Health inspection·June 5, 2024

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Risk indicated Resident #35 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize wheelchairs. The Elopement Risk Evaluation indicated in Section B, Moderate Risk indicated Resident #35 was cognitive impaired and had a history of leaving the community without informing staff. The Elopement Risk in Section C Imminent risk indicated physically Resident #35 failed to ambulate, propel self, wander, or intentionally or unintentionally attempted to leave the community. Section D Additional Information indicated Resident #35 was a risk for elopement related to the elopement evaluation risk score. The goal indicated Resident #35 would remain safe within facility unless accompanied by staff other authorized persons, engage in activities of choice, report to the physician potential elopements such as wandering, repeated requests to leave the facility, statements such as I'm leaving, I'm going home, attempts to leave facility elopement attempts from previous facility or hospital and supervise closely and make regular compliance rounds whenever resident was in her room. Record review of the admission MDS dated [DATE] indicated Resident #35 was usually understood and was sometimes understood by others. The MDS indicated Resident #35's BIMS score was 12 indicating she had moderate cognitive impairment. Section E-Behavior indicated Resident #35 had not demonstrated any wandering behaviors. The MDS in section GG-Functional Abilities and Goals indicated Resident #35 had not attempted to sit to stand, chair/bed-to-chair transfer, toilet transfers, care transfers, or walking. Record review of the Comprehensive Care Plan dated 3/07/2024 and revised on 3/20/2024 indicated Resident #35 was at risk for elopement related to the elopement evaluation score and resided on the secured unit. The goal of Resident #35's care plan indicated she would remain safe within the facility unless accompanied by staff other authorized persons. The care plans interventions included to engage Resident #35 in activities, report to the physician the risk for potential elopement such as wandering, repeated requests to leave the facility, stating I'm going home, and attempts to leave the facility. The care plan interventions failed to indicate Resident #35's elopement risk assessment score would reflect a score of high/imminent to reside on the secured unit. Record review of the Quarterly MDS dated [DATE] indicated Resident #35 was usually understood and understood others. The MDS indicated Resident #35's BIMS score was 10 indicating moderate cognitive impairment. The MDs in Section E0900 Wandering-Presence and Frequency indicated no behavior of wandering was exhibited. The MDS in Section GG-Functional Abilities and Goals indicated Resident #35 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfers, and toilet. transfers. The MDS indicated Resident #35 had not attempted to ambulate but had wheeled her wheelchair 150 foot with supervision or touching assistance. Record review of a Medication Administration Record dated May 2024 indicated Resident #35 received an antianxiety medication and was observed for behaviors such as agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panicking, or other behaviors. The Medication Administration Record had no documented behaviors for the entire month of May on day shift, evening shift, or night shift. Record review of an Elopement Risk Evaluation dated 6/04/2024 (after state surveyor intervention) indicated in Section A: No Risk indicated this area was answered yes indicating Resident #35 was able to make decision regarding task of daily living (decisions consistent and reasonable). Section A indicated Resident #35 was able to ambulate or mobilize a wheelchair. Record review of the direction of this section indicated if A1 or A2 was answered yes then the assessment was complete. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 2 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Record review of a Medication Administration Record dated June 2024 indicated Resident #35 received an antianxiety medication and was observed for behaviors such as agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panicking, or other behaviors. The Medication Administration Record had no documented behaviors for June 1,2,3,4, and 5 on day shift, evening shift, or night shift. Residents Affected - Some Record review of Resident #35's progress notes dated 3/07/2024 until 6/03/2024 failed to indicate Resident #35 had any elopement attempts, behaviors indicative of wanting to exit the facility, or any verbalizations of wanting to leave the facility since admission to the facility's secured unit. Record review of a Notification of a Room Change dated 6/04/2024 2:31 p.m., B.1. Reason for room change was Resident #35 no longer met the requirement to be on the secured unit. 2) Record review of a face sheet dated 6/05/2024 indicated Resident #23 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of Alzheimer's dementia, lack of coordination, need for assistance with personal care, unsteadiness to her feet, abnormalities of gait and mobility, fatigue, and reduced mobility. Record review of the Consolidated Physician's Orders dated 6/05/2024 indicated on 1/18/2024 Resident #23 was ordered to admit to the secured unit due to exit seeking behaviors. Record review of the progress notes dated 1/18/2024-6/04/2024 failed to indicate Resident #23 had episodes of elopement attempts, verbalization of the desire to leave, or wandering. Record review of an admission MDS dated [DATE] indicated Resident #23 was usually understood, and usually understood others. The MDS indicated Resident #23's BIMS score was a 2 indicating severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #24 had not displayed any wandering behaviors. The MDS in Section GG-Functional Abilities and Goals indicated on admission Resident #23 required substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and sit to stand. The MDS indicated Resident #23 was dependent for chair/bed-to-chair transfers, toilet transfer, shower transfers, and walking 10 foot was not attempted. The MDS indicated Resident #23 required substantial/maximal assistance for wheelchair mobility. Record review of a Quarterly MDS dated [DATE] indicated Resident #23 was usually understood, and usually understood others. The MDS indicated Resident #23's BIMS score was 1 indicating severe cognitive impairment. The MDS in section E0900 Wandering-Presence and Frequency indicated Resident #23 had not demonstrated any wandering behaviors. Section GG-Functional Abilities and Goals indicated Resident #23 required partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing. The MDS indicated Resident #23 required substantial/maximal assistance with chair/bed-to-chair transfers and was dependent for toilet transfers. The MDS indicated Resident #23 had not attempted to ambulate. The MDS indicated Resident #23 required substantial/maximal assistance with use of a manual wheelchair for mobilization at 50 feet. Record review of the Comprehensive Care Plan dated 2/01/2024 failed to indicate Resident #23 resided on the secured unit, any goals, and any interventions. Record review of the Medication Administration Record dated May 2024 indicated Resident #23 received an anti-anxiety medication for anxiety and should be monitored closely for significant behaviors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 3 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of agitation, anxiety, nervousness, compulsiveness, physical aggression, combative excitation/irritability, verbal aggression, panicking, and other. The Medication Administration Record indicated for the month of May 2024 Resident #23 had not demonstrated any behaviors. Record review of the Medication Administration Record dated June 2024 indicated Resident #23 received an anti-anxiety medication for anxiety and should be monitored closely for significant behaviors of agitation, anxiety, nervousness, compulsiveness, physical aggression, combative excitation/irritability, verbal aggression, panicking, and other. The entry indicated for June 1st ,2nd, 3rd, 4th, and 5th; Resident #23 had no behaviors demonstrated. Record review of an Elopement Risk Evaluation dated 6/04/2024 (after state surveyor intervention) indicated Resident #23 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and she was unable to ambulate or mobilize a wheelchair. The Elopement Risk Evaluation indicated Resident #23 was not at risk to elope. 3) Record review of a face sheet dated 6/04/2024 indicated Resident #38 was a 72-[NAME]-old male who admitted on [DATE], readmitted on [DATE], and most recently readmitted on [DATE] with the diagnoses of stroke, difficulty walking, and muscle weakness. Record review of the Progress Notes dated 2/03/2024 - 6/03/2024 failed to reveal documentation of Resident #38 attempting to exit the secured unit or verbalization he desired to leave the secured unit/facility. Record review of the Comprehensive Care Plan dated 6/30/2023 and revised on 6/30/2023 indicated Resident #38 was at risk for elopement and wandering as evidenced by impaired safety awareness and his residing on the secured unit. The care plan goal was Resident #38 would remain safe. The care planned intervention was distract Resident #38 from wandering by offering pleasant diversions, structed activities, food, conversation, television, and book initiated and revised on 6/30/2024. The care plan failed to indicate Resident #38's elopement risk score would have indicated he required to reside on the secured unit. Record review of an Annual MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS was a 3 indicating he had severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #38 had not wandered. The MDS indicated Resident #38 was independent with sit to stand, lying to sitting on side of bed, chair/bed-to-chair transfers. The MDS indicated Resident #38 required supervision with walking 10 feet, 50 feet, and 150 feet. Record review of a Medication Administration Record dated June 2024 indicated Resident #38 received a psychotropic medication and should be closely observed for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, delusions, repetitive verbalizations, and other. The Medication Administration Record reflected Resident #38 had no behaviors demonstrated on June 1st, 2nd, 3rd, and 4th. Record review of the Consolidated Physician's Orders dated 6/04/2024 indicated on 6/10/2022 Resident #38 had a physician's order indicating he may admit to the secured unit due to exit seeking behaviors. Record review of an Elopement Risk Evaluation indicated for admission indicated on 1/10/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 4 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #38 was not able to make decisions regarding task of daily living (decisions were consistent and reasonable). Section B Moderate Risk indicated Resident #38 was cognitively impaired and wandered aimlessly. Section C Imminent Risk and Section D Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #38 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 4/01/2024 indicated Resident #38 was not able to make decisions regarding task of daily living (decisions were consistent and reasonable). The Elopement Risk Evaluation indicated Resident #38 was able to ambulate. Section B of the Elopement Risk Evaluation indicated Resident #38 was cognitively impaired and had a history of elopement while at home. The Section Imminent Risk and Additional Information was unanswered. The assessment scored Resident #38 as a moderate risk for elopement. 4) Record review of a face sheet dated 6/05/2024 indicated Resident #18 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of severe dementia with behavioral disturbances, and unsteadiness on feet, weakness, difficulty walking, abnormalities with gait and mobility, and reduced mobility. Record review of an Annual MDS dated [DATE] indicated Resident #18 was understood and understood others. The MDS indicated Resident #18's BIMS score was 1 indicating she had severe cognitive impairment. The MDS indicated in Section E0900 Wandering-Presence and Frequency indicated Resident #18 wandered daily. The MDS in Section E1000 Wandering-Impact indicated Resident #18 was not coded as wandering posed a significant risk of getting to a potentially dangerous place (outside of the facility) or wandered significantly to intrude on privacy or activities of others. Record review of a Quarterly MDS dated [DATE] indicated Resident #18 was understood, and usually understood others. The MDS indicated Resident #18 had a BIMS score of 1 indicating severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #18 wandered 1 to 3 days. The MDS in Section GG-Functional Abilities and Goals indicated Resident #18 was dependent for toileting hygiene. The MDS indicated Resident #18 was independent with sit to lying, lying to sitting on side of bed, sitting to standing. The MDS indicated Resident #18 was set up with chair/bed-to-chair transfers, toilet transfers, and walking. Record review of a Comprehensive Care Plan dated 10/27/2022 indicated Resident #18 was an elopement risk/wanderer as evidenced by a moderate risk score. The goal of the care plan indicated Resident #18 would have her safety maintained. The care plan intervention was to distract Resident #18 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book initiated on 6/30/2023. The Comprehensive Care Plan also included Resident #18 was at risk for feeling isolated due to being on the facility's secured unit related to dementia. The care plan interventions were to admit to the secured unit according to the physician's orders, and to assist and monitor resident for off unit activities and involve Resident #18 in daily activities designed for the secured unit. Record review of the physician's orders dated June 2024 indicated Resident #18 resided on the secured unit as of 10/27/2022. Record review of the progress notes dated 3/05/2024 -6/04/2024 there was no documentation noted of Resident #18 attempting to exit the secured unit or expressing a desire to leave the secured unit. Record review of an Elopement Risk Evaluation dated 12/29/2023 indicated Resident #18 was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 5 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk and Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of an Elopement Risk Evaluation dated 3/04/2024 indicated Resident #18 was unable to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk and Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of an Elopement Risk Evaluation dated 6/04/2024 indicated Resident #18 was unable to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk indicated Resident #18 had not ambulated or propelled self, wandered, or intentionally or unintentionally attempted to leave the facility or had not verbalized a plan to elope. The Additional Information section the assessment indicated Resident #18 was at risk to elope due to the elopement risk score and would remain safe within the facility unless accompanied by staff other unauthorized persons. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of the Medication Administration Record dated May 2024 indicated Resident #18 was receiving an antipsychotic medication and required monitoring closely for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, repetitive verbalization, or other behaviors for all of May dating May 1, 2024 - May 31, 2024. Record review of the Medication Administration Record dated June 2024 indicated Resident #18 was receiving an antipsychotic medication and required monitoring closely for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, repetitive verbalization, or other behaviors for June 1st, 2nd, 3rd, 4th, and the 5th. 5). Record review of a face sheet dated 6/05/2024 indicated Resident #47 was a [AGE] year-old-male who admitted on [DATE] and readmitted on [DATE] with diagnoses of dementia with mood disturbances and without behaviors disturbances, muscle weakness, and unsteadiness on his feet. Record review of a Comprehensive Care Plan dated 3/16/2022 and revised on 1/12/2024 indicated Resident #47 resided on the secured unit for his safety related to his diagnosis of dementia. The goal of the care plan was Resident #47 would not leave the facility unassisted. The interventions included to distract Resident #47 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. The care plan also indicated to provide Resident #47 with structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record review of the Consolidated Physician's orders dated June 2024 indicated on 3/13/2024 Resident #47 had an order to be admitted on the secured unit due to exit seeking behaviors. Record review of an Elopement Risk Evaluation dated 2/12/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 6 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 3/14/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 6/04/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. During an observation on 6/03/2024 at 10:17 a.m., Resident #23 was sitting in the dining room in her wheelchair at the dining table in the secured unit. Resident #23 was unable to be interviewed. During an observation and interview on 6/03/2024 at 10:18 a.m., Resident #35 was lying in her bed asleep on the secured unit. Resident #35 said she was just sleeping. During an observation on 6/03/2024 at 10:39 a.m., Resident #18 was sitting in her wheelchair in the dining room on the secured unit. Resident #18 said she was doing well. Resident #18 was unable to be further interviewed. During an observation on 6/03/2024 at 10:48 a.m., Resident #47 was lying in his bed on the secured unit. Resident #47 was unable to be interviewed. During an interview on 6/03/2024 at 1:50 p.m., LVN A said Resident #'s 35, 23, 18, and 47 have not attempted elopement behaviors in several months but she said Resident #47 had a history of attempting elopement but was unsure of the date. During an observation on 6/04/2024 at 10:16 a.m., Resident #23 was sitting at the dining table in the secured units dining room. During an observation and interview on 6/04/2024 at 10:18 a.m., Resident #35 said she was just resting in her bed in the secured unit. Resident #35 said she felt her needs were being met and denied abuse. During an observation and interview on 6/04/2024 at 10:22 a.m., Resident #47 was sitting in the secured units dining room having a snack. Resident #47 said his snack was good. During an observation and interview on 6/04/2024 at 10:24 a.m., Resident # 18 was sitting in her wheelchair in the dining room of the secured unit eating a snack. Resident #18 said her snack was good. During an interview on 6/04/2024 at 1:40 p.m., the DON said she was unsure why Resident #'s 23, 18, 47, and 35 remained on the secured unit when their elopement risks scores were indicative a moderate risk to elope the facility. The DON was asked to provide documentation of elopement behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 7 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/04/2024 at 1:51 p.m., CNA B said she was routinely providing care for the residents for the secured unit. CNA B said Resident #''s 47 had a history of going to the doors to attempt to leave but not demonstrated this behavior recently. CNA B said Resident #'s 23,18, and 35 had not attempted wandering to the doors in more than two months. During an observation and interview on 6/05/2024 at 7:49 a.m., Resident #35 was no longer on the secured unit. Resident #35 was observed in the general community. Resident #35 said she was moved, and she liked her new room. Resident #35 said the staff seemed nicer and was okay with her remaining in the bed. During an interview on 6/5/24 at 2:30 PM, RN C said She said Resident #18 went on hospice 2 weeks ago. She said Resident #18 had not tried to leave the unit or showed any desires she had wanted to leave. RN C said Resident #18 was more confused. RN C said Resident #23 had behaviors but was not able to walk. RN C said Resident #23 would not be able to leave the building. RN C said she did not feel the residents were appropriate to be in the unit if they are unable to leave the building or trying to exit seek. During an interview on 6/05/2024 at 3:49 p.m., the DON said the Elopement Risk Assessments were completed on admission and quarterly by the nurses. The DON said the Elopement Risk Assessments were reviewed on Fridays. The DON said when a resident no longer qualified for the secured unit the physician was notified for an order to come off the secured unit and the family and resident were notified. The DON said she believed the Secured Unit policy gave discretion to the Administrator to keep a resident on the secured unit although the assessment failed to meet the criteria for placement. The DON said she was unable to provide documentation of exit seeking behaviors. The DON said the Administrator could explain further. The DON said she would not want to live on the secured unit if she was a resident and had not demonstrated a need to reside on the unit. The DON said a resident could have failure to thrive issues, and a decline in socialization. During an interview on 6/05/2024 at 4:06 p.m., the Administrator said he expected the Elopement Risk Assessments and the documentation to reflect a resident's need to reside on the secured unit. The Administrator was unable to provide documentation of elopement behaviors for Resident #'s 50, 23, 18, 47, and 35. The Administrator said the DON was responsible for ensuring the resident documentation supports the residents to reside in the secured unit. The Administrator said he believed the policy for the secured unit allowed for his discretion not to move a resident from the secured unit when the assessments reflect otherwise. The Administrator said he would want to reside where he was supposed to reside if he was a resident on the secured unit with no supporting documentation to be on the unit he would not want to reside on the secured unit. Record review of a Secure Care neighborhood policy dated 8/2020 indicated the goal of the Secure Care neighborhood was to meet the individual needs of residents with dementia related illness. The Secure Care neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. Policy: l. The secure care neighborhood may be sued to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed with a physician order completed. ll. Residents eligible for admission to the Secure Care Neighborhood will have a diagnosis of dementia or dementia related illness. Procedure: l. Resident eligible for admission for the Secure Care Neighborhood will have a diagnosis of dementia or a dementia related illness. A. The need for admission to the Secure Care neighborhood must have a physician's order. ll. The following criteria must be met in order for the resident to meet for participation in the Secure Care neighborhood program. If one of more of the criteria is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 8 of 30 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 06/05/2024 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 0603 Level of Harm - Minimal harm or potential for actual harm met, an exception for admission may be made only at the discretion of the administrator. Exception of admission will be made on an individual case by case basis. A. The resident must have a diagnosis of dementia or related illness. B. The resident musts be medically stable with no IV's or feeding tubes. Residents Affected - Some C. If the resident expresses physical abusive and/or combative behaviors, they must be manageable through therapeutic approaches and/or low to moderate mediations. D. The resident must be alert at least 50% of the day. E. The resident must be able to assist in ADL activities including dressing, bathing, and toileting independently or with the assist of one. F. The resident must be able to participate in at least three activity programs per day which are scheduled to meet the individual needs of the residents. G. The resident must be a high-risk wander. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 9 of 30 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 06/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 6/04/2024 indicated Resident #38 was a [AGE] year-old male who admitted on [DATE], readmitted on [DATE], and most recently readmitted on [DATE] with the diagnoses of stroke and dementia. Record review of an Annual MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS score was a 3 indicating he had severe cognitive impairment. The MDS indicated Resident #38 was independent with personal hygiene which included shaving. Record review of the Comprehensive Care Plan dated 4/27/2022 indicated Resident #38 had a stroke. The goal of the care plan was Resident #38 would be able to communicate needs daily and be free from complications related to a stroke. The interventions of this care plan were to monitor and document the resident's abilities for ADLs and assist Resident #38 as needed and allow Resident #38 to do what he could do for himself. During an observation on 6/03/2024 at 10:19 a.m., Resident #38 was sitting in his recliner. Resident #38 has his television remote and a disposable personal razor sitting in his window on the ledge. During an observation, and interview on 6/04/2024 at 10:30 a.m., Resident #38 had a disposable razor sitting on the ledge of the window next to his recliner. LVN A said when asked about the razor said, Resident #38 you know you need to give the razor back to us when you finish using it. LVN A was asked does Resident #38 have a diagnosis of dementia, and she agreed. LVN A said Resident #38 should not have kept the razor and stored the razor in his window ledge. LVN A said the unit had residents who wandered and could have an injury from obtaining the razor. During an interview on 6/05/2024 at 3:49 p.m., the DON said a razor should be placed in a sharps container once used. The DON said the unit staff were responsible for ensuring the proper discarding of used razors. The DON said this was monitored with every 2-hour rounds by the nursing staff. The DON said a resident could obtain the opened, used razor and injure themselves. During an interview on 6/05/2024 at 4:20 p.m., the Administrator said storing a disposable razor in the window ledge was not the appropriate place to store a razor. The Administrator said the storing of an open and used razor in the window ledge posed a safety risk. The Administrator said the secured unit staff were responsible for ensuring sharps were stored properly. Record review of the facility policy titled, Smoking, dated November 2023, indicated, It is the policy to respect the resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers #8. All smoking materials will be stored in a secure area to ensure they are kept safe. Record review of a Sharps Disposal policy dated 6/2020 indicated, The purpose of the policy was to ensure nursing staff discarded contaminated sharps in designated containers. l. Nursing staff using sharps discard them as soon as feasible into designated containers. Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of cigarettes to prevent accidents or hazards for 1 of 3 residents reviewed (Resident #54) and the facility failed to ensure 1 of 1 unit environment remained free of accident hazards for 1 of 18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 10 of 30 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 06/05/2024 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 0689 residents (Resident #38) reviewed for accidents and hazards. Level of Harm - Minimal harm or potential for actual harm 1. The facility did not ensure Resident # 54 did not have his cigarettes which were left out on his bedside table. Residents Affected - Few 2. The facility failed to ensure Resident #38's personal disposable razor was disposed of or stored properly after use to prevent accidents. These failures could place residents at risk for injury. Findings included: 1.Record review of Resident #54's face sheet, dated 06/05/24, indicated Resident #54 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), Insomnia (when you are not sleeping as you should), depression(sadness), and high blood pressure. Record review of Resident #54's quarterly MDS assessment, dated 01/26/24, indicated Resident #54 understood and was understood by others. Resident #54's BIMS score was 15, which indicated he was cognitively intact. Resident #54 required assistance with bathing and independent with toileting, personal hygiene, transfer, dressing, bed mobility, and eating. Record review of Resident # 54's Smoking assessment dated [DATE] indicated Resident #54 was a smoker. It indicated he required minimal supervision while smoking and his smoking material should have been kept at the nurses' station. Record review of Resident #54's comprehensive care plan dated 03/13/23 indicated he was a smoker. The intervention was for the staff to keep his smoking material at the nurses' station. During an observation on 06/03/24 at 10:00 a.m., cigarettes were observed on Resident #54's bedside table. During an interview on 06/03/24 at 12:10 p.m., Resident #54 said he kept his cigarettes and lighter. He said unknown staff were aware he kept his cigarettes and lighter. He said he signed himself out to smoke and it was too much of a hassle to ask for his cigarettes and lighter each time he signed out on pass. During an interview on 06/05/24 at 4:06 p.m., LVN E said he does not know how Resident #54 gets his cigarettes. He said he does ask Resident #54 for his lighter and cigarettes when he returns from outside or out on pass. He said cigarettes and lighters should be kept at the nurse's station. He said another resident could get the cigarettes and lighter if left out and cause a fire. During an interview on 06/05/24 at 4:09 p.m., the DON said she was unaware Resident #54 had his cigarettes on him. She said she was aware Resident #54 signed himself out to smoke. She said the nurses should ensure they collect all smoking material of all residents who had smoked during smoking times and residents who had signed back in from out on pass. She said it was their policy for residents to smoke in designated areas and for all smoking material to be kept in a box at the nurses' station. She said if Resident #54 had his smoking material and left them out it could be a potential fire hazard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 11 of 30 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 06/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/24 at 4:49 p.m., ADON, LVN F said Resident #54's cigarettes and lighter should be at the nurses' station like all other residents who smoke. She said whoever took the residents out to smoke should receive all smoking material back from the residents and the nurses should receive all smoking material back when the resident(s) signed back in from out on pass. She said failure to keep smoking material at the nurses' station could result in burns. Residents Affected - Few During an interview on 06/05/24 at 5:03 p.m., the Administrator said all residents who smoked should have their smoking material locked up at the nurses' station. He said Resident #54 had been non-compliant with following the smoking policy and they had issued him a 30-day notice. The Administrator said he still expected Resident #54 to have his smoking material locked up at the nurses' station for safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 12 of 30 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 06/05/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs (without adequate behavior or side effect monitoring) for 3 of 8 (Resident # 54, Resident # 64, and Resident # 3) residents who were reviewed for psychotropic medication. 1. The facility failed to ensure Resident #54 had behavior monitoring (monitor activities and mood) for his prescribed Venlafaxine (an antidepressant used to treat major depression) for the months of May and June 2024. 2. The facility failed to ensure Resident #64 had behavior monitoring (monitor activities and mood) and side effects (unwanted undesirable effects that are possibly related to a drug) for his prescribed Lexapro (an antidepressant used to treat depression) for the months of May and June 2024. 3. The facility failed to ensure Resident #3 had behavior monitoring (monitor activities and mood) for her prescribed Duloxetine (an antidepressant; that is used to treat depression and anxiety) for the months of May and June 2024. These deficient practices could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #54's face sheet, dated 06/05/24, indicated Resident #54 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included depression (a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Insomnia (when you are not sleeping as you should), and high blood pressure. Record review of Resident #54's quarterly MDS assessment, dated 04/05/24, indicated Resident #54 understood and was understood by others. Resident #54's BIMS score was 15, which indicated he was cognitively intact. Resident #54 required assistance with bathing and independent with toileting, personal hygiene, transfer, dressing, bed mobility, and eating. The MDS indicated Resident #54 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #54's physician order dated 05/14/24 indicated an order for Venlafaxine (Effexor) 75 mg, give 1 capsule by mouth daily for diagnosis of depression. Resident #54 had a medication dose change and no order for behavior monitoring was noted. Record review of Resident #54's physician order dated 06/13/23 and discontinued 05/14/24 indicated an order for Venlafaxine (Effexor) 150 mg, give 1 capsule by mouth daily for diagnosis of depression. No order for behavior monitoring was noted. Record review of Resident #54's comprehensive care plan dated 03/13/23 indicated Resident #54 required antidepressant medication for diagnosis of Depression. Intervention for staff was to give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 13 of 30 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 06/05/2024 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 0758 antidepressant medications ordered by the physician and monitor/document side effects. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #54's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Residents Affected - Some Record review of Resident #54's pharmacy recommendations dated 04/01-04/12/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. 2. Record review of Resident #64's face sheet dated 06/10/24 indicated Resident #64 was a [AGE] year-old, male admitted on [DATE] and readmitted on [DATE] with diagnosis including depressive disorders (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Dementia( forgetfulness). Record review of Resident #64's quarterly MDS assessment dated [DATE] indicated Resident #64 was usually understood and usually understood by others. The MDS indicated Resident #64 had a BIMS score of 06 which indicated moderately impaired cognition. The MDS indicated Resident #64 required total assistance for all ADLs. The MDS indicated Resident #64 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #64's care plan dated 11/15/23, indicated Resident #64 required antidepressant medication for diagnosis of Depression. Intervention for staff was to give antidepressant medications ordered by physician and monitor/document side effects. Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Record review of Resident #64's physician order dated 01/16/24 indicated an order for Lexapro, 10mg, give 1 tablet, daily for diagnosis of depressive disorders. No order for monitoring behavior or side effects was noted. Record review of Resident #64's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Record review of Resident #64's MAR dated 06/01/24-06/31/24 did not indicate any side effect monitoring. Record review of Resident #64's pharmacy recommendations dated 04/01-04/12/24 and 05/01-05/05/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. 3. Record review of Resident #3's face sheet dated 06/10/24 indicated Resident #3 was a [AGE] year-old, female admitted on [DATE] and readmitted on [DATE] with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act), dementia (Forgetfulness) and Diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 14 of 30 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 06/05/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's admission MDS assessment dated [DATE] indicated Resident #3 was sometimes understood and understood by others. The MDS indicated Resident #3 had severely impaired cognition. The MDS indicated Resident #3 required total assistance for all ADLs. The MDS indicated Resident #3 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #3's care plan dated 01/15/24, indicated Resident #3 received antidepressant medication related to major depression. The intervention was for staff to give antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness. Record review of Resident #3's physician order dated 03/06/24 indicated an order for Duloxetine HCL 60MG, give 1 capsule daily for depression. No order for behavior monitoring was noted. Record review of Resident #3's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Record review of Resident #3's pharmacy recommendations dated 04/01-04/12/24 and 05/01-05/05/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. During an interview on 06/05/24 at 4:06 p.m., LVN E said if a resident had psychoactive medication, then they should have side effects and behavior monitoring. He said the nurses were supposed to place an order for behavior and side effect monitoring when they received the new order. He said without proper monitoring nurses would not know if the resident was having side effects or change in mood or behavior related to the medication. During an interview on 06/05/24 at 4:09 p.m., the DON said behavior monitoring and side effects monitoring were on the MAR/TAR. She said the charge nurses were responsible for entering the behavior monitoring and/or the side effects monitoring when they did an admission or started a new medication. She said ADON #1 was responsible for ensuring nurses had inputted the behavior monitoring or side effects monitoring as needed. She said behavior monitoring was to monitor if the resident had behaviors related to what the medication was prescribed to treat. She said side effects should be monitored to see if any other interventions need to be placed or medication discontinued if causing side effects. She said failure to have behavior monitoring or side effect monitor could cause the nurses to miss a side effect or behavior. During an interview on 06/05/24 at 4:49 p.m., ADON LVN F said the nurses were supposed to write orders for side effects and behavior monitoring when they received an order for psychoactive medication. She said she was responsible as the overseer for the side effects and behavior monitor sheets. She said she had been at the facility for a month and was working on a system to ensure the monitoring was in place. She said she was learning the process of pharmacy recommendations. She said she had been trained but had not had enough time to review all residents who took psychoactive medications for side effects or behavior monitoring. She said they monitored residents to see if they had an improvement, were stable, or needed medication changes. During an interview on 06/05/24 at 5:03 p.m., the Administrator said the nurses were responsible for ensuring the side effects and behavior monitoring sheets were in place and the nurse managers were the overseers. He said without monitoring, nurses would not know if the medication had been effective or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 15 of 30 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 06/05/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's Psychotherapeutic Drug Management, policy dated 06/2020 indicated, To implement the most desirable and effective intervention to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and or decreasing or negatively impacting the resident's quality of life. Behavior interventions for individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychological cycle social environment, directed towards understanding, preventing, relieving, and or accommodation accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident mental cycle or psychosocial well-being . X Nursing Responsibility: B. Will monitor psychotropic drug use daily noting any adverse effects. (i.e., EPS, Tardive dyskinesia, excessive dose, or distressed behavior). C. Will monitor the presence of target behaviors daily D. Review the use of the medication with the physician and the interdisciplinary team at least quarterly to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use . Event ID: Facility ID: 675367 If continuation sheet Page 16 of 30 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 06/05/2024 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 that its medication error rates were not 5 percent or greater. There were 3 errors out of the 58 opportunities, resulting in a 5.17 percent medication error rate involving 2 out of 5 residents reviewed for medication errors. (Residents #6 and #35) Residents Affected - Few 1. The facility failed to ensure Resident #6's MiraLAX (laxative) was administered as ordered on 06/04/24. 2. The facility failed to ensure Resident #35's fluticasone (nasal spray that treats allergy symptoms) and guaifenesin (medication used to relieve chest congestion) were administered as ordered on 06/04/24. These failures could place residents at risk of not receiving the therapeutic outcomes and possible negative outcomes. Findings included: 1. Record review of Resident #6's face sheet dated 06/05/24, indicated a [AGE] year-old female who admitted to the facility on [DATE], and readmitted on [DATE]. Resident #6 had diagnoses of type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), weakness, and hypertension (high blood pressure). Record review of Resident #6's annual MDS assessment dated [DATE], indicated was able to make herself understood and understood others. The MDS assessment indicated Resident #6 had a BIMS of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #6 did not refuse care or had constipation. Record review of Resident #6's comprehensive care plan dated 05/17/24, did not indicate she had constipation issues or was receiving MiraLAX. Record review of Resident #6's order summary report dated 06/05/24, indicated she had an order for MiraLAX powder 17 GM/scoop give 17 grams by mouth in the morning for constipation with an order start date of 10/19/2021. Record review of Resident #6's medication administration record dated 06/01/24- 06/30/24 indicated she had received MiraLAX 17 on 06/04/24. During an observation of the medication administration on 06/04/24 at 08:07 AM, MA G did not administer the MiraLAX as ordered to Resident #6. During an interview on 06/05/24 at 09:30 AM, MA G said Resident #6 did not like to take her MiraLAX daily and usually took it every other day. MA G said she thought she had signed the medication out as given but she should have struck it out and marked out as drug refused. MA G said since she was moving so fast, she accidently marked it as given. MA G said by Resident #6 was at risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 17 of 30 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 06/05/2024 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 constipation by not administering the MiraLAX. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #35's face sheet dated 06/05/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), dementia (memory loss), essential hypertension (high blood pressure), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Residents Affected - Few Record review of Resident #35's comprehensive care plan dated 03/13/24 did not indicate Resident #35 was receiving fluticasone for allergic rhinitis or guaifenesin for cough. Record review of Resident #35's quarterly MDS assessment dated [DATE], indicated she understood others and usually was able to make herself understood. The MDS assessment indicated he had a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of Resident #35's order summary report dated 06/05/24, indicated she had the following orders: *Fluticasone propionate nasal suspension 50mcg /act: 2 sprays in both nostrils in the morning for allergic rhinitis with a start date of 03/08/24. *Guaifenesin ER (extended release) 600mg tablet: give one tablet by mouth every 12 hours as needed for cough with an order start date of 03/08/24. Record review of Resident #35's medication administration record dated 06/01/24-06/30/24, indicated Resident #35 received fluticasone 50mcg/act 2 sprays each nostril and guaifenesin 600mg 1 tablet by mouth on 06/04/24. During an observation of the medication administration on 06/04/24 at 08:33 AM, MA G did not administer Resident #35's guaifenesin tablet and only administered one spray of fluticasone to each nostril. MA G failed to administer Resident #35's guaifenesin and fluticasone as ordered. During an interview on 06/05/24 at 09:30 AM, MA G said Resident #35 should have received 2 sprays of fluticasone to each nostril and 1 tablet of guaifenesin during the medication pass on 06/04/24. MA G said they did not have the guaifenesin tablets available at the facility and had told medical records that the medication needed to be ordered. MA G said she should have marked the guaifenesin as not administered and notified the nurse that medication was not available. MA G said Resident #35 was at risk for stuffy nose and congestion since medications were not administered as ordered. MA G said the medications rights were as follows: the right dose, the right time, the right medication, the right patient, and the right route. MA G said she had been checked off on medication administration. MA G said she was in a hurry and to nervous but should have had paid better attention to the medication administration record. During an interview on 06/05/24 at 3:02 PM, ADON F said she expected medications to be administered as ordered. ADON F said Resident #6's MiraLAX should have been administered unless Resident #6 had refused. ADON said medications refused should have been marked as refused and not administered. ADON F said Resident #35's fluticasone and guaifenesin should have been administered as ordered. ADON F said if a medication was not available, staff should notify medical records staff and the nurse so medication could have been reordered. ADON F said medications not administered should not have been documented as given. ADON F said Resident #6 was at risk for constipation and Resident #35 was at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 18 of 30 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 06/05/2024 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 risk for allergy problems. ADON F said MA G was responsible for administrating medications as ordered. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/24 at 03:24 PM, the DON said she expected medications to be administered as ordered. The DON said Resident #6 refusal of MiraLAX should have been documented as refused and not administered. The DON said Resident #35 should have received 2 sprays of fluticasone and 1 tablet of guaifenesin as ordered. The DON said MA G was responsible for ensuring medications were administered as ordered. The DON said Resident #35 was at risk for medications not being effective and congestion. Residents Affected - Few During an interview on 06/05/24 at 03:25 PM, the Administrator said he expected medications to be administered per the physician's orders. The Administrator said residents were at risk for adverse effects for not receiving medications as ordered. The Administrator said MA G was responsible for administering medications as ordered by the physician. The Administrator said the DON and ADON were responsible for ensuring the medication aides were checked off on medication administration. Record review of the facility's undated policy Medication-Administration indicated . Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law . The licensed nurse must know the following information about any medication they are administering. A. The drug's name. B. The drug's route of administration. C. The drug's action. D. the Drug's indication for use and desired outcome. E. The drug's usual dosage. F. The drug's side effects and adverse effects. G. Any precautions and special considerations .When a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 19 of 30 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 06/05/2024 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 - Few 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 observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 nurse medication carts and 2 of 23 residents reviewed in sample (Residents #69 and #43). 1. The facility failed to ensure Resident #69 did not have prescribed medication Prostat AWC oral liquid (medication used to aid in wound healing) left at bedside on 06/04/24. 2. LVN D failed to ensure the 400 hall nurse medication cart was locked when it was left unattended on 06/04/24 when she went to wash her hands. 3. The facility failed to ensure LVN D properly secured Resident #43's insulin pen inside the nurse's medication cart on 06/04/24. These failures could place residents at risk of injury. Findings included: 1.Record review of Resident #69's face sheet dated 06/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of partial traumatic amputation of left foot, Dementia (a disease in which causes a decline in a person's cognitive ability to perform day to day activities, Schizophrenia (mental disorder characterized by episodes of psychosis generally misperceptions of real life), Diabetes Mellitus (disease in which it causes too much sugar in the blood), and weakness. Record review of Resident #69's quarterly MDS dated [DATE] indicated he had a BIMS score of 8 which meant he had moderately impaired cognition. The MDS also indicated he required maximal assistance with toileting, transfers, dressing, and bathing, and he was independent with eating. Record review of Resident #69's care plan dated 04/24/24 indicated he had wounds to his bilateral feet that he was being seen by outpatient wound care with interventions for Resident #69 to have no complications to his right and left feet, and to have Prostat AWC (medication used to aid in wound healing) 30ml twice a day until they were healed. Record review of Resident #69's order summary report dated 06/04/24 indicated he had an order as followed: 1.Prostat AWC Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30 ml by mouth two times a day for wound healing until all wounds are healed with a start date of 05/18/24 and no end date. Record review of Resident #69's administration record dated June 2024 indicated Medication Aide G administered the Prostat AWC liquid (medication used to aid in wound healing) to Resident #69 on 06/04/24 at 8:00 AM dose, when it was found at Resident #69's bedside. During an observation and interview on 06/04/24 at 08:23 AM Resident #69 was sitting on the side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 20 of 30 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 06/05/2024 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 - Few his bed eating his breakfast and showed the surveyor his wound healing medication that was left at his bedside for him to take. He said he did not like taking the medication until he ate. During an observation and interview on 06/04/24 at 08:33 AM the MDS Nurse came into Resident #69's room while he had his Prostat AWC liquid (medication used to aid in wound healing) in a 30ml medicine cup and said he should not have his medication at his bedside and that the medication aide should have stood there while the resident took his medicine. The MDS Nurse said the importance of the staff standing at bedside until a resident completely took their medications, was to ensure the resident took the medication and prevented a wandering resident from getting medication and taking it. During an interview on 06/04/24 at 08:57 AM Medication Aide G said she gave Resident #69 his 08:00 Am medication. She said that while she was giving him his medication, she was distracted by another resident and forgot to ensure Resident #69 took his medications. Medication Aide G said she was responsible for ensuring residents took their medications prior to her leaving the bedside. She said the failure could have placed Resident #69 at risk for not taking his medication or possibly allowed another resident to get the medication and take it. During an interview on 06/05/24 at 04:02 PM the DON said no medications should have been left at Resident #69's bedside. She said she expected the nurses and Medication Aides to be watching all medications being administered. The DON said the failure placed a risk for other residents taking the medications and placed the facility at risk for not following doctor orders. The DON said she was responsible for ensuring the med aides and nurse were administering medications correctly. During an interview on 06/05/24 at 04:31 PM the Administrator said he expected the staff to remain with residents and observe the residents take medications. He said the failure placed a risk for Resident #69 not taking his medication as ordered or risk for another resident to get the medication and take. 2. Record review of Resident #43's face sheet dated 06/05/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #43 had diagnoses type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), cerebral infarction (stroke), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow). Record review of Resident #43's comprehensive care plan dated 02/18/23 indicated Resident #43 had diabetes and used diabetic medications. The care plan interventions indicated to administer diabetic medications as ordered. Record review of Resident #43's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #43 received insulin injections 7 out of the 7 day look back period. Record review of Resident #43's order summary report dated 06/05/24, indicated he had an order for Fiasp FlexTouch (fast acting insulin indicated to improve glycemic control in patients with diabetes) 100 unit/ml per sliding scare before meals for diabetes with a start date of 04/29/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 21 of 30 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 06/05/2024 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 - Few Record review of Resident #43's nurse administration record dated 06/01/24-06/30/24, indicated he received Fiasp 100unit/ml per sliding scale three times a day. During an observation and interview on 06/04/24 at 10:31 AM, LVN D entered Resident #43's bathroom to wash her hands. LVN D left the 400-hall nurse's medication cart unlocked. LVN D obtained Resident #43's blood sugar and administered his insulin. LVN D placed Resident #43's Fiasp Flexpen on top of the nurse medication cart and went inside Resident #43's bathroom to wash her hands. LVN D left the nurse medication cart unlocked. LVN D failed to properly secure Resident #43's insulin pen and the nurse medication cart when she them out of her view. LVN D said she was responsible for ensuring the cart was locked and medications secured when leaving the cart and medications unattended. LVN D said someone passing by could have gotten the insulin or the medications inside the cart. During an interview on 06/05/24 at 03:02 PM, ADON F said she expected medications to be properly secured inside the medication cart and the medications cart to be locked when leaving them unattended. ADON F said the person administering medications was responsible for ensuring medications and carts were properly secured. ADON F said by not properly securing medications, residents or people passing by could get the medications. During an interview on 06/05/24 at 3:24 PM, the DON said she expected the medication cart to be always locked and medications to be properly secured inside the cart. The DON said the staff administering medications was responsible for ensuring medications were properly secured. The DON said by leaving medications on top of the cart or the cart unlocked, anyone passing by could get the medications. During an interview on 06/05/24 at 3:25 PM, the Administrator said he expected the medication carts to always remain locked. The Administrator said he expected medications to be properly secured and not left on top of the medication cart. The Administrator said by leaving medications on top of the cart or the cart unlocked, residents passing by could get the medications. The Administrator said the person administering medications was responsible for properly securing the medications. Record review of the facility's undated policy Medication-Administration indicated . Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law . The licensed nurse must know the following information about any medication they are administering. A. The drug's name. B. The drug's route of administration. C. The drug's action. D. the Drug's indication for use and desired outcome. E. The drug's usual dosage. F. The drug's side effects and adverse effects. G. Any precautions and special considerations .VIII. Medications will not be left at bedside .When a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR. Record review of the facility's policy Storage of Medications revised 08/2020 indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 22 of 30 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 06/05/2024 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 Residents Affected - Few 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 service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure 3 muffin tins were free from carbon build-up, rust, and food particles on 6/03/24. This failure could place residents at risk of foodborne illness, and food contamination. Findings included: During an observation of the facility's kitchen on 06/03/24 and interview at 11:33 AM, three muffin tins were observed at the bottom of the steam table. The three muffin tins were black, had carbon build up, rust and light-yellow food particles. The Dietary [NAME] said they had been using the muffin tins. When asked if the muffin tins appeared clean, she said No. The Dietary [NAME] said it could get in the resident's food and cause them to get sick. During an interview on 06/03/24 at 11:36 AM, the Dietary Manager said he did not believe the carbon build up or rust could get in the resident's food since it was not inside the muffin tin but on top. When demonstrated that the black buildup could be peeled off, and food particles were still inside the muffin tin he said that it could get in the resident's food, cause bacteria, and make them sick. The Dietary Manager said he tried to check the kitchen equipment as frequently as possible to ensure they were in good working order. During an interview on 06/05/24 at 3:25 PM, the Administrator said he did not expect the muffin tins to be used because it would not be beneficial to the residents and probably cause stomach issues. The Administrator said the Dietary Manager was responsible for ensuring the kitchen equipment was kept in working order. Record review of the facility's policy Equipment Operation and Sanitation revised 12/2020, indicated . To establish guidelines for safe equipment operation and sanitation . a. all equipment must be thoroughly washed and sanitized between uses in different food preparation tasks . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 23 of 30 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 06/05/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 1 of 4 residents (Resident #43) reviewed for infection control. Residents Affected - Few The facility failed to ensure LVN D performed hand hygiene during Resident #43's insulin administration on 06/04/24 . This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Record review of Resident #43's face sheet dated 06/05/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #43 had diagnoses type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), cerebral infarction (stroke), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow). Record review of Resident #43's comprehensive care plan dated 02/18/23 indicated Resident #43 had diabetes and used diabetic medications. The care plan interventions indicated to administer diabetic medications as ordered. Record review of Resident #43's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #43 received insulin injections 7 out of the 7 day look back period. Record review of Resident #43's order summary report dated 06/05/24, indicated he had an order for Fiasp FlexTouch (fast acting insulin indicated to improve glycemic control in patients with diabetes) 100 unit/ml per sliding scale before meals for diabetes with a start date of 04/29/24. Record review of Resident #43's nurse administration record dated 06/01/24-06/30/24, indicated he received Fiasp 100unit/ml per sliding scare three times a day. During an observation of the medication administration on 06/04/24 at 10:31 AM, LVN D donned gloves and obtained Resident #43's blood sugar. After removing her gloves LVN D failed to perform hand hygiene. LVN D reapplied a clean set of gloves. LVN D then obtained Resident #43's insulin from the nurse's cart. Insulin was drawn as ordered and LVN D performed hand hygiene and donned clean gloves. LVN D administered the insulin to Resident #43. LVN D removed her gloves but failed to perform hand hygiene. LVN D said she should have performed hand hygiene in between glove changes and failure to do so was an infection control issue. LVN D said she knew she had to perform hand hygiene in between glove changes but had been very nervous. LVN D said she was responsible of ensuring proper hand hygiene was performed during tasks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 24 of 30 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 06/05/2024 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 06/05/24 at 3:02 PM, ADON F said she expected hand hygiene to be performed after removing gloves and in between glove changes. ADON F said failure to perform hand hygiene in between glove changes was an infection control issue. ADON F said the LVN D was responsible for ensuring proper hand hygiene was performed during a procedure. During an interview on 06/05/24 at 03:24 PM, the DON said she expected hand hygiene be performed before and after care and in between glove changes. The DON said failure to perform hand hygiene in between glove changes could cause pathogens to be passed to other residents. The DON said anyone performing care was responsible for performing proper hand hygiene. During an interview on 06/05/24 at 03:25 PM, the Administrator said he expected hand hygiene to be performed in between glove changes. The Administrator said failure to perform proper hand hygiene was an infection control issue. The Administrator said the staff performing the task was responsible for ensuring proper hand hygiene was performed. Record review of the facility's policy Blood Glucose Monitoring revised on 06/2020, indicated . XI. After collecting the blood sample, briefly apply pressure to the puncture site to stop the bleeding. XII. wait the recommended manufacturer's timing for the blood glucose results then read the digital display. XIII. remove the test strip and discard. XIV. Remove gloves and wash hands . Record review of the facility's policy Hand Hygiene indicated . The facility considers hand hygiene the primary means to prevent the spread if infections . Hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand hygiene procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 25 of 30 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 06/05/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 23 residents (Resident #69) reviewed for physical environment. Residents Affected - Few The facility failed to ensure Resident #69 had a working call light in the room on 06/04/2024. This failure could place residents at risk of not being able to get assistance when needed. Findings included: 1.Record review of Resident #69's face sheet dated 06/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of partial traumatic amputation of left foot, Dementia (a disease in which causes a decline in a person's cognitive ability to perform day to day activities, Schizophrenia (mental disorder characterized by episodes of psychosis generally misperceptions of real life), Diabetes Mellitus (disease in which it causes too much sugar in the blood), and weakness. Record review of Resident #69's quarterly MDS dated [DATE] indicated he had a BIMS score of 8 which meant he had moderately impaired cognition. The MDS also indicated he required maximal assistance with toileting, transfers, dressing, and bathing, and he was independent with eating. Record review of Resident #69's care plan dated 02/09/24 indicated he had impaired cognitive function/dementia or impaired thought processes related to psychosis. During an observation and interview on 06/04/24 at 08:23 AM Resident #69 was sitting on the side his bed eating his breakfast. He said sometimes he had to wait a long time for someone to come assist him at times because his call light did not work. Resident #69 pressed the call light button and surveyor checked the light and there was no indication the light was working in the hallway. During an observation and interview on 06/04/24 at 08:33 AM The MDS Nurse was in Resident #69's room and pressed the call light and it failed to come on for her. She said she thought they just changed the light and went to get the maintenance man. During an observation on 06/04/24 at 08:38 AM The Maintenance Director and the Administrator came to Resident #69's room and confirmed the call light was not working because the light did not shine as it was working in the hallway when the button was pressed. The Maintenance man then fixed the light. During an interview on 06/05/24 at 03:45 PM the Maintenance Director said he was not aware Resident #69's call light did not work until the MDS Nurse notified him on 06/04/24. He said it should have been noticed during the morning rounds because the staff check each call light. The Maintenance Director said all staff were responsible for ensuring the call lights function and when they do not, he was responsible for fixing the call lights. The Maintenance Director said the failure of the call light not functioning could have placed Resident #69 at risk of getting hurt or to have to sit in feces longer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 26 of 30 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 06/05/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/24 at 04:03 PM The DON said she expected all the residents' call lights to function properly. She said the MDS Nurse was responsible for angel rounds on that room and the call light should have been checked and if not functioning properly she should have placed it in the maintenance book. The DON said the failure of the call light no functioning placed a risk for the Resident #69 having delayed care or a delay meeting his needs in an emergency. Residents Affected - Few Review of the facility's Communication-Call System revised 06/2020 indicated: Purpose To provide a mechanism for residents to promptly communicate with nursing staff. Policy The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities .Should the primary call system become inoperable for any reason, the Facility shall provide a bell for each resident room. Additionally, resident safety check rounds shall be conducted at least hourly and documented until the primary call system is operable again .If call bell is defective, it will be reported immediately to maintenance and replaced immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 27 of 30 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 06/05/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 8 resident rooms (Resident #8 and Resident #234) reviewed for clean and sanitary environment. Residents Affected - Few The facility failed to ensure Resident #8 and Resident #234's rooms did not have gnats. This failure could put all residents at risk of not having a clean, sanitary, and comfortable environment. Findings included: Record review of Resident #8's face sheet, dated 06/10/24, indicated Resident #8 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Atrial fibrillation {A fib} (an irregular and often very rapid heart rhythm), Depression (sadness), and Dementia (forgetfulness). Record review of Resident #8's quarterly MDS assessment, dated 05/06/24, indicated Resident #8 understood and was understood by others. Resident #8's BIMS score was 10, which indicated she was cognitively moderately impaired. Resident #8 required extensive assistance with bathing and independent with toileting, personal hygiene, transfer, dressing, bed mobility, and eating. Record review of Resident #8's comprehensive care plan dated 12/14/22 indicated she had behavior related to hoarding things in her drawer and closet. The intervention was for the staff to go through her belongings and help contain things/food in containers to be kept in the room. During an observation on 06/03/24 at 10:54 a.m., Resident #8 was sitting in her recliner with several gnats around her and in the room. Resident #8 said she saw the gnats and did not know why they were in her room. During an observation on 06/04/24 at 8:12 a.m., Resident #8 was in the bathroom. Several gnats were noted around her bed and chair. During an interview on 06/04/24 at 8:14 a.m., LVN D walked into Resident #8's room and saw the gnats. She said her room needed to be cleaned because of the gnats and odor. LVN D said Resident #8 does hoard things at times. She then got the DON and the housekeeper to come assist and clean Resident #8's room. During an interview on 06/04/24 at 10:19 a.m., Housekeeper K said she cleaned Resident #8's room like she cleaned all other rooms. She said she had not been told to do any extra checks on Resident #8's room for cleanliness. She said Resident #8 did refuse to have her room cleaned at times but she would get staff to help her. She said she had not cleaned her room today (06/05/24) but had on yesterday (6/04/24). 2. Record review of Resident #234's face sheet, dated 06/10/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included fracture of the pelvis (broken bone on the hip), depression (mood disorder that causes a persistent feeling of sadness), and high (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 28 of 30 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 06/05/2024 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 0925 blood pressures. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #234's admission MDS assessment, dated 06/03/24, indicated Resident #234 was understood and understood by others. Resident #234's BIMS score was 13, which indicated she was cognitively intact. The MDS indicated Resident #234 required assistance with bathing, toileting bed mobility, dressing, personal hygiene, transfers, supervision, and eating. Residents Affected - Few Record review of Resident #234's comprehensive care plan was not due to be completed before exit on 06/05/24. During an interview on 06/05/24 at 9:56 a.m., LVN D said she had seen some gnats and flies throughout the facility at times but nothing like yesterday (06/04/24) in Resident #8's room. She said this morning (06/05/24) Resident #234 complained about gnats in her room. She said she had not reported to housekeeping yet to come and clean Resident #234 but she would. During an interview on 06/05/24 at 10:12 a.m., Resident #234 said the gnats were bad. She said it was numerous gnats at times and other times it was only a few. She said she had not reported them until this morning (06/05/24) because she was tired of dealing with them and she wanted them gone. During an interview and observation on 06/05/24 at 10:16 a.m., the pest control technician was standing at the nurses' station. He said he had sprayed in the common areas (areas in the facility where residents may gather together with other residents, visitors, and staff or engage in individual pursuits, apart from their residential rooms), dining room, and kitchen. He said he was not told about any gnats. He showed his paperwork which revealed he sprayed the common area, dining room, and kitchen for flies and roaches. During an interview and interview on 06/05/24 at 4:06 p.m., the Maintenance Supervisor said he was not aware of any gnats. He said if he had known about the gnats, he would have treated them. He said all staff were responsible for reporting any pests they may have seen and placing the problem in the maintenance book. We reviewed the maintenance book for the last 5 days and only flies had been documented on 6/4/24 in the kitchen area. During an interview on 06/05/24 at 04:09 p.m., the DON said she was aware of the gnats. She said she saw them in Resident #8's room. She said all staff was responsible for reporting if they saw pests anywhere in the facility but the Maintenance Supervisor was the overseer. She reviewed the pest control visit for today (06/05/24) and it only revealed he sprayed for flies and roaches. She said she could see a potential hazard because a resident could attempt to hit the gnats and hit themselves or fall and if a visitor saw gnats, it could show a lack of cleanliness. During an interview on 06/05/24 at 4:49 p.m., ADON LVN F said she had seen gnats and flies at times. She said she had notified the Maintenance Supervisor by their department app or verbally. She said she would not want gnats in her home. She said it could look like the facility was not clean. During an interview on 06/05/24 at 5:03 p.m., the Administrator said he was aware of the gnats. He said pest control had been coming from time to time and he thought they were aware of the gnats. He said all staff should report if they see any pest but the Maintenance Supervisor was the overseer. He said having gnats could cause the residents not to be uncomfortable in their own home. Record review of the facility policy titled, Pest Control, dated 08/2020, indicated, To ensure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 29 of 30 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 06/05/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. Record review of the facility policy titled, Resident Rooms and Environment, dated 08/2020, indicated To provide residents with a safe, clean, comfortable and homelike environment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 30 of 30