's face sheet, dated 02/27/2023, revealed Resident #60 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in your blood), unspecified dementia without behavioral disturbance (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), and hyperlipidemia (blood has too much fat). Record review of the MDS assessment, dated 11/24/2022, revealed Resident #60 had clear speech and was sometimes understood by staff. The MDS revealed Resident #60 was usually able to understand others. The MDS revealed Resident #60 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #60 had no behaviors or rejection of care during the look-back period. The MDS revealed Resident #60 required supervision with a one-person assistance for dressing, toilet use, and personal hygiene. The MDS revealed Resident #60 was occasionally incontinent of urine. Record review of the comprehensive care plan, last reviewed on 12/07/2022, revealed Resident #60 had mixed bladder incontinence related to dementia. The interventions included check the resident every 2 hours and as required for incontinence. The care plan further revealed Resident #60 had an ADL self-care performance deficit related to dementia. The interventions revealed Resident #60 required supervision with one staff assistance for toilet use. During an observation on 02/26/2023 at 11:11 AM, Resident #60 was found in the bathroom with no staff assistance. The floor had a wet streak from Resident #60's bed to the bathroom. Resident #60 was pushing small white pieces of his disintegrated brief into a pile with his shoe. Resident #60 walked out of the bathroom with his walker and ambulated down the hallway to the dining room. Resident #60's shoes were squeaking and sticking to the floor. Resident #60 sat in the dining room through lunch with no staff assistance to the toilet. During an interview on 03/01/2023 at 4:26 PM, CNA Q stated Resident #60 should have been toileted every 2 hours. CNA Q stated Resident #60 took himself to the bathroom sometimes but ultimately staff was responsible for ensuring Resident #60 was toileted and had a clean brief. CNA Q stated it was important to ensure Resident #60 was toileted, so he did not feel ashamed for sitting in a dirty brief. CNA Q stated it was lack of dignity and could have caused skin breakdown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 16 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/01/2023 at 4:55 PM, LVN M stated Resident #60 should have been provided reminders and assistance to the toilet. LVN M stated no residents should have a disintegrated brief. LVN M stated the importance of ensuring Resident #60 was toileted and provided a clean brief was to maintain dignity and decrease the risk for infection and skin breakdown. During an interview on 03/01/2023 at 6:04 PM, the DON stated CNAs were responsible for toileting the residents. The DON stated nurses were responsible for ensuring toileting was completed. The DON stated ADL care was monitored by education and frequent rounding. The DON stated she expected the staff to toilet Resident #60. The DON stated the harm to Resident #60 for failing to toilet him was lack of dignity, proper care, and increased risk for infection and skin breakdown. During an interview on 03/01/2023 at 6:27 PM, the ADM stated he expected the staff to toilet Resident #60. The ADM stated nursing management was responsible for ensuring residents were provided proper ADL care. The ADM stated the harm to Resident #60 for failing to toilet him was lack of dignity and increased risk for health issues. 2. Record review of the face sheet, dated 3/01/2023, revealed Resident #13 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (impairment of muscular coordination), unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.), cognitive communication deficit (difficulty communicating related to memory loss), abnormal posture and muscle weakness. Record view of the MDS, dated [DATE], revealed Resident # 13 had a BIMS of 12 (mildly impaired). Resident #13 required extensive assistance of one person for dressing, bathing, and personal hygiene ADLs. The MDS revealed Resident #13 did not reject care or evaluation. Record review of Resident #13's care plan, with a revision date of 12/27/2022, indicated Resident # 13 has an ADL self-care performance deficit. Care plan goals included maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The care plan interventions include, Resident # 13 requires extensive assist of one staff. During an observation on 2/26/2023 at 10:22 a.m. Resident # 13 was observed with chin hair approximately 6-7 (cm) in length. During an observation on 2/27/2023 at 9:47 a.m. Resident # 13 was observed with chin hair approximately 6-7 (cm) in length. During an observation on 2/27/2023 at 3:30 p.m. Resident # 13 was observed with chin hair approximately 6-7 (cm) in length. During an observation on 03/01/2023 at 9:14 a.m. Resident # 13 was observed with chin hair approximately 6-7 (cm) in length. During an interview on 03/01/2023 at 9:14 a.m. with CNA A, stated she didn't notice Resident # 13 had hair on her chin. She stated the shower aide usually [NAME] them during their shower. CNA A stated the importance to remove Resident #13 chin hair is because she is a woman. During an interview on 03/01/2023 at 9:35 a.m. with CNA B stated she showered her yesterday and didn't notice hair on Resident # 13 chin. CNA B stated if she would have noticed she would have asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 17 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Resident #13 if she wanted it removed. CNA B Stated the importance is dignity. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/01/2023 at 3:47 p.m. with DON stated CNAs are expected to do the task of facial hair removal and this should be offered during shower time. The DON stated it is her responsibility to monitor the CNAs, however all of management do daily rounds to monitor. The DON stated the importance of removing facial hair was dignity. Residents Affected - Few During an interview on 03/01/2023 at 4:40 p.m. with ADM stated he expects CNAs to ensure female residents don't have hair on their chin. The ADM stated it is the responsibility of the DON to monitor the CNAs. The ADM stated he does daily rounds to look at each resident, however he didn't see Resident # 13. The ADM stated the importance of removing facial hair was dignity. Record review of the Care Standards policy, last revised 06/2020, revealed All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Record review of the facilities undated policy titles shaving revealed purpose to increase cleanliness and improve the resident's self-image. The facility provides for the removal of facial hair as a component of the resident's hygienic program. Male residents may be shaved daily, and female residents may be shaved as needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 18 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 secured unit and 3 of 19 residents reviewed for activities on the secured unit. (Resident's #53, #55, #62) Residents Affected - Some The facility failed to ensure activity care plans and quarterly activity assessments were completed for Resident's #53, #55, and #62. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #53's face sheet, dated 02/27/2023, revealed Resident #53 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and unspecified dementia, severe, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities). Record review of order summary report, dated 03/01/2023, revealed Resident #53 had an order, which started on 12/31/2022, that stated May attend activities of choice as tolerated. Record review of Resident #53's activity quarterly assessments revealed the last activity assessment was completed on 08/25/2022. Record review of the comprehensive MDS assessment, dated 12/11/2022, revealed Resident #53 had clear speech and was understood by staff. The MDS revealed Resident #53 was able to understand others. The MDS revealed Resident #53 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #53 had delusions, hallucinations, verbal, physical, and wandering behaviors during the look-back period. The staff interview for daily and activity preferences on the MDS revealed Resident #53 preferred the following: choosing clothes to wear, caring for her personal belongings, receiving showers, eating snacks between meals, staying up past 8:00 PM, family involvement of discussions about her care, a place to lock her personal belongings, listening to music, being around animals, attending group activities, participating in her favorite activities, spending time outdoors, and participating in religious activities. Record review of Resident #53's comprehensive care plan, last reviewed on 12/27/2022, revealed no care plan for activities. 2. Record review of Resident #55's face sheet, dated 02/27/2023, revealed Resident #55 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a gradually progressive condition that causes problems with memory, thinking and behavior) and bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of the order summary report, dated 03/01/2023, revealed Resident #55 had an order, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 19 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0679 which started on 06/01/2022, that stated May attend activities of choice as tolerated. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #55's activity quarterly assessments revealed the last activity assessment was completed on 09/09/2022. Residents Affected - Some Record review of the comprehensive MDS assessment, dated 02/13/2023, revealed Resident #55 had clear speech and was understood by staff. The MDS revealed Resident #55 was able to understand others. The MDS revealed Resident #55 was unable to complete the BIMS interview. The MDS revealed Resident #55 had delusions and wandering behavior during the look-back period. The staff interview for daily and activity preferences on the MDS revealed Resident #55 preferred the following: choosing clothes to wear, caring for his personal belongings, receiving showers, bed baths, and sponge baths, eating snacks between meals, staying up past 8:00 PM, family involvement of discussions about his care, listening to music, being around animals, attending group activities, participating in his favorite activities, spending time away from the nursing home, spending time outdoors, and participating in religious activities. Record review of Resident #55's comprehensive care plan, last reviewed on 02/17/2023, revealed no care plan for activities. 3. Record review of Resident #62's face sheet, dated 02/27/2023, revealed Resident #62 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a gradually progressive condition that causes problems with memory, thinking and behavior). Record review of the order summary report, dated 03/01/2023, revealed Resident #62 had an order, which started on 01/27/2023, that stated May attend activities of choice as tolerated. Record review of the comprehensive MDS assessment, dated 02/06/2023, revealed Resident #62 had clear speech and was understood by staff. The MDS revealed Resident #62 was able to understand others. The MDS revealed Resident #62 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #62 hallucinated, had delusions, and wandering behaviors during the look-back period. The staff interview for daily and activity preferences on the MDS revealed Resident #55 preferred the following: choosing clothes to wear, caring for his personal belongings, receiving showers, eating snacks between meals, staying up past 8:00 PM, family involvement of discussions about his care, reading books, newspaper, and magazines, having a place to lock up his personal belongings, listening to music, being around animals, attending group activities, participating in his favorite activities, spending time away from the nursing home, spending time outdoors, and participating in religious activities. Record review of Resident #62's comprehensive care plan, last reviewed 02/18/2023, revealed no care plan for activities. During an interview to obtain more information on 03/01/2023 at 4:02 PM, CNA L did not answer the telephone and a brief message was left. CNA L did not return the call upon exit of the facility. During an interview to obtain more information on 03/01/2023 at 4:09 PM, LVN H did not answer the telephone and a brief message was left. LVN H did not return the call upon exit of the facility. During an interview on 03/01/2023 at 4:55 PM, the Social Worker stated the AD was in the hospital and was unable to be interviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 20 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/01/2023 at 6:08 PM, the DON stated the AD was responsible for ensuring activity assessments and care plans were completed. The DON stated performing activity assessments and ensuring activities were care planned was important to provide stimulation and decrease in behaviors. During an interview on 03/01/2023 at 6:31 PM, the ADM stated he expected activity assessments and care plans to be completed. The ADM stated the AD was responsible for performing activity assessments and completing the activity care plans. The ADM stated performing activity assessments and completing the activity care plan was important to improve quality of life. Record review of the Activities Program policy, last revised in 06/2020, revealed Policy: II. A variety of activities should be offered on a daily basis, which includes weekends and evenings. The policy further revealed Procedure: II. Care Plan A. After completion of the initial Activity Assessment and the MDS, an individualized Care Plan will be developed and implemented for each resident. VII. Progress Notes A. No less than quarterly, the Director of Activities or his or her designee will make a progress note in the Facility's electronic health record (EHR) as part of the resident's health record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 21 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 4 residents (Resident #38) reviewed for respiratory care and services. Residents Affected - Few The facility failed to administer oxygen between 2-3 liters per minute via nasal cannula as prescribed by the physician for Resident #38 This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: Record review of Resident #38's order summary report, dated 03/01/2023, indicated Resident #38 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included respiratory disorder (disease that affects the lungs that makes breathing difficult), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). Further review of the order summary report, dated 03/01/2023, indicated Resident #38 received oxygen between 2-3 liters per minute via nasal cannula every shift for SOB with a start date 10/27/2022. Record review of Resident #38's annual MDS assessment, dated 11/15/2022, indicated Resident #38 understood others and made himself understood. The assessment indicated Resident #38 was moderately cognitive impaired with a BIMS score of 9. The assessment indicated Resident #38 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #38 was receiving oxygen therapy. Record review of Resident #38's care plan did not address oxygen therapy. During an observation and interview on 02/26/2023 at 8:50 a.m., Resident #38 was lying in bed wearing oxygen via nasal cannula. Resident #38's five-liter oxygen concentrator was set on 1.5 liters per minute. Resident #38 stated he wore oxygen continuously due to SOB. During an observation on 02/27/2023 at 9:00 a.m., Resident #38 was lying in bed wearing oxygen via nasal cannula. Resident #38's five-liter oxygen concentrator was set on 1.5 liters per minute. During an observation on 02/27/2023 at 2:15 p.m., Resident #38 was lying in bed wearing oxygen via nasal cannula. Resident #38's five-liter oxygen concentrator was set on 1.5 liters per minute. During an observation on 02/28/2023 at 10:38 a.m., Resident #38 was lying in bed wearing oxygen via nasal cannula. Resident #38's five-liter oxygen concentrator was set on 1.5 liters per minute. During an observation and interview on 03/01/2023 at 9:35 a.m., LVN S stated she was Resident #38 6a-2p charge nurse. LVN S stated Resident #38 used O2 continuously for SOB. LVN S observed with the surveyor Resident #38's oxygen concentrator set at 1.5 liter per minute. LVN S stated Resident #38 O2 setting should be between 2-3 liters per minute. LVN S stated it was the charge nurse's responsibility to ensure the rate was correct on every shift. LVN S stated due to state being in the building (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 22 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did not check to see if Resident #38 oxygen setting was correct during her 6a-2p shifts this week. LVN S stated there was no place to document in the electronic medical records the oxygen settings for Resident #38. LVN S stated the risk associated with not setting the O2 at prescribed rate could potentially put residents at risk for hypoxia (low levels of oxygen in the body tissues). During an interview on 03/01/2023 at 3:42 p.m., the DON stated she expected Resident #38's oxygen to be set between 2-3 liters per minute per the physician order. The DON stated the charge nurses were responsible for ensuring the rate was between 2-3 liters per minute. The DON stated she was responsible for ensuring charge nurses were following the physicians' orders by making daily rounds throughout the day spot checking the O2 concentrators. The DON stated during her daily rounds this week Resident #38's oxygen setting was not at 1.5 liters per minute. The DON stated the risk associated with not setting O2 at prescribed rate was low oxygen levels. During an interview on 03/01/2023 at 4:28 p.m., the Administrator stated he expected physician's orders to be followed. The Administrator stated this was monitored by the DON. The Administrator stated this failure put Resident #38 at risk for hypoxia. Record review of the facility's Oxygen Administration policy, revised 06/2020, indicated, . to prevent or reverse hypoxemia (low level of oxygen in the blood) and provide oxygen to the tissues . procedure VI. Turn on the oxygen at the prescribed rate . VIII. Document in patient's record: B. oxygen flow rate and device being used . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 23 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #52) reviewed for dialysis. Residents Affected - Few The facility failed to ensure nursing staff was checking Resident #52's shunt (vascular access used for hemodialysis) to left upper arm for bruit (sound heard through a stethoscope when held over the shunt) and thrill (vibration or buzz felt when fingers are laid on top of the shunt). This failure could place residents who receive dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of a face sheet dated, 03/01/2023, revealed Resident #52 was a [AGE] year old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (kidney failure), unspecified dementia, unspecified severity without behavioral disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #52 understood and was understood by others. The MDS assessment revealed Resident #52 had a BIMS score of 11, indicating cognition was moderately impaired. The MDS assessment revealed Resident #52 received dialysis while a resident at the facility. Record review of Resident #52's care plan last revised 02/17/2023, revealed Resident #52 needed dialysis related to renal failure three times a week on Tuesday, Thursday, and Saturday with a chair time of 9:45 AM, and interventions included to monitor/document/report to medical director as needed any signs or symptoms of infection to access site: redness, swelling, warmth or drainage. Record review of Resident #52's order summary report dated 02/28/2023 revealed, assess dialysis site (right upper chest) every shift for signs and symptoms of infection, redness, and/or bleeding every shift for prevention with start date of 12/27/2022, dialysis site (right upper chest): change dressing every 7 days every day shift every Tuesday with start date of 01/03/2023, dialysis: 3 times a week on Tuesday, Thursday, and Saturday chair time at 9:45 AM every Tuesday, Thursday, Saturday with start date of 12/29/2022, and monitor sutures to left upper arm every shift for signs and symptoms of infection every shift for surgical incision with start date of 2/16/2023. Record review of Resident #52's order summary report did not reveal orders or special instructions for the care of Resident #52's shunt to left upper arm. Record review of the Nurse Administration Record and the Treatment Administration record for the month of February 2023 did not indicate Resident #52's shunt was being monitored by the nurses for bruit and thrill. Record review of Resident #52's After Visit Summary from the hospital dated 02/13/2023 revealed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 24 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0698 Level of Harm - Minimal harm or potential for actual harm discharge instructions for AV access creation. The discharge instructions included to notify the physician if the thrill was not as strong as it was before. Record review of Resident #52's implant information card, indicated Resident #52 had a left arm [NAME] acuseal vascular graft (vascular access/shunt used to perform dialysis) placed on 02/13/2023. Residents Affected - Few During an interview on 02/27/2023 at 3:40 PM, Resident #52 stated she went to dialysis on Tuesdays, Thursdays, and Saturdays. Resident #52 stated she had a shunt placed in her left upper arm a couple weeks ago, but it was not used for dialysis yet. Resident #52 stated the dialysis clinic was using the access in her right upper chest. Resident #52 stated the nurses were not checking her shunt to her left upper arm for bruit or thrill. During an interview on 03/01/2023 at 10:01 AM, LVN S stated, she was the nurse for Resident #52. LVN S stated she was aware Resident #52 had a new shunt placed about 3 weeks ago in her left arm. LVN S stated she had not been checking the bruit or thrill on Resident #52's shunt because the dialysis center was using the access in her right upper chest. LVN S stated she was not responsible for checking the bruit and thrill that the treatment nurse was checking Resident #52's bruit and thrill. LVN S stated Resident #52's shunt should be getting checked daily to make sure it did not clot and stop working. During an interview on 03/01/2023 at 10:11 AM, the treatment nurse stated she was not checking Resident #52's bruit or thrill. The treatment nurse stated the nurses were responsible for checking Resident #52's bruit and thrill. The treatment nurse stated she was only checking the surgical site to Resident #52's left upper arm for signs and symptoms of infection. The treatment nurse stated it was important to check the bruit and thrill to make sure the shunt was working properly and that it should be checked every day. During an interview on 03/01/2023 at 1:41 PM, ADON K stated she was aware Resident #52 had a shunt in her left upper arm. ADON K stated the nurses should have been checking Resident #52's shunt every shift and after dialysis. ADON K stated Resident #52 should have an order that prompted the nurses to check the shunt. ADON K stated she did not know where it should be documented, but that it should have populated because most of the monitoring was populated. ADON K stated she did not know who was responsible for putting in the orders for the dialysis shunt because she was new, and she was still learning the process of all the things that she should do. ADON K stated it was important to check for the bruit and thrill to make sure the shunt was functioning right. During an interview on 03/01/2023 at 3:46 PM, ADON T stated he barely found out today Resident #52 had a shunt. ADON T stated the nursing staff should be checking the thrill and bruit daily. ADON T stated Resident #52 should have had an order to check for the bruit and the thrill. ADON T stated he was responsible for ensuring Resident #52 had an order to check for the bruit and thrill. ADON T stated by not checking for the bruit and thrill Resident #52 could have trouble with her shunt. During an interview on 03/01/2023 at 4:20 PM, the administrator stated he expected the nursing staff to coordinate care with the dialysis clinic, and that the nurses should be monitoring Resident #52's shunt. The administrator stated it was important to check Resident #52's shunt to make sure it was functioning properly. During an interview on 03/01/2023 at 4:25 PM, the DON stated Resident #52 did not have a shunt in her left upper arm. The DON stated Resident #52 had an access in her right upper chest and this was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 25 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few used for dialysis. The DON stated a shunt should be monitored by the nurses daily for patency (checking for bruit or thrill to ensure the shunt is still working properly), and that this was important to ensure that it did not malfunction and for the dialysis resident to receive proper treatment and to check for infection. During an observation and interview on 03/01/23 at 6:16 PM, Resident #52's left upper arm shunt had no signs and symptoms of infection, thrill was present over Resident #52's shunt. Resident #52 stated today was the first time 4 staff members came to check her shunt. Record review of the facility's undated policy, titled Dialysis Care, revealed, D. Arteriovenous (AV) Shunt/Fistula I. Inspect shunt site area for color, warmth, redness, tenderness, pain, edema, drainage, and bruit once per shift. II. To check for a bruit (a pulsation felt of blood flowing through the arteriovenous anastomosis): a. Place your fingertip slightly over the vein and feel for the thrill. b. Place the stethoscope over the vein and listen for the buzz or bruit. c. document the findings in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 26 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 9 errors out of 36 opportunities, resulting in a 25 percent medication error rate for 2 of 7 residents reviewed for medication error. (Resident #6, Resident #24) Residents Affected - Some The facility failed to ensure the following: 1. Resident #24 received clonazepam (antianxiety) at the prescribed time. 2. Resident #24 did not receive vitamin C after the prescribed 10 days. 3. Resident #24 received sucralfate (used to prevent ulcers in the intestines) at the prescribed time and on an empty stomach. 4. Resident #24 received ondansetron (used for nausea) at the prescribed time. 5. Resident #24 received 5 mg dose of Trintellix (antidepressant). 6. Resident #6 received Bactrim DS (antibiotic) at the prescribed time. 7. Resident #6's losartan, metoprolol, and amlodipine (blood pressure medications) were held due to physician parameters. These failures could place residents at risk for inaccurate drug administration. The findings included: 1. Record review of Resident #24's face sheet, dated 03/01/2023, revealed Resident #24 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic peripheral angiopathy (blood vessel disease caused by high blood sugar levels), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and unspecified intellectual disabilities (term for when a person has limited ability to learn and function in daily life, often due to brain problems before or after birth). Record review of Resident #24's order summary report, dated 03/01/2023, revealed the following: 1. Resident #24 had an order, which started on 01/13/2023, for clonazepam 0.5 mg - give one tablet by mouth three times a day related to anxiety. 2. Resident #24 had an order, which started on 08/14/2020, for vitamin C 500 mg- give one tablet by mouth two times a day for preventative for 10 days. 3. Resident #24 had an order, which started on 11/18/2020, for sucralfate 1 gram - give one tablet by mouth before meals for GERD (acid reflux). The special instructions revealed administer on an empty stomach and separate antacids by 30 minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 27 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0759 Level of Harm - Minimal harm or potential for actual harm 4. Resident #24 had an order, which started on 04/20/2018, for ondansetron 4 mg - give one tablet by mouth before meals for nausea or vomiting. 5. Resident #24 had an order, which started on 04/14/2021, for Trintellix 5 mg - give one tablet (with a 10 mg tablet to equal 15 mg) by mouth one time a day related to depression. Residents Affected - Some Record review of the MAR, dated February 2023, revealed the following: 1. clonazepam 0.5 mg was scheduled for 7 AM. 2. sucralfate 1 GM was scheduled for 6:30 AM. 3. ondansetron 4 mg was scheduled for 6:30 AM. Record review of the MDS assessment, dated 01/27/2023, revealed Resident #24 had clear speech and was understood by staff. The MDS revealed Resident #24 was able to understand others. The MDS revealed Resident #24 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #24 had no behaviors or rejection of care behaviors. Record review of the comprehensive care plan, last reviewed on 01/18/2023, revealed Resident #26 took medications for several diagnoses including: GERD (acid reflux), bipolar disorder, depression, and hypertension (high blood pressure). The interventions included: Administer medication as ordered. During a medication pass observation on 02/27/2023 at 8:42 AM, MA F performed hand hygiene and prepared Resident #24's medications. MA F verified medication to the MAR and placed clonazepam 0.5mg (1 tablet), vitamin C 500 mg (1 tablet), sucralfate 1 GM (1 tablet, which was given after she had eaten breakfast), ondansetron 4 mg (1 tablet), and Trintellix 5 mg (1 tablet) into the medication cup. MA F took the medication cup into the room and administered medication to Resident #24. 2. Record review of Resident #6's face sheet, dated 03/01/2023, revealed Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (too much fat in blood), and atrial fibrillation (irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart). Record review of Resident #6's order summary report, dated 03/01/2023, revealed the following: 1. Resident #6 had an order, which started on 07/27/2022, for Bactrim DS 800-160 mg - give one tablet by mouth once a day on Monday, Wednesday, and Saturday related to urinary tract infection. 2. Resident #6 had an order, which started on 12/14/2020, for losartan potassium 100 mg - give one tablet by mouth one time a day for hypertension (high blood pressure). The special instructions revealed Hold for systolic blood pressure less than 100 mmHg (millimeters of mercury - used to measure blood pressure) or diastolic blood pressure less than 60 mmHg. 3. Resident #6 had an order, which started on 12/14/2020, for metoprolol tartrate 50 mg - give one tablet by mouth two times a day for hypertension. The special instructions revealed Hold for systolic blood pressure less than 100 mmHg or diastolic blood pressure less than 60 mmHg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 28 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Resident #6 had an order, which started on 05/25/2021, for amlodipine besylate 10 mg - give one tablet by mouth in the morning for elevated blood pressure. The special instructions revealed Hold for systolic blood pressure less than 100 mmHg or diastolic blood pressure less than 60 mmHg. Record review of Resident #6's MAR, dated February 2023, revealed the Bactrim DS 800-160 mg was scheduled for 7 AM. Record review of the MDS assessment, dated 12/15/2022, revealed Resident #6 had clear speech and was understood by staff. The MDS revealed Resident #6 was able to understand others. The MDS revealed Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed no behaviors or rejection of care. Record review of the comprehensive care plan, last reviewed on 02/17/2023, revealed Resident #6 had hypertension. The interventions revealed Give hypertensive medication as ordered. During a medication pass observation on 02/27/2023 at 8:46 AM, MA F performed hand hygiene and obtained Resident #6's blood pressure. The blood pressure reading was 111/55 mmHg (systolic 111 and diastolic 55). MA F returned to the medication cart and prepared Resident #6's medication. MA F verified medication to the MAR and included Bactrim DS (1 tablet), losartan (1 tablet), metoprolol tartrate (1 tablet), and amlodipine (1 tablet) in the medication cup. MA F entered Resident #6's room and handed her the medication cup. The surveyor intervened prior to Resident #6 taking the medication to prevent Resident #6 from receiving medications that should have been held. During an interview on 02/27/2023 at 8:53 AM, MA F stated she was glad the surveyor intervened prior to Resident #6 taking the medication. MA F stated she did not normally give blood pressure medications that should have been held. MA F stated she was distracted and nervous because state was in the building. MA F stated the failure to Resident #6 for receiving blood pressure medications that should have been held was lowering blood pressure that was already low. During an interview on 03/01/2023 at 4:04 PM, MA F did not answer the phone. Message left and returned call revealed it was the wrong phone number. During an interview on 03/01/2023 at 5:14 PM, MA P stated medications should have been passed an hour before the scheduled time or an hour after the scheduled time. MA P stated medications should have been given according to the special instructions and per the doctors' orders. MA P stated the electronic charting system shows the number of days an order should have been given. MA P stated orders should have been verified if the medication did not stop after the prescribed number of days. MA P stated it was important to administer medications as prescribed by the doctor to prevent medication errors and to ensure the medication did what it was intended to do. During an interview on 03/01/2023 at 5:48 PM, the DON stated medications should have been given between one hour before the prescribed time and one hour after the prescribed time. The DON stated medications should have been administered per the special instructions or parameters instructed by the doctor. The DON stated the MAs were responsible for ensuring medications were administered at the appropriate time and according to the doctors' instructions. The DON stated the nurses were responsible for ensuring medications had a stop date if instructed by the doctor. The DON stated she was responsible for ensuring the medication aides administered medications appropriately without error. The DON stated she was responsible for checking and verifying new orders from the doctor. The DON stated it was important to administer medications at the scheduled time and according to parameters to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 29 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ensure residents receive the proper medications and to ensure the medications work appropriately and effectively. During an interview on 03/01/2023 at 6:22 PM, the ADM stated he expected nursing staff to administer medications at the appropriate time and per the doctors' parameters. The ADM stated nursing management was responsible for ensuring medications were given appropriately. The ADM stated the importance of administering medications appropriately was to prevent medication errors and potential harm to the residents. Record review of the Medication - Administration policy, undated, revealed Policy: V. Medications may be administered one hour before or after the scheduled medication administration time. VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medications and recorded in the medical record . The policy further revealed Procedure: IV. Nursing staff will keep in mind the seven 'rights' of medication when administering medications: . D. the right time . F. right indication. VI. Approach medication preparation task in a calm manner and do not allow for distractions during the process unless under emergent conditions. VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including: A. Manufacturer's specifications regarding the preparation and administration of the drug B. accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 30 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for medication pass. (Resident #6) Residents Affected - Some The facility failed to ensure MA F held Resident #6's losartan, metoprolol, and amlodipine (blood pressure medications) when her blood pressure was below the parameters ordered by the doctor. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of Resident #6's face sheet, dated 03/01/2023, revealed Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (too much fat in blood), and atrial fibrillation (irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart). Record review of Resident #26's order summary report, dated 03/01/2023, revealed the following: 1. Resident #6 had an order, which started on 12/14/2020, for losartan potassium 100 mg - give one tablet by mouth one time a day for hypertension (high blood pressure). The special instructions revealed Hold for systolic blood pressure less than 100 mmHg (millimeters of mercury - used to measure blood pressure) or diastolic blood pressure less than 60 mmHg. 2. Resident #6 had an order, which started on 12/14/2020, for metoprolol tartrate 50 mg - give one tablet by mouth two times a day for hypertension. The special instructions revealed Hold for systolic blood pressure less than 100 mmHg or diastolic blood pressure less than 60 mmHg. 3. Resident #6 had an order, which started on 05/25/2021, for amlodipine besylate 10 mg - give one tablet by mouth in the morning for elevated blood pressure. The special instructions revealed Hold for systolic blood pressure less than 100 mmHg or diastolic blood pressure less than 60 mmHg. Record review of the MDS assessment, dated 12/15/2022, revealed Resident #6 had clear speech and was understood by staff. The MDS revealed Resident #6 was able to understand others. The MDS revealed Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed no behaviors or rejection of care. Record review of the comprehensive care plan, last reviewed on 02/17/2023, revealed Resident #6 had hypertension. The interventions revealed Give hypertensive medication as ordered. During a medication pass observation on 02/27/2023 at 8:46 AM, MA F performed hand hygiene and obtained Resident #6's blood pressure. The blood pressure reading was 111/55 mmHg (systolic 111 and diastolic 55). MA F returned to the medication cart and prepared Resident #6's medication. MA F verified medication to the MAR and included losartan (1 tablet), metoprolol tartrate (1 tablet), and amlodipine (1 tablet) in the medication cup. MA F entered Resident #6's room and handed her the medication cup. The surveyor intervened prior to Resident #6 taking the medication to prevent Resident #6 from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 31 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0760 receiving medications that should have been held. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/27/2023 at 8:53 AM, MA F stated she was glad the surveyor intervened prior to Resident #6 taking the medication. MA F stated she did not normally give blood pressure medications that should have been held. MA F stated she was distracted and nervous because state was in the building. MA F stated the failure to Resident #6 for receiving blood pressure medications that should have been held was lowering blood pressure that was already low. Residents Affected - Some During an interview on 03/01/2023 at 4:04 PM, MA F did not answer the phone. Message left and returned call revealed it was the wrong phone number. During an interview on 03/01/2023 at 5:14 PM, MA P stated medications should have been given according to the special instructions and per the doctors' orders. MA P stated blood pressure medications should have been held if the blood pressure was too low. MA P stated blood pressure medications that were held must be documented in the MAR. MA P stated it was important to administer medications as prescribed by the doctor to prevent medication errors and to ensure the blood pressure did not drop. During an interview on 03/01/2023 at 5:48 PM, the DON stated medications should have been administered per the special instructions or parameters instructed by the doctor. The DON stated the MAs were responsible for ensuring medications were administered according to the doctors' instructions. The DON stated she was responsible for ensuring the medication aides administered medications appropriately without error. The DON stated medication administration was monitored by pulling reports and during monthly visits by the pharmacy consultant. The DON stated it was important to administer medications according to parameters to ensure resident's blood pressure did not drop. During an interview on 03/01/2023 at 6:22 PM, the ADM stated he expected nursing staff to administer medications per the doctors' parameters. The ADM stated nursing management was responsible for ensuring medications were given appropriately. The ADM stated the importance of administering medications appropriately was to prevent medication errors and potential harm to the residents. Record review of the Medication - Administration policy, undated, revealed Policy: VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medications and recorded in the medical record . The policy further revealed Procedure: IV. Nursing staff will keep in mind the seven 'rights' of medication when administering medications: . F. right indication. VI. Approach medication preparation task in a calm manner and do not allow for distractions during the process unless under emergent conditions. VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including: A. Manufacturer's specifications regarding the preparation and administration of the drug B. accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 32 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and were stored in a locked compartment and only accessible by authorized personnel for 1 of 19 residents (Resident #61) reviewed for medication storage and 2 of 4 medication carts (Hall 3 & secure unit) reviewed for drugs and biologicals. 1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #61 had 1 bottle of Chlorhexidine Gluconate Solution (mouthwash) on his bedside table. 2. The facility failed to ensure multi-dose bottles of over-the-counter medications on the hall 3 and secured unit medication carts were dated when opened. 3. The facility failed to discard a bottle of expired docusate sodium 100 mg tablets (stool softener) on the secured unit medication cart. 4. The facility failed to discard a bottle of chest congestion relief DM 400-20mg tablets with the label torn so no instructions or expiration dates were visible on the secured unit medication cart. These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: 1. Record review of Resident #61's order summary report, dated 03/01/2023, indicated Resident #61 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included Parkinson's (brain disorder that causes unintended or uncontrollable movements), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Further record review of the order summary report, dated 03/01/2023, indicated Resident #61 was ordered to receive Chlorhexidine Gluconate Solution 2% (15 ml by mouth BID) for routine care, rinse for 30 seconds and spit out with a start date 03/01/2023. Record review of Resident #61's admission MDS assessment, dated 07/15/2022, indicated Resident #61 usually understood others and made himself understood. The assessment indicated Resident #61 was moderately cognitive impaired with a BIMS score of 12. The assessment indicated Resident #61 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of Resident #61's care plan did not address medications left at bedside. During an observation and interview on 02/26/2023 at 8:55 a.m., Resident #61 was sitting on the edge of the bed visiting with a friend. There was a black bottle with a white labeled Chlorhexidine Gluconate sitting on his bedside table. Resident #61 stated he used the medication to rinse out his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 33 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0761 mouth. Level of Harm - Minimal harm or potential for actual harm During an observation on 02/27/2023 at 9:05 a.m., Resident #61 was lying in bed. There was a black bottle with a white labeled Chlorhexidine Gluconate sitting on his bedside table. Residents Affected - Some During an observation on 02/27/2023 at 2:17 p.m., Resident #61 was sitting on the edge of the bed. There was a black bottle with a white labeled Chlorhexidine Gluconate sitting on his bedside table. During an observation on 02/28/2023 at 10:40 a.m., Resident #61 was standing on the side of the bed. There was a black bottle with a white labeled Chlorhexidine Gluconate sitting on his bedside table. During an interview and observation on 03/01/2023 at 9:35 a.m., LVN S stated she was Resident #61 6a-2p charge nurse. LVN S observed with the surveyor Chlorhexidine Gluconate sitting on Resident #61 bedside table. LVN S stated she was not aware of the medication at his bedside until surveyor intervention. After reviewing Resident #61 electronic medical records, LVN S stated Resident #61 did not have an order for the medication or to self-administer medications. LVN S stated an order should be obtained for the medication first and then the resident needed to be educated, assessed, and able to demonstrate he can safely administer his medications by the charge nurse before medications were left at bedside to administer. LVN S stated due to this medication requiring the resident to swish and swallow and not ensuring he was educated this failure could potentially put Resident #61 at risk for seizures (sudden, uncontrolled electrical disturbance in the brain). During an interview on 03/01/2023 at 3:42 p.m., the DON stated an order should have been obtained for Chlorhexidine Gluconate Solution. The DON stated a resident should be educated, assessed, and able to demonstrate he could safely administer his medications by the charge nurse to allow medications at bedside. The DON stated she was responsible for monitoring to ensure medications were not left at bedside by conducting daily rounds. The DON stated she conducted rounds daily this week and did not notice the Chlorhexidine Gluconate sitting on Resident #61 bedside table. The DON stated this failure could cause medication interactions and medication error. During an interview on 03/01/2023 at 4:28 p.m., the Administrator stated unless Resident #61 had an order and had been educated, assessed, and able to demonstrate he can safely administer his medications, medications should be kept in the med cart. The Administrator stated a resident should be educated, assessed, and able to demonstrate he could safely administer his medications by the IDT which included the Administrator, DON, ADON, and the MD to ensure the resident was capable of taking the medication. The Administrator stated this failure could cause a resident to ingest too much medication and cause an illness. 2. During an observation of the secured unit medication cart with MA N on 02/28/2023 at 5:18 PM, the following was observed: 1. One bottle of aspirin 81 mg tablets had no opened date. 2. One bottle of vitamin B12 1,000 mcg tablets had no opened date. 3. One bottle of Melatonin 1 mg tablets had no opened date. 4. One bottle of docusate sodium 100 mg tablets had an expiration date of 01/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 34 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. One bottle of chest congestion relief DM 400 - 20 mg tablets had a torn label revealing no expiration date or instructions for use. During an interview on 02/28/2023 at 5:24 PM, MA N stated she had worked at the facility since January of 2023. MA N stated medication aides were responsible for checking the medication carts for expired, undated, and unlabeled medications. MA N stated opened dates were required on over-the-counter medications to her knowledge. MA N stated staff should have checked the over-the-counter medications as they were used. MA N stated the importance of checking the medication carts for expired, undated, and unlabeled medications was to ensure residents did not have a reaction. During an observation of the hall 3 medication cart with MA P on 02/28/2023 at 5: 36 PM, the following was observed: 1. One bottle of aspirin 81 mg tablets had no opened date. 2. One bottle of senna 8.6 mg tablets had no opened date. 3. One bottle of zinc 220 mg tablets had no opened date. During an interview on 03/01/2023 at 4:52 PM, LVN M stated the medications aides were responsible for ensuring medications were labeled, dated, and not expired. LVN M stated the nurses were responsible for monitoring medications aides. LVN M stated staff might have overlooked the expiration or opened dates. LVN M stated the importance of ensuring over-the-counter medications were labeled, dated, and not expired was to ensure residents did not receive expired medications that could have made them sick. LVN M stated giving residents expired medications could have caused them to receive an ineffective dose of medication. During an interview on 03/01/2023 at 5:18 PM, MA P stated medication carts should have no expired or unlabeled medications. MA P stated over-the-counter medications should have the opened date written on the bottle. MA P stated it was important to ensure the over-the-counter medications were labeled, dated, and not expired to ensure the residents receive the therapeutic dose of medication. During an interview on 03/01/2023 at 5:56 PM, the DON stated all over-the-counter medications should be labeled, dated, and not expired. The DON stated the medication aides were responsible for ensuring over-the-counter medications were labeled, dated, and not expired. The DON stated the nurses were responsible for monitoring the medication aides. The DON stated she was responsible for ensuring nursing staff monitored the medication carts. The DON stated she monitored medication carts by performing cart checks and audits by the pharmacy consultant. The DON stated the last audit was completed earlier in the month. The DON was unsure why the medication bottles were not dated. The DON stated it was important to ensure the over-the-counter medications were labeled, dated, and not expired to ensure the residents receive the therapeutic dose of medication. During an interview on 03/01/2023 at 6:24 PM, the ADM stated he expected nursing staff to ensure medication carts had no unlabeled, undated, or expired medications. The ADM stated nursing management was responsible for monitoring medication carts. The ADM stated he would not want to take expired medications so he would not want his residents to take it. Record review of the Medication - Administration policy, undated, revealed VIII. Medication will not be left at the bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 35 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility's Self-Administration of Medications policy, revised 09/2018, indicated, . in order to maintain the resident's high level of independence residents who desire to self-administer medications are permitted to do so if the facility's IDT has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer . 5. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted Record review of the House-Supplied (Floor Stock) Medications policy, effective 09/2018, revealed Floor stock medications are kept in the original manufacturer's container. The manufacturer's packaging label should include the following: d. accessory/auxiliary instructions f. expiration date g. manufacturer and/or distributor. The policy further revealed 5. When required by state regulation and/or in accordance with facility policy, the nurse shall write, the date the container was first opened directly on the original manufacturer's container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 36 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service department for 2 of 9 dietary staff (Dietary Aide C and Dietary Aide D). The facility failed to ensure that dietary staff (Dietary Aide C and Dietary Aide D) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for foodborne illnesses. Findings included: Record review of the food handler certificates provided by the Dietary Manager on 02/27/23 revealed: Dietary Aide C's Food Handler Certificate was issued on 02/23/2021, valid through 02/23/2023 Dietary Aide D's Food Handler Certificate was issued on 02/23/2021, valid through 02/23/2023. During an interview on 03/01/2023 at 8:56 AM, the Regional Dietician stated the food handler certificates were good for 2 years. The Regional Dietician stated the Dietary Manager was responsible for making sure the food handler certificates stayed up to date. The Regional Dietician stated she spot checked to make sure the certificates were not expired. The Regional Dietician stated, Very recently I checked them, and they were all up to date. The Regional Dietician stated it was important to keep the food handler certificates up to date because it was good to have a refresher, and to make sure the dietary staff were not contaminating the food or potentially leaving food left out. During an interview on 03/01/2023 at 9:08 AM, Dietary Aide D stated the food handler certificate should be renewed once a year. Dietary Aide D stated she was not aware her food handler certificate had expired that she had not paid attention to the expiration date. Dietary Aide D stated it was important to have the food handler certificate because it was required by the law and to make sure all the food was safe and at the right temperature. Dietary Aide D stated not having an up-to-date food handler certificate placed the residents at risk for bacteria because the dietary staff would not know the guidelines to follow. During an interview on 03/01/2023 at 9:11 AM, the Dietary Manager stated the food handler certificate should be updated every 2 years. The Dietary Manager stated he tried to look over the certificates to make sure they were not expired. The Dietary Manager stated the last time he looked at the food handler certificates was in January 2023, and he had noticed Dietary Aide C's and Dietary Aide D's food handler certificates were about to expire. The Dietary Manager stated he should have followed up with Dietary Aide C and Dietary Aide D to make sure they completed the food handler certification in a timely fashion. The Dietary Manager stated having the food handler certificates up to date was important, so all staff were updated on labeling, dating, sanitation, cleanliness, kitchen safety, food temperature control, and the danger zone for foods. The Dietary Manager stated the staff not having the proper education could result in making the residents sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 37 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0802 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/01/2023 at 11:06 AM, Dietary Aide C stated he worked in the kitchen. Dietary Aide C stated the food handler certificate should be updated every 2 years. Dietary Aide C stated about a week or two ago he had noticed his food handler certificate was expired, but he had been real busy and had not renewed it. Dietary Aide C stated it was important to have an up-to-date food handler certificate because it kept you updated with kitchen safety information. Residents Affected - Few During an interview on 03/01/2023 at 4:07 PM, the administrator stated he expected all the dietary staff to have up to date food handler certificates. The administrator stated the Dietary Manager was responsible for making sure they stayed up to date. The administrator stated it was important for the dietary staff to have an up-to-date food handler certificate for them to have the knowledge base and to know how to properly handle food safely. During an interview on 03/01/2023 at 5:54 PM, the Regional Dietician stated the facility did not have a policy regarding keeping the food handler certificates up to date that the facility followed the regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 38 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 19 residents (Resident #8, Resident #18, and Resident #26) reviewed for dietary services. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was not hot and did not taste or look good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 2/26/2023 at 9:11 AM, Resident #26 stated the food was bland and sometimes cold. During an interview on 2/26/2023 at 9:13 AM, Resident #18 stated the food looked and tasted nasty and was bland. During an interview on 02/27/2023 at 9:40 AM, Resident #8 stated, sometimes the food just don't taste good. During an observation and interview on 02/27/2023 starting at 12:48 PM, a lunch tray was sampled by the Dietary Manager and six surveyors. The sample tray consisted of a country fried pork patty, mashed potatoes with brown gravy, cabbage, cornbread, and frosted banana cake. The country fried pork patty was mushy, soggy, and lukewarm. The Dietary Manager stated it was mushy and soggy due to the gravy, and that it could have been hotter. The cabbage was mushy, overcooked, salty, had a slight, black-tinged color to it, and was lukewarm. The Dietary Manager stated it was overcooked, the color was appropriate for the cabbage, and it was lukewarm. During an interview on 03/01/2023 at 8:35 AM, the Regional Dietician stated she occasionally had residents that complained about the food. The Regional Dietician stated she tried to go see what it was that the residents did not like and discussed it with the cook and Dietary Manager. The Regional Dietician stated all the dietary staff were responsible for ensuring the residents received food that was palatable, attractive, and the appropriate temperature. The Regional Dietician stated it was important for the residents to receive food that was palatable, attractive, and the appropriate temperature for their overall wellbeing and nutritional status. The Regional Dietician stated if the residents received food that was not palatable, attractive and the appropriate temperature they would not eat it. During an interview on 03/01/2023 at 9:15 AM, the Dietary Manager stated the last food complaints he had received was a resident did not like the texture of a sandwich and the bread was soggy. The Dietary Manager stated if he received food complaints, he would address them individually with the residents and corporately by providing education to the dietary staff. The Dietary Manager stated he tried the food daily. The Dietary Manager stated he believed first people ate with their eyes and the more attractive the food looked the more likely they were to eat it. The Dietary Manager stated if the food was not palatable, attractive and the appropriate temperature it could result in the residents having major weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 39 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/01/23 at 9:56 AM, LVN S stated residents had told her the food did not taste good, and she had offered them a substitute and notified the DON or the administrator. LVN S stated if the residents did not like the food, they would not be able to maintain their nutrition and they would lose weight. During an interview on 03/01/23 at 10:20 AM, CNA A stated the residents had told her the food was not good, and she had notified the dietary staff. CNA A stated it was important for the residents to like the food so they would not starve and have weight loss. During an interview on 03/01/23 at 1:16 PM, [NAME] E stated she had not had any residents complain to her about the food. [NAME] E stated usually the residents spoke with the Dietary Manager when they had food complaints. [NAME] E stated it was her responsibility that the food be palatable, attractive and the appropriate temperature. [NAME] E stated she sometimes tasted the food to see if it tasted good. [NAME] E stated it was important for the food to taste and look good and be the right temperature so the residents would gain weight and stay healthy. [NAME] E stated if they did not eat the food, they could get bed sores. During an interview on 03/01/2023 at 4:10 PM, the administrator stated he had not had any food complaints. The administrator stated if he had any food complaints, he notified the Dietary Manager and followed up with him to make sure he addressed the food complaints. The administrator stated he expected for the food to be attractive, palatable, and the appropriate temperature. The administrator stated it was important for the food to be palatable, attractive and the appropriate temperature to prevent weight loss and for the resident's nutrition. During an interview on 03/01/2023 at 4:32 PM, the DON stated she had not received any food complaints from the residents. The DON stated if she received food complaints the staff offered a supplement. The DON stated it was important for food to be palatable, attractive and the appropriate temperature so the residents would not have any weight loss. Record review of the facility's policy titled, Preparation of Foods, from the Dietary Services Policy & Procedure Manual 2012, revealed, We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value . 2. All food will be prepared by methods that preserve nutritive value, flavor, and appearance with a variety of color, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 40 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o expired food items were discarded. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 02/26/23 starting at 8:35 AM: Refrigerator R-1: pint size bag of diced tomatoes with no date Ziploc bag with 2 opened blocks of cheddar cheese and a package of opened provolone cheese slices with no dates Ziploc bag with opened turkey bologna package dated 2/10 had thick, white slimy juices Freezer F-1: 3 unopened packages of frozen turkey bologna with no dates Ziploc bag with crunchy breaded fish unsealed, with no dates 5 logs of ground beef with no dates Freezer F-2: open box of frozen cookie dough open to air, unsealed dated 2/22/23 opened blue bunny sherbet bucket with no open date 5 packages of corn with no dates 2 pecan pies with no dates (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 41 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0812 Refrigerator R-2: Level of Harm - Minimal harm or potential for actual harm 1 milk container with no date 1 loaf of opened raisin bread with no open date had a white spot on the bottom Residents Affected - Some 1 package of coleslaw with use by date of 02/09/23 1 package of coleslaw with use by date of 02/20/23 opened package of iceberg lettuce dated 2/08/23 was brown, slimy 5 cabbage heads shriveled, and brown were dated 02/12/23 12 loaves of white breads with no dates 1 opened package of white bread with no dates 3 raisin bread loaves with no dates 3 donuts in individual pint size bags with no date/label 2 fruit punch containers with no dates Dry storage: 1 gallon jug of opened apple cider vinegar best use by 4/24/21 1 gallon jug of blended oil with no open date 1 gallon jug of opened pancake syrup with no open date 1 gallon of karo corn syrup received 2/21/2019 the jug was dusty and the expiration date faded Spice Shelf: 1 container of white pepper with no open date and the expiration date faded 1 container of ground cloves received 10/25/2018 with no open date and no expiration date 1 container of corn starch with no open date and no expiration date During an interview on 03/01/2023 at 8:48 AM, the Regional Dietician stated all food items in the refrigerator and freezer should be labeled with a receive date and then an open date, when opened. The Regional Dietician stated all food items in the refrigerator and freezer should be airtight, nothing should be open to air. The Regional Dietician stated expired food items should have been thrown out. The Regional Dietician stated all dietary staff were responsible for labeling, dating, and storing food appropriately. The Regional Dietician stated all the dietary staff should discard expired food items. The Regional Dietician stated the cooks daily should be making sure all expired food items (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 42 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0812 Level of Harm - Minimal harm or potential for actual harm are discarded. The Regional Dietician stated labeling, dating, and storing food items was important to make sure things stayed fresh and at their peak to make the food palatable and maintain the residents' nutritional needs. The Regional Dietician stated not appropriately labeling, dating, and storing food items could cause harm to the residents and result in food-borne illness and could alter the taste of food and reduce the resident's intake and this could result in reduced nutritional status. Residents Affected - Some During an interview on 03/01/2023 at 9:05 AM, Dietary Aide D stated all food items in the refrigerator and freezer should have a label on them with a receive date and then an open date. Dietary Aide D stated all dietary staff were responsible for making sure the food items were discarded. Dietary Aide D stated maybe they were not discarded because they might have been in a hurry and not noticed. Dietary Aide D stated it was important to label, date, and store food appropriately so people don't get sick. Dietary Aide D stated it was important to discard expired food items, so nobody used it and so the residents do not get sick. During an interview on 03/01/2023 at 9:21 AM, the Dietary Manager stated if it was a left over the dietary staff should put a date on the food and then discard it by the third day. The Dietary Manager stated all the dietary staff were responsible for labeling, dating, and storing food appropriately that it was a collective group effort. The Dietary Manager stated the dry goods should have a receive date and an open date. The Dietary Manager stated all food items in the refrigerator and freezer should have a receive date and an open date. The Dietary Manager stated it was important to discard items because after a certain number of days bacteria started to grow on the food and this could lead to food poisoning. The Dietary Manager stated it was important to date and label food items appropriately to ensure they were used in their proper time. During an interview on 03/01/2023 at 11:06 AM, Dietary Aide C stated when the truck came in on Wednesdays the dietary staff put up all the groceries and put a receive date on them. Dietary Aide C stated when dietary staff opened food they should put it in a Ziploc bag, date, and seal it. Dietary Aide C stated he was not responsible for throwing out food, but if needed he would do it. Dietary Aide C stated it was important to label and date food items appropriately just in case something did not need to be in the refrigerator. Dietary Aide C stated it was important to discard, label and date food items appropriately because the residents could get sick if something was not discarded or labeled correctly. During an interview on 03/01/2023 at 1:18 PM, [NAME] E stated food items should have a receive date and an open date. [NAME] E stated all the kitchen staff were responsible for labeling, dating, and discarding food items. [NAME] E stated expired food items should be discarded daily. [NAME] E stated it was important to label, store, date, and discard food items to know when things need to be thrown out and to keep the residents from getting sick. During an interview on 03/01/2023 at 4:15 PM, the administrator stated he expected the dietary staff to label, store and date food items. The administrator stated he expected the dietary staff to discard expired food items. The administrator stated the Dietary Manager, and the dietary staff were responsible for making sure all food items were labeled, stored, dated, and discarded appropriately. The administrator stated he randomly went to the kitchen to check it to make sure things are labeled and discarded. The administrator stated it was important to label and date food items because nobody wanted to eat expired food. The administrator stated he did not know the degree of harm that could be caused by expired food items, that it depended on what the food was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 43 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0812 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Dietary Services Policy & Procedure Manual 2012 with a policy titled, Food Safety, revealed . Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly . Do not keep potentially hazardous food in refrigerator past the labeled expiration date . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 44 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 3 of 19 residents (Resident #11, Resident #53, Resident #62) reviewed for accuracy of medical records. 1. The facility failed to ensure Resident #62's responsible party signed the antipsychotic consent form after giving consent to administer the medication. 2. The facility failed to ensure Resident #53's responsible party signed the antipsychotic consent form after given consent to administer the medication. 3. The facility did not ensure Resident #11's OOH-DNR was dated by the physician. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #62's face sheet, dated [DATE], revealed Resident #62 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a gradually progressive condition that causes problems with memory, thinking and behavior). Record review of the order summary report, dated [DATE], revealed Resident #62 had an order, which started on [DATE], for ABH gel (Ativan, Benadryl, and Haldol - which was given for anxiety or agitation). Record review of the MAR, dated February 2023, revealed Resident #62 received ABH gel daily. Record review of Resident #62's psychotropic consent form, dated [DATE], revealed the resident representative did not give consent for Haldol (antipsychotic that was part of the ABH gel). Record review of the comprehensive MDS assessment, dated [DATE], revealed Resident #62 had clear speech and was understood by staff. The MDS revealed Resident #62 was able to understand others. The MDS revealed Resident #62 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #62 hallucinated, had delusions, and wandering behaviors during the look-back period. The MDS revealed Resident #62 took an antipsychotic medication 2 out 7 days during the look-back period. Record review of the comprehensive care plan, last reviewed [DATE], revealed Resident #62 was taking antipsychotic medications for anxiety and agitation. During a family interview on [DATE] at 3:45 PM, Resident #62's family member stated she was told by the facility that they were going to start him on a ABH gel medication a few days after he admitted to the facility. The family member stated she gave her verbal consent for the medication to the facility but was not provided any education on the medications such as potential risks and side effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 45 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0842 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #53's face sheet, dated [DATE], revealed Resident #53 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and unspecified dementia, severe, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities). Residents Affected - Some Record review of order summary report, dated [DATE], revealed Resident #53 had an order, which started on [DATE], for Seroquel 25 mg (antipsychotic). Record review of Resident #53's psychotropic consent form, dated [DATE], revealed no signature from the family representative. Record review of the MAR, dated February 2023, revealed Resident #53 received Seroquel daily. Record review of the comprehensive MDS assessment, dated [DATE], revealed Resident #53 had clear speech and was understood by staff. The MDS revealed Resident #53 was able to understand others. The MDS revealed Resident #53 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #53 had delusions, hallucinations, verbal, physical, and wandering behaviors during the look-back period. The MDS revealed Resident #53 received an antipsychotic 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, last reviewed on [DATE], revealed Resident #53 required psychotropic medications related to psychosis. During an interview on [DATE] at 12:31 PM, Resident #53's family member stated she had given verbal consent for the psychotropic medication when the medication was started and understood the risk and potential for side effects. During an interview on [DATE] at 4:58 PM, LVN M stated the nurses were responsible for ensuring psychotropic consent forms were completed accurately and completely. LVN M stated there was no excuse for documenting inaccurately. LVN M stated he was unsure why the psychotropic consent forms for Resident #53 and Resident #62 were not filled out accurately. LVN M stated the importance of ensuring psychotropic consent forms were accurate and complete was to ensure medication error did not occur and informed consent was given. During an interview on [DATE] at 6:02 PM, the DON stated nursing management was responsible for ensuring consent forms were completed accurately and filled out completely. The DON stated audits were completed routinely on psychotropic consent forms. The DON was unsure why Resident #53 and Resident #62 had inaccurate and un-completed consent forms. The DON stated the importance of ensuring psychotropic consent forms were accurate and complete was to ensure informed consent was given. During an interview on [DATE] at 6:29 PM, the ADM stated he expected nursing staff to ensure psychotropic consent forms were accurate and filled out completely. The ADM stated nursing management was responsible for monitoring consent forms. The ADM stated it was important to ensure psychotropic consent forms were accurate and filled out completely so residents or families could make an informed decision and the facility staff would respect their wishes. 3. Record review of Resident #11's order summary report, dated [DATE], indicated Resident #11 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 46 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0842 Level of Harm - Minimal harm or potential for actual harm an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Stage 5 kidney disease (kidneys are severely damaged and have stopped filtering waste from blood), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Residents Affected - Some Further review of the order summary report, dated [DATE], indicated an active physician's order for code status; DNR with an order date [DATE]. Record review of the admission MDS dated [DATE], indicated Resident #11 understood others and made herself understood. The assessment indicated Resident #11 was severely cognitively impaired with a BIMS score of 2. Record review of an undated care plan indicated Resident #11 had an order for DNR. The care plan interventions included all aspects of DNR will be explained to Resident #11 or responsible party, and in absence of blood pressure, pulse, respiration, CPR will not be initiated. Record review of the OOH-DNR form revealed a missing date by the physician. During an interview on [DATE] at 8:49 a.m., the Social Worker stated prior to [DATE] she did not know that she was the sole person responsible for ensuring DNRs were completed. The Social Worker stated she only reviewed the DNRs that were given to her by hospice or staff. The Social Worker stated she was unaware prior to surveyor intervention Resident #11's DNR was missing a physician date. The social worker stated it was important that all DNRs be accurately documented and completed to ensure the resident's and family's wishes were honored. The Social Worker stated not ensuring a DNR was completed could result in interventions not wished upon by the resident or family. During an interview on [DATE] at 4:28 p.m., the Administrator stated he expected the DNR to be completed. The Administrator stated the social worker was responsible for ensuring the DNRs were accurately completed and documented. The Administrator stated upon admission the DON/ADON should review the DNRs and coordinate with the social worker. The Administrator was unable to state why the physician date was missing from Resident #11's DNR. The Administrator stated a potential negative outcome of an invalid DNR would be her wishes not being respected. Record review of the Documentation - Nursing policy, last revised in 06/2020, revealed Nursing documentation will be concise, clear, pertinent, accurate, and evidenced based. Record review of the Advance Directives policy, last revised on [DATE], revealed to ensure that the facility respects advance directives . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 47 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 staff (CNA U and CNA V) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA U and CNA V performed hand hygiene between glove changes while providing incontinent care. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 02/26/2023 at 11:10 AM, CNA U and CNA V provided incontinent care for Resident #27. During the incontinent care CNA U put on gloves and wiped Resident #27 buttocks. CNA U's gloves were soiled with feces, and she removed the gloves and applied a new pair of gloves. CNA U did not perform hand hygiene after removing her dirty gloves. CNA U continued and wiped Resident #27's buttocks, and gloves became soiled with feces. CNA U removed dirty gloves and applied a new pair of gloves. CNA U did not perform hand hygiene after removing her dirty gloves. CNA U finished cleaning resident's buttocks and removed dirty gloves and applied a new pair of gloves. CNA U did not perform hand hygiene. CNA V was holding Resident #27 on his side and at this point assisted CNA U by removing the dirty adult brief and dirty wipes. After removing the dirty adult briefs and dirty wipes, CNA V removed her dirty gloves and applied a new pair of gloves. CNA V did not perform hand hygiene after removing her dirty gloves. CNA U and CNA V then applied a clean adult brief and finished providing incontinent care. During an interview on 02/26/2023 at 11:27 AM, CNA U stated, You should change gloves every time you touch the resident and in between glove changes. CNA U stated it was important to perform hand hygiene to make sure hands were always clean. CNA U stated, As soon as you take gloves off you should wash your hands. CNA U stated she had not performed hand hygiene after removing her gloves because she did not prepare, she did not have any hand sanitizer with her, and she was nervous. CNA U stated she could have gone to the resident's bathroom and washed her hands. CNA U stated if hand hygiene was not performed, residents could get an infection, and that hand hygiene was to protect both the residents and the staff. During an interview on 02/26/2023 at 11:32 AM, CNA V stated she should have performed hand hygiene after changing gloves, after removing the dirty brief in between glove changes and before and after providing care. CNA V stated she did not perform hand hygiene in between glove changes because she did not have any hand sanitizer, but she should have gone to the sink. CNA V stated it was important to perform hand hygiene to prevent infections between residents and between what they were doing, to prevent cross contamination; and to prevent infection for them and the resident, and for safety. During an interview on 03/01/2023 at 10:07 AM, LVN S stated hand hygiene should be performed before starting care, after removing gloves, and when they were finished. LVN S stated all nurses were responsible for the CNAs and nurse management was also responsible. LVN S stated it was important to perform hand hygiene to prevent transferring bacteria. LVN S stated not performing hand hygiene could result in the residents getting a nasty infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 48 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/01/2023 at 3:57 PM ADON T stated hand hygiene should be performed before the start of care, while providing care, and after providing care. ADON T stated hand hygiene should be performed after glove removal to prevent infection from being transferred to other residents who were more prone to getting urinary tract infections. ADON T stated nurse management was responsible for making sure the CNAs performed hand hygiene. ADON T stated in-services were done to ensure staff were performing hand hygiene properly. ADON T stated he watched the CNAs provide incontinent care every day to ensure they were doing it correctly. During an interview on 03/01/2023 at 4:24 PM, the administrator stated he expected the CNAs to perform hand hygiene while providing incontinent care. The administrator stated the staff should perform hand hygiene before touching the resident, before entering a room, after taking off their gloves, and in between touching dirty things and then going to a clean area. The administrator stated it was important to perform hand hygiene to prevent infection. The administrator stated ensuring the staff performed hand hygiene was a collective team responsibility, and nurse management should oversee it. During an interview on 03/01/2023 at 4:45 PM, the DON stated hand hygiene should be performed before entering the room, before providing care, in between care, and after glove removal. The DON stated it was important to perform hand hygiene to make sure you do not spread infection. The DON stated everyone was responsible for ensuring hand hygiene was performed. The DON stated she did weekly check offs on hand hygiene, and she made daily rounds to check staff for performing hand hygiene. Record review of the facility's policy titled, Perineal Care, last revised 06/2020, revealed, To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown . I. Wash hands .V. Put on gloves. VI. Wash the pubic area .XII. Remove gloves. Wash hands or use alcohol-based hand sanitizer Note: Do not touch anything with soiled gloves after procedure (i.e., curtain, side rails, clean linen, call bell, etc.) XIII. Put on clean gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 49 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0920 Level of Harm - Minimal harm or potential for actual harm Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation, interview and record review the facility failed to ensure sufficient space to accommodate dining and activities for 1 of 2 dining rooms observed. (Secured unit) Residents Affected - Some The facility did not provide a dining room on the secured unit that accommodated all residents who wanted to eat in the dining room without causing resident crowding. This failure could place the residents at risk for injury, discomfort, and decreased quality of life. The findings included: During an observation on 02/26/2023 between 8:39 AM - 9:05 AM, 12 residents were eating in the dining room during breakfast meal. Four chairs were counted in the dining room, and all were occupied by the residents who ambulated with a walker. There were 2 recliners in the dining room were two of the residents were sitting with a meal tray on the bedside table in front of them. Resident #62 was sitting between a table and the wall. He required assistance to move his wheelchair away from the dining table because of the tight space. CNA L was standing up while feeding Resident #58. When mealtime was complete the ambulatory residents had to wait for wheelchair bound residents to have been assisted before they were able to leave. During an interview on 02/26/2023 at 9:06 AM, CNA L stated she normally fed residents while standing. CNA L stated she was feeding Resident #58 while standing because she had no chairs to sit in while in the dining room. During an observation on 02/26/2023 at 12:17 PM, there were 15 residents in the dining room with only 4 resident chairs available to accommodate seating. Four chairs were counted in the dining room, and all were occupied by the residents who ambulated with a walker. There were 2 recliners in the dining room were two of the residents were sitting with a meal tray on the bedside table in front of them. While meal trays were being passed out, staff had difficulty maneuvering through the dining room as evidence by pushing residents closer to the tables and turning sideways to carry trays to the table. When mealtime was complete the ambulatory residents had to wait for wheelchair bound residents to have been assisted before they were able to leave. During an interview for more information on 03/01/2023 at 4:02 PM, CNA L (who was present during dining observations on 02/26/2023) did not answer the telephone and a brief message was left. CNA L did not return the call upon exit of the facility. During an interview for more information on 03/01/2023 at 4:09 PM, LVN H (who was present during dining observations on 02/26/2023) did not answer the telephone and a brief message was left. LVN H did not return the call upon exit of the facility. During an interview on 03/01/2023 at 4:23 PM, CNA Q stated there could have been more table and chair space in the dining room. CNA Q stated there would not have been enough room if all the residents in the secured unit wanted to eat in the dining room. CNA Q stated having adequate seating and tables in the dining room was important so the residents could have enough space to be comfortable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 50 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/01/2023 at 4:46 PM, LVN M stated there was not enough space in the dining room on the secured unit. LVN M stated the staff should have ensured there was enough table space and chairs to prevent overcrowding. LVN M stated the administrator should have been notified if there were not enough table and chair space in the dining room. LVN M stated he had not had to notify the administrator. LVN M stated it was important to ensure residents had adequate space to prevent a lack of dignity and provide a comfortable environment. During an interview on 03/01/2023 at 6:20 PM, the ADM stated he expected staff to report accommodation of resident needs in the dining areas. The ADM stated he was responsible for ensuring residents had appropriate accommodations and space in the dining rooms. The ADM stated he monitored this by performing observation rounds. The ADM stated the importance of having enough table and chair space was to make the environment more homelike for the residents. Record review of the Resident Rooms and Environment policy, last revised in 08/2020, did not address dining room accommodations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 51 of 52 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area. Residents Affected - Few The facility failed to ensure cigarette butts were disposed of appropriately. This failure could place the residents at risk for injury. Findings include: During an observation on 02/27/2023 at 3:30 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an observation on 02/28/2023 at 11:15 a.m., the designated smoking area had numerous cigarette butts laying on the ground. During an interview on 03/01/2023 at 9:16 a.m., the Activity Director stated the staff member supervising the residents during smoke breaks were responsible for ensuring cigarettes butts were disposed properly in the smoking area. The Activity Director stated cigarette butts should be disposed in the ash tray or in the red trash can. The Activity Director stated she did not notice the cigarette butts on the ground. The Activity Director stated, I didn't have on my glasses. The Activity Director stated this failure could allow residents to re-smoke used cigarette butts or potentially start a fire. During an interview on 03/01/2023 at 9:24 a.m., the Housekeeping Supervisor stated the staff member supervising the residents during smoke breaks were responsible for ensuring cigarettes butts were disposed properly in the smoking area. The Housekeeping Supervisor stated cigarette butts should be disposed in the ash tray or in the red trash can. The Housekeeping Supervisor stated she did not notice the cigarette butts on the ground. The Housekeeping Supervisor stated she was focusing more on supervising the residents. The Housekeeping Supervisor stated this failure could potentially start a fire. During an interview on 03/01/2023 at 4:28 p.m., the Administrator stated he expected staff/residents to dispose cigarette butts in the provided receptacles. The Administrator stated he was responsible for ensuring cigarette butts were disposed of correctly in the smoking area. The Administrator stated this was completed by daily rounds. The Administrator stated due to the state being in the building rounds were not completed this week. The Administrator stated this failure could potentially cause a fire. Record review of the Smoking by Residents policy, last revised on 06/2020, revealed to respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers . XII. Cigarette butts are disposed of only in provided receptacles . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 52 of 52