Inspection·April 19, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ,Record review of the maintenance logs for March 2023 and April 2023 revealed no maintenance issues were noted for Resident #29's ceiling tile repair/replacement. During an interview on 04/19/2023 at 10:31 a.m., the Maintenance Director said he knew resident safety was important. He said Resident #29's ceiling tile needed to be replaced as soon as possible. He said Resident #29 had several [NAME] knacks in her room. He said Resident #29 was a tough resident to work with and was very particular about who went into her room. He said Resident #29 had no problem with him changing the ceiling tiles, but she was the kind of resident that did not want to be disturbed. The maintenance man said he needed to go into her room and change the tile when she was out of the room. He stated he planned to change the tiles while she was in the dining room or doing activities, but he always seemed to miss the opportunity to do so. The maintenance man said he did environmental rounds daily and he looked for issues that needed maintenance or repair. He stated he typically made a mental note, and he sometimes logged into his daily maintenance log when a maintenance job needed to be complete. He said Resident #29 never reported the tiles were sagging to him. He stated he was replacing the tiles as soon as he left the interview. He stated there was a stock of drop-down tiles in the shop that was on the facility grounds. He said management allowed him a sufficient budget to complete all maintenance projects. During an interview on 04/19/2023 at 10:57 a.m., the Administrator said normally he did environmental rounds daily. He said he was aware that Resident #29's ceiling tiles were sagging. He said he did not think the Maintenance Director had time to replace the tiles. He said that the maintenance man, was responsible for replacing the ceiling tiles. The Administrator said he knew the tiles were sagging since last week but did not know the exact day the tiles began to sag. The Administrator said the reason it took so long to replace them was Resident #29 was always in her bed. He said he looked for issues with the building regarding maintenance during his walkthrough daily. 2. Record review of a face sheet dated 04/20/23 revealed Resident #28 was [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's (a progressive disease that destroys memory and other important mental functions) and dysphagia (difficulty swallowing foods or liquids). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed she was rarely/never understood and rarely/never understood others. The MDS revealed Resident #28 BIMS was unable to be completed due to her being rarely/never understood. The MDS revealed Resident #28 had short-and-long term memory loss and moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #28 was total dependent for all ADLs. Record review of the care plan dated 05/31/21 revealed Resident #28 had an ADL self-care performance deficit related to severe cognition deficits, blindness, difficulty understanding others, and incontinent. Interventions included may utilize Geri chair for comfort and positioning but if unable may utilize wheelchair and required assistance by 1 staff to eat. 3. Record review of a face sheet dated 04/18/23 revealed Resident #33 was [AGE] year-old female admitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and aphasia (a language disorder that affects a person's ability to communicate). Record review of Resident #33's quarterly MDS assessment dated [DATE] revealed she rarely/never understood and rarely/never understood others. The MDS revealed Resident #33 BIMS was unable to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 2 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed due to her being rarely/never understood. The MDS revealed Resident #33 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #33 was total dependent for all ADLs. Record review of the care plan dated 04/05/23 revealed Resident #33 had an ADL self-care performance deficit related to dementia and Parkinson's disease. Interventions included assist of one staff member for locomotion while in Geri chair and assist of one staff member to feed her each meal. During an observation on 04/17/23 at 11:39 a.m., revealed Resident #28 and Resident #33 were in the dining room pulled up to tables. The edges near the lower part of the seat on both sides of Resident #28's Geri chair had a moderate amount of different colored, dried stains. The edges near the lower part of the seat on both sides of Resident #33's Geri chair had a large amount of different colored, dried stains. During an observation on 04/18/23 at 09:57 a.m., revealed Resident #28 and Resident #33 were in the dining room facing a television. The edges on both sides of Resident #28's Geri chair had a moderate amount of different colored, dried stains. The edges on both sides of Resident #33's Geri chair had a large amount of different colored, dried stains. During an observation on 04/18/23 at 11:52 a.m., revealed Resident #28 and Resident #33 were in the dining room pulled up to tables. The edges on both sides of Resident #28's Geri chair had a moderate amount of different colored, dried stains. The edges on both sides of Resident #33's Geri chair had a large amount of different colored, dried stains. 4. Record review of a face sheet dated 04/18/23 revealed Resident #4 was [AGE] year-old male admitted on [DATE] with diagnoses including sacral spina bifida (a gap in the bones in the spine but the spinal cord and meninges do not push through it) and artificial openings of gastrointestinal tract status (pathway by which food enters the body and solid wastes are expelled). Record review of Resident #4's annual MDS assessment dated [DATE] revealed he was usually understood and understood others. The MDS revealed Resident #4 had BIMS of 15 which indicated intact cognition. The MDS revealed Resident #4 required total dependence for all ADLs except eating which required extensive assistance. The MDS revealed Resident #4 received feeding tube for nutritional support. Record review of the care plan dated 04/05/23 revealed Resident #4 required an alternate method of nourishment due to nothing by mouth status and required use of feeding tube. Interventions included to hold enteral (a form of nutrition that is delivered into the digestive system as a liquid) nutrition times 2 hours for bowel rest from midnight to 2 a.m. two time a day for gastrostomy status and nutrition supplements give 65 milliliter/hour via percutaneous endoscopic gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach) times 19 hours. During an observation and interview on 04/17/23 at 12:07 p.m., revealed Resident #4 was laying in his bed on his left side. A feeding pump (a machine that delivers the enteral feeding to the gastrostomy) was attached to a metal pole. On the front side of the feeding pump a small amount of dried, beige substance was noted. At the base of the metal pole, a moderate amount of dried, beige substance was noted. Hanging on the hooks of the metal pole was a bag of water and a container of beige liquid which was the enteral feeding. Attempted to communicate with Resident #4 by writing on a piece of paper; then attempted Resident #4's tablet but was unable to interview him. The DON was called to Resident #4's room for assistance and Resident #4 wanted her in the room during interview. Unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 3 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 question Resident #4 about the dried enteral feeding on feeding pump and base of pole stand. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/19/23 at 1:49 p.m., LVN A said she had been working at the facility for a year. She said she worked the North Hall where Resident #28, Resident #33, and Resident #4 resided. LVN A said she did not know if cleaning the feeding pump and pole was designated to someone. She said the nurses were disconnecting and attaching the enteral feeding for medications and feedings, so the nurse should be making sure if it leaked then they cleaned it. LVN A said she honestly had not noticed the dried enteral feeding on the metal pole stand. LVN A said the night shift staff was supposed to clean patient equipment such as wheelchairs and Geri chairs. She said unclean equipment could potentially attract insects. Residents Affected - Some During an interview on 04/19/23 at 2:41 p.m., CNA B said she had been employed at the facility for 10 years. She said nurses and CNAs were responsible for cleaning the feeding pumps and poles. CNA B said wheelchairs and Geri chairs were supposed to be cleaned by CNAs but primarily night shift CNAs. She said it was important to have clean equipment for infection control. CNA B said residents were at risk for getting an infection from using unclean equipment. During an interview on 04/19/23 at 3:51 p.m., the DON said nurses should clean the feeding pump and poles but so could CNAs. She said it was important to have a sanitized environment to decrease the risk of infection. During an interview on 04/19/23 at 4:46 p.m., the Administrator said resident equipment like wheelchairs, Geri chairs, and feeding pumps were supposed to be cleaned by direct care staff on night shift. He said it was important to provide residents a homelike, sanitary environment. The ADM said currently there was no form or log for staff to sign daily or weekly to ensure direct care staff were cleaning equipment. The ADM said the charge nurses should be ensuring the equipment was getting cleaned. Record review of a facility Homelike Environment policy dated 02/21 revealed . residents are provided with a safe, clean, comfortable and homelike environment .the facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .clean, sanitary and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 4 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 4 of 14 residents reviewed for MDS accuracy. (Resident #13, Resident #16, Resident #7, and Resident #204) Residents Affected - Some 1. The facility failed to accurately document Resident #13's and Resident #16's antidepressant usage. 2. The facility failed to accurately document Resident # 7's PASRR status. 3. The facility failed to accurately document Resident #204's fall history on the MDS. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of an undated face sheet revealed Resident #13 was a 76- year-old-female, admitted on [DATE] with the diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells), depression (a group of conditions associated with the elevation or lowering of a person's mood), and COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). Record review of a MDS dated [DATE] for Resident #13 revealed a BIMS of 13, which indicated minimal memory or cognitive impairment. The MDS also revealed Resident #13 required limited staff assistance with bed mobility and no staff assistance for eating, transfers, and toileting. The MDS revealed Resident #13 received 7 days of antipsychotic medication between 03/15/2023 and 03/21/2023. The MDS revealed Resident #13 had not taken any antidepressants between 03/15/2023 and 03/21/2023. Record review of March 2023 consolidated physician's orders revealed Resident #13 had an order dated 04/23/2021 for nortriptyline (antidepressant) 25 mg to be administered nightly at bedtime. The March 2023 consolidated physician's orders revealed Resident #13 had no order for antipsychotic medications. Record review of Resident # 13's MAR dated 03/01/2023 to 03/31/2023 indicated Resident #13 had taken nortriptyline 25mg at bedtime each day. Resident #13's MAR dated 03/02/2023 to 03/31/2023 indicated no antipsychotic medications were administered during that time. 2. Record review of an undated face sheet revealed Resident #16 was a 70- year-old-male, admitted on [DATE] with the diagnoses heart failure (occurs when the heart muscle doesn't pump blood as well as it should), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a MDS dated [DATE] for Resident #16 revealed a BIMS of 15, which indicated no memory or cognitive impairment. The MDS also revealed Resident #16 required extensive staff assistance with bed mobility, transfers, and toileting. The MDS revealed Resident #16 had not taken any antidepressants between 01/31/2023 and 02/06/2023. Record review of January and February 2023 consolidated physician's orders revealed Resident #16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 5 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had an order dated 01/06/2021 for Cymbalta (antidepressant) 60mg delayed release capsules ordered 08/23/2021 to be administered once daily. Record review of Resident # 16's MAR dated 01/01/2023 to 01/31/2023 indicated Resident #16 had taken Cymbalta 60mg at 8 a.m. on 01/31/2023. Resident #16's MAR dated 02/01/2023 to 02/28/2023 indicated daily administration of Cymbalta 60mg. 3. Record review of an undated face sheet revealed Resident #7 was a 53- year-old-male, admitted on [DATE] with the diagnoses of schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of an annual MDS dated [DATE] for Resident #7 revealed a BIMS of 11, which indicated mild memory or cognitive impairment. The MDS also revealed Resident #7 was independent with bed mobility, transfers, and toileting. The MDS revealed Resident #7 was not PASRR level II positive and was not considered to have a serious mental illness and/or an intellectual disability. The MDS revealed mental illness and intellectual disability diagnoses. Record review of the PASRR Level II evaluation dated 11/26/2019 revealed Resident #7 was PASRR level II positive for mental illness and intellectual disability. The PASRR level II revealed Resident #7 had diagnoses of schizoaffective disorder, intellectual disability (a term used when there are limits to a person's ability to learn at an expected level and function in daily life), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder and anxiety (a feeling of fear, dread, and uneasiness). 4. Record review of a face sheet dated 04/18/23 revealed Resident #240 was [AGE] year-old female admitted on [DATE] with diagnoses including difficulty walking, weakness, muscle wasting and atrophy (shortening), and lack of coordination. Record review of Resident #204's quarterly MDS assessment dated [DATE] revealed she was understood and understood others. The MDS revealed Resident #204 had a BIMS of 03 which indicated severely impaired cognition and required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS revealed no falls since admission/entry or reentry or prior assessment, whichever was more recent. Record review of a care plan dated 04/16/23 revealed Resident #204 was at risk for falls related to gait/balance problems, psychoactive drug use, diagnosis of stroke, muscle wasting and atrophy of left and right shoulder, weakness, and unspecified lack of coordination. Falls on 09/10/22 (with injury), 11/25/22 (without injury), and 2/10/23 (fall without injury). Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance (initiated on 09/10/22) and non-skid tape applied to restroom floor for grip (initiated on 02/08/23). Record of the facility's incident reports by incident types dated 10/17/22 -04/17/23 revealed a witnessed fall for Resident #204 on 02/10/23 at 10:15 a.m. During an interview on 04/19/23 at 2:58 p.m., the MDS coordinator said she was responsible for MDSs and care plans for the facility. She said Resident #13 was on an anti-depressant not anti-psychotic. The MDS coordinator said Resident #13 was a data entry error. She said Resident #7 was PASRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 6 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some positive and had been for a long period of time. The MDS coordinator said Resident #7's 04/27/22 MDS should have been coded PASRR positive. She said after she reviewed Resident #16's MAR, he was on an antidepressant and had been on it during last 7 days of the assessment. The MDS coordinator said Resident #204's fall without injury on 02/08/23 should have been added to her 03/21/23 MDS. The MDS coordinator said the corporate MDS coordinator was currently doing an audit but there was no set schedule. She said she was responsible for 2 facilities and recently started working at the facility instead of from home. The MDS coordinator said she occasionally made data errors or missed things. She said incorrect information on MDSs could affect payer source and create an inadequate picture of residents. The MDS coordinator said she was primarily responsible for the MDSs, but the Social Worker and Activity Director had to input some information. She said the DON had to sign the MDSs due to her not being an RN, but her signature only signified the MDS was completed not necessarily correct. During an interview on 04/19/23 at 3:51 p.m., the DON said she expected the MDSs to be accurately coded. She said the MDS coordinator was responsible for the accuracy of the MDS. The DON said the corporate MDS coordinator was supposed to oversee the facility's MDS to ensure accurate MDSs. She said her signature on the paperwork only signified the MDS was completed. The DON said an inaccurate MDS affected payment amounts and development of the care plan. She said the residents could not receive the services they needed. During an interview on 04/19/23 at 4:46 p.m., the Administrator said he relied on the MDS coordinator to input the correct information on the MDSs. He said during daily morning meetings, he asked about the transmission of the MDSs being on time to the state. The ADM said he expected accurate and timely MDSs. He said incorrect MDSs affected the information transmitted to State. The ADM said the MDS coordinator was responsible for accurate MDSs and the corporate MDS was monitoring with frequent audits. Record review of a facility Certifying Accuracy of the Resident Assessment policy dated 11/19 revealed .the information captured on the assessment reflects the status of the resident during the observation period for that assessment .the Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 7 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 6 residents (Resident #4, Resident #19, Resident #33, Resident #42) reviewed for comprehensive person-centered care plans related to limited range of motion or contractures. The facility failed to care plan Resident #19's and Resident #33's limited range of motion. The facility failed to develop interventions for Resident #4 to address contractures and limited range of motion. The facility failed to implement an intervention to document meal consumption for Resident #19 and Resident #42. These failures could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. Findings included: 1. Record review of a face sheet dated 04/18/23 revealed Resident #4 was [AGE] year-old male admitted on [DATE] with diagnoses including sacral spina bifida (a gap in the bones in the spine but the spinal cord and meninges do not push through it), quadriplegia (paralysis of all four limbs or of the entire body below the neck), muscle wasting and atrophy (shortening), lack of coordination, contracture (a fixed tightening of muscle, tendons, ligaments, or skin), and cerebral palsy (a group of disorders that affect movement and muscle tone or posture). Record review of Resident #4's annual MDS assessment dated [DATE] revealed usually understood and understood others. The MDS revealed Resident #4 had BIMS of 15 which indicated intact cognition. The MDS revealed Resident #4 required total dependence for all ADLs except eating which required extensive assistance. The MDS revealed Resident #4 had functional limitation in range of motion to unilateral upper extremity and bilateral lower extremities. Record review of a care plan dated 04/05/23 revealed Resident #4 had cerebral palsy, quadriplegia, and spina bifida, muscle wasting and atrophy to multiple sites, lack of coordination, contracture of hand and muscle spasms. Interventions included maintain good body alignment to prevent contractures, OT/PT/ST to monitor/document and treat as indicated. The care plan did not reveal an intervention to prevent further decrease in range of motion. Record review of the Resident #4's consolidated physician's orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. During an observation on 04/17/23 at 12:07 p.m., revealed Resident #4 was lying in his bed on his left side. Resident #4's left arm was contracted, and his hand was clenched into a fist. Resident #4's lower extremities appeared to be shortening and his knees were contracted. No contracture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 8 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some management tools such as hand rolls or carrot hand splint (positions the finger away from the palm to protect the skin from moisture, pressure, and nail puncture) were noted in Resident #19's hand or in the room. 2. Record review of a face sheet dated 04/18/23 revealed Resident #19 was [AGE] year-old female and admitted on [DATE] with diagnoses including muscle wasting and atrophy (shortening), rheumatoid arthritis (a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints), spondylosis (a degenerative process affecting the vertebral disc and facet joints that gradually develops with age), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and protein-calorie malnutrition (undernutrition resulting from inadequate intake, digestion, or absorption of protein or calories). Record review of the annual MDS assessment dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS of 15 which indicated intact cognition and required supervision for eating, limited assistance for dressing, extensive assistance for bed mobility, transfer, toilet use, and personal hygiene, and total dependence for bathing. The MDS revealed Resident #19 required total dependence for locomotion on (moves between locations in her room and adjacent corridor on same floor) and off (moves to and returns from off-unit locations such as dining, activities, or treatment) the unit by wheelchair. The MDS revealed Resident #19 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. The MDS revealed Resident #19 did not have weight loss of 5% or more in the last month or 10% in the last 6 months. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS of 14 which indicated intact cognition and required extensive assistance for bed mobility, transfer, locomotion off unit, dressing, eating, and total dependence for locomotion on unit toilet use, personal hygiene, and bathing. The MDS revealed Resident #19 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. The MDS revealed Resident #19 did not have weight loss of 5% or more in the last month or 10% in the last 6 months. Record review of Resident #19's care plan dated 06/10/21 revealed she had Parkinson's disease, potential for impaired mobility, fall, and decline in cognitive status. Interventions included adaptive devices as recommended by therapy or MD and give medications as ordered by the physician. Record review of Resident #19's care plan dated 08/15/19 revealed she had an ADL self-care performance deficit related to pain, Parkinson's diseases, RA, multiple cardiac diagnosis, history of falling, muscle wasting and atrophy multiple sites. Interventions included ensure all articles needed to maintain/perform good oral/personal hygiene. The care plan did not reveal Resident #19's functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. Record review of Resident #19's consolidated physician's orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. Record review of Resident #19's care plan dated 04/05/23 revealed she was on a no salt on tray, low concentrated sweet diet, regular texture, and consistency related to diagnoses of protein calorie malnutrition, dysphagia (difficulty swallowing), oropharyngeal phase. Interventions included 02/16/23 offer ice cream with assistance twice a day times 30 days at lunch and dinner to prevent further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 9 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm weight loss, encourage meal completion and document amount consumed, offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Record review of Resident #19's weight chart dated 04/20/23 revealed on 04/05/23 she weighed 212.4 lbs. and 216.9lbs. on 11/09/22. Residents Affected - Some Record review of Resident #19's meal intake record dated February 2023 revealed 4 out 28 days of breakfast meals were not documented. The meal intake record revealed 4 out 28 days of lunch meals were not documented. The meal intake record revealed 15 out of 28 days of dinner meals were not documented. Record review of Resident #19's meal intake record dated March 2023 revealed 15 out of 31 days breakfast and lunch meals were not documented. The meal intake record revealed 22 out of 31 days of dinner meals were not documented. Record review of Resident #19's meal intake record dated April 2023 revealed 10 out of 18 days breakfast and lunch meals were not documented. Th meal intake record revealed 15 out 18 days dinner meals were not documented. During an observation 04/17/23 at 11:39 a.m., revealed Resident #19 was in the dining room sitting in her wheelchair at a table. Resident #19's left, and right hands were clenched into a fist. Resident #19 was assisted with her meal by staff members. During an observation and interview on 04/18/23 at 9:57 a.m., revealed Resident #19 was sitting in her recliner with a touch pad call light within reach. Resident #19's left, and right hands were clenched into fists. She said she had rheumatoid arthritis in her hands, and it had progressively gotten worse over the years. Resident #19 said she needed help with her hygiene and eating. During an observation on 04/19/23 at 12:49 p.m., revealed Resident #19 was in the dining room sitting in her wheelchair at a table. Resident #19 left and right hand were clenched into fist. Resident #19 had a spoon loosely held in her right hand and only her milk and tea cups were empty. Resident #19 started to glance around the dining room until she caught the DON's attention. The DON sat down and assisted Resident #19 with her meal. 3. Record review of a face sheet dated 04/18/23 revealed Resident #33 was [AGE] year-old female admitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #33's quarterly MDS assessment dated [DATE] revealed rarely/never understood and rarely/never understood others. The MDS revealed Resident #33 BIMS was unable to be completed due to being rarely/never understood. The MDS revealed Resident #33 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #33 was total dependent for all ADLs. The MDS revealed Resident #33 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremity on one side and lower extremities on both sides. The MDS revealed Resident #33 did not use a mobility device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 10 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of care plan dated 04/05/23 revealed Resident #33 had ADL self-care performance deficit related to dementia and Parkinson's disease. Interventions included assist of one staff member for locomotion while in Geri chair and assist of one staff member to feed her each meal, bedfast all or most of the time, and not ambulatory. The care plan did not reveal Resident #33 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremity on one side and lower extremities on both sides. Record review of Resident #33's consolidated physician orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. During an observation on 04/17/23 at 11:39 a.m., revealed Resident #33 was sitting in a Geri chair with a positioning wedge on her right side. Resident #33 was covered with a blanket and the surveyor was unable to visualize limited range of motion or contractures, tremors noted. 4. Record review of a face sheet dated 04/18/23 revealed Resident #42 was [AGE] year-old female admitted on [DATE] with diagnoses including mild protein calorie malnutrition (undernutrition resulting from inadequate intake, digestion, or absorption of protein or calories), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and pressure ulcer of sacral region, stage 3 (bed sores have gone through the second layer of skin into the fat tissue). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #42 was sometimes understood and sometimes understood others. The MDS revealed the BIMS was unable to be completed due Resident #42 being rarely/never understood. The MDS revealed Resident #42 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #42 required extensive assistance for eating. The MDS revealed Resident #42 did not have weight loss of 5% or more in the last month or 10% in the last 6 months. Record review of a care plan dated 01/16/23 revealed Resident #42 was on a regular diet and had diagnosis of protein calorie malnutrition. Interventions included 2/13/23 fortified foods at breakfast times for 30 days to prevent weight loss, encourage meal completion and document amount consumed. Record review of Resident #42's weight chart dated 04/18/23 revealed on 03/07/23 she weighed 91.5 lbs. and on 01/26/23 weighed 93.6 lbs. Record review of Resident #42's meal intake record dated February 2023 revealed 10 out 28 days of breakfast meals were not documented. The meal intake record revealed 16 out 28 days of lunch meals were not documented. The meal intake record revealed 24 out 28 days of dinner meals were not documented. Record review of Resident #42's meal intake record dated March 2023 revealed 16 out of 31 days breakfast meals were not documented. The meal intake record revealed 19 out 31 days of lunch meals were not documented. The meal intake record revealed 27 out 31 days of dinner meals were not documented. Record review of Resident #42's meal intake record dated April 2023 revealed 10 out 18 days of breakfast and lunch meals were not documented. The meal intake record revealed 18 out 18 days of dinner meals were not documented. During an interview on 04/19/23 at 1:49 p.m., LVN A said nursing staff was supposed to chart meal intake. She said nursing staff chart what they did to get paid for providing services. LVN A said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 11 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNAs charted meal intake, which was important to address weight decline, help decide if a resident needed a health shake, and to know if the resident received proper nutrition. She not documenting meal intake could provide the wrong information or picture to upper management, MD, or dietician. LVN A said nurses should make sure CNAs document meal intakes. During an interview on 04/19/23 at 2:41 p.m., CNA B said CNAs were responsible for documenting every meal intake in the computer system. She said after each meal CNAs were supposed to write percentages on a sheet in the dining room then input the information into the computer system as soon as possible. CNA B said it was important to document meal intakes to see if residents were eating, monitor weight loss, decide if they needed a supplement. She said good meal intake was important for nutrition and wound healing. During an interview on 04/19/23 at 2:28 p.m., the MDS coordinator said she was responsible for MDSs and care plans for the facility. She said Resident #4, Resident #19 and Resident #33 were coded on the MDS for limited range of motion. The MDS coordinator said some residents had limited range of motion without having contractures. She said if the limited range of motion did not affect their functional ability or there was no contracture diagnosis then she would not care plan the limited range of motion. The MDS coordinator said until recently she worked from home and could not assess residents limited range of motion. She said she did get a list of residents today (04/19/23) of all the residents with contractures and was in the process of making care plan problems. The MDS coordinator said she assessed Resident #4, Resident #19, and Resident #33 and they had limited range of motion with contractures which should have been care planned. She said the Rehab Director had also recently started so they had not developed a process to communicate with each other about resident with contractures and intervention in place by therapy that needed to be added to the care plan such as Resident #4's interventions. The MDS coordinator said the facility was going to start having daily skilled nursing meetings regarding residents with limited range of motion/contractures, therapy, and restorative care instead of weekly to help ensure residents care areas were properly care planned. During an interview on 04/19/23 at 3:51 p.m., the DON said residents with limited range of motion and/or contractures such as Resident #19 and Resident #33 should have had a care plan developed. She said if the limited range of motion was coded on the MDS, then it should have been care planned. The DON said the MDS coordinator, nurses, and interdisciplinary team were responsible for the development of comprehensive care plans. She said care plans were important to inform staff of what the resident needed, and the care plan was able to be viewed by CNAs in the computer system. The DON said CNAs were responsible for charting meal intakes. She said nurses were responsible to ensure it was happening. The DON said it helped determine weight loss causes. She said it was important to ensure the residents received adequate nutrition. During an interview on 04/19/23 at 4:46 p.m., the Administrator said in daily morning meetings they discussed issues and decided what should be care planned. He said care plans let all staff know the plan of care for the residents. The ADM said it was a type of communication between staff members, residents, and resident representatives. He said the MDS coordinator and nurses were responsible for the development of care plans. The ADM said the corporate MDS coordinator should be overseeing the process. Record review of the facility's Contracture list dated 04/17/23 revealed the list included Resident #4, Resident #19, and Resident #33. Record review of a facility Resident Mobility and Range of Motion policy dated 07/17 revealed .the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 12 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed .the care plan will include specific intervention s, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .the care plan will include the type, frequency, and duration of intervention, as well as measurable goals and objectives Record review of a facility Food and Nutrition Services policy dated 10/17 revealed .nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems .variations from usual eating or intake pattern will be recorded in the resident's medical record and brought to the nurse attention . Event ID: Facility ID: 675387 If continuation sheet Page 13 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 04/18/23 revealed Resident #33 was [AGE] year-old female admitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Residents Affected - Few Record review of Resident #33's quarterly MDS assessment dated [DATE] revealed she was rarely/never understood and rarely/never understood others. The MDS revealed Resident #33 BIMS was unable to be completed due to being rarely/never understood. The MDS revealed Resident #33 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #33 was total dependent for all ADLs. The MDS revealed Resident #33 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremity on one side and lower extremities on both sides. Record review of the care plan dated 04/05/23 revealed Resident #33 had an ADL self-care performance deficit related to dementia and Parkinson's disease. Interventions included assist of 1 staff member for bathing and personal hygiene. During an observation on 04/17/23 at 11:39 a.m., revealed Resident #33 was sitting in a Geri chair with a positioning wedge on her right side. Resident #33 was covered with a blanket and tremors noted. Resident #33 had a moderate amount of blonde facial hair to her upper lip and chin. Resident #33 was in a hospital gown with an oily hair in a ponytail. During an observation on 04/18/23 at 09:57 a.m., revealed Resident #33 was sitting in a Geri chair, in the dining room facing a television. Resident #33 had a moderate amount of blonde facial hair to her upper lip and chin. Resident #33 was in a hospital gown with an oily hair in a ponytail. Record review of the undated North Hall Shower Schedule revealed . [Resident #33] .Nights Mondays, Wednesdays, Fridays Record review of CNA/LVN Weekly Bath Checklist dated 01/23 revealed Resident #33 received 2 (1/2/23 and 1/13/23) out of 13 scheduled bed baths. Record review of CNA/LVN Weekly Bath Checklist dated 02/23 revealed Resident #33 received 0 of 12 scheduled bed baths. Record review of CNA/LVN Weekly Bath Checklist dated 03/23 revealed Resident #33 received 5 (3/1/23, 3/7/23, 3/14/23, 3/20/23, 3/25/23) out of 14 scheduled bed baths. Record review of CNA/LVN Weekly Bath Checklist dated 04/01/23- 04/18/23 revealed Resident #33 received 3 (4/12/23, 4/15/23, 4/17/23) out of 7 scheduled bed baths. Record review of CNA/LVN Weekly Bath Checklist dated 04/12/23, completed by CNA C, revealed .[Resident #33] .facial hair not removed Record review of CNA/LVN Weekly Bath Checklist dated 04/15/23, completed by CNA D, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 14 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 .[Resident #33] .facial hair not removed . Level of Harm - Minimal harm or potential for actual harm Record review of CNA/LVN Weekly Bath Checklist dated 04/17/23, completed by CNA C, revealed .[Resident #33] .facial hair not removed . Residents Affected - Few During an interview on 04/19/23 at 1:49 p.m., LVN A said Resident #33 did not reject care and she would probably not like to have facial hair. She said women should be shaved, not only on bath days but as needed. LVN A said the CNAs were responsible for shaving and bathing/showering of residents. She said nurses should ensure CNAs were shaving and bathing residents on scheduled days. LVN A said she had not noticed Resident #33's facial hair but it would be embarrassing. During an interview on 04/19/23 at 2:41 p.m., CNA B said CNAs were responsible for showers, shaving, and nail care of residents. She said showers were documented on a shower sheet and in their computer system. CNA B said shaving should happen on shower days and as needed. She said resident's' shower days were posted in the shower book. CNA B said Resident #33's shower time was on the night shift. She said it would be embarrassing to have a beard and not be able to take care of it. During an interview on 04/19/23 at 3:51 p.m., the DON, with the ADON present, said CNAs were responsible for facial hair and bed baths/showers. She said charge nurses should be ensuring ADL care was happening. The DON said CNAs should document on bath sheets if shaving occurred. She said Resident #33 would not like to have facial hair. The DON said providing ADL care for dependent residents was important to assess status and changes. She said women with unwanted facial hair was a dignity issue. The DON said bathing was important for cleanliness and hygiene. During an interview on 04/19/23 at 4:46 p.m., the Administrator he expected the shower schedule to be followed and women to be shaved as needed. He said CNAs should provide scheduled showers and shave men and women during. The ADM said the ADON, and charge nurse ensured that was happening. He said it was important for cleanliness and dignity to provide ADL care to dependent residents. Record review of the facility's Activities of Daily Living, Supporting policy dated 03/18 revealed, .residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy and procedure on care of Fingernails/Toenails, care of dated revised February 2018 revealed that the purpose of the procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Under General Guidelines, nail care includes daily cleaning and regular trimming. Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for residents who are unable to carry out activities of daily living receives the for 2 of 16 residents reviewed for ADLs (Residents #10, Resident #33). The facility did not clean or trim Resident #10's fingernails. The facility failed to ensure Resident #33 did not have facial hair and received schedule shower/bed baths. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 15 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 breakdown, feelings of poor self-esteem, lack of dignity and health. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Few 1. Review of Resident #10's electronic face sheet dated 04/29/2022 revealed he was admitted to the facility on [DATE] with diagnoses of paralytic syndrome (symmetric, ascending weakness), muscle wasting and atrophy (Muscle atrophy is the wasting or thinning of muscle mass), dysphagia (swallowing difficulties), oropharyngeal phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat), lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), cognitive communication deficit (difficulty with thinking and how someone uses language), diffuse traumatic brain injury (tearing of the brain's long connecting nerve.) Record review of Resident #10's annual MDS dated [DATE] revealed a BIMS with a score of 3, which indicated Resident #10 had severely impaired cognition. The MDS also revealed Resident #10 required total dependance with personal hygiene. Resident #10 required one-person physical assistance with personal hygiene, including nail hygiene. During an observation and interview on 04/17/2023 at 9:52 a.m. Resident #10 was observed lying in his bed. He appeared unkempt and had long dirty fingernails. Fingernails were approximately half an inch long with black substance underneath. In a direct question interview at the same time, he stated the staff did not trim his fingernails, but that he would like them trimmed. During an interview and observation on 04/18/2023 at 9:24 a.m. revealed all of Resident #10's fingernails were long with dirt underneath. He stated he wanted his fingernails cut. He said he did not remember the last time he had his nails cut. He stated he did not like that they were long and dirty. He nodded his head up and down to affirm when he was asked if it was embarrassing to him. During an interview with the DON on 04/19/2023 at 9:01 a.m. she stated there should be a schedule for residents fingernails to be cleaned and trimmed. She stated residents' nails should be cleaned and trimmed on Sundays. She stated that trimming of nails was an infection control issue. She stated that if a resident had long and dirty nail beds they would be placed at risk for infection or disease. She stated residents should not have dirty nail beds and should be cleaned by staff if a resident's nail beds were observed to be dirty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 16 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 6 residents (Resident #4, Resident #19, Resident #33) reviewed for range of motion and mobility, in that: Resident #4 who had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to unilateral upper extremity and bilateral lower extremities was not provided treatment and services to prevent further decrease in range of motion. Resident #19 who had functional limitation in range of motion to bilateral upper extremities was not provided treatment and services to prevent further decrease in range of motion. Resident #33 who had functional limitation in range of motion to unilateral upper extremity and bilateral was not provided treatment and services to prevent further decrease in range of motion. These failures had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities. Findings included: 1. Record review of a face sheet dated 04/18/23 revealed Resident #4 was [AGE] year-old male admitted on [DATE] with diagnoses including sacral spina bifida (a gap in the bones in the spine but the spinal cord and meninges do not push through it), quadriplegia (paralysis of all four limbs or of the entire body below the neck), muscle wasting and atrophy (shortening), lack of coordination, contracture (a fixed tightening of muscle, tendons, ligaments, or skin), and cerebral palsy (a group of disorders that affect movement and muscle tone or posture). Record review of Resident #4's annual MDS assessment dated [DATE] revealed usually understood and understood others. The MDS revealed Resident #4 had BIMS of 15 which indicated intact cognition. The MDS revealed Resident #4 required total dependence for all ADLs except eating which required extensive assistance. The MDS revealed Resident #4 had functional limitation in range of motion to unilateral upper extremity and bilateral lower extremities. Record review of a care plan dated 04/05/23 revealed Resident #4 had cerebral palsy, quadriplegia, and spina bifida, muscle wasting and atrophy of multiple sites, lack of coordination, contracture of hand and muscle spasms. Interventions included maintain good body alignment to prevent contractures, OT/PT/ST to monitor/document and treat as indicated. The care plan did not reveal interventions to prevent further decrease in range of motion. Record review of Resident #4's consolidated physician's orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. During an observation on 04/17/23 at 12:07 p.m., revealed Resident #4 was lying in his bed on his left side. Resident #4's left arm contracted, and his hand was clenched into a fist. Resident #4's lower extremities appeared to have shortened and his knees contracted. No contracture management tools (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 17 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some such as hand rolls or a carrot hand splint (positions the finger away from the palm to protect the skin from moisture, pressure, and nail puncture) were noted in Resident #4's hand or in the room. During an observation on 04/18/23 at 09:57 a.m., revealed Resident #4 was lying in his bed on his left side. Resident #4's left arm contracted, and his hand was clenched into a fist. Resident #4's lower extremities appeared to have shortened and his knees contracted. No contracture management tools such as hand rolls or a carrot hand splint (positions the finger away from the palm to protect the skin from moisture, pressure, and nail puncture) were noted in Resident #4's hand or in the room. During an observation on 04/18/23 at 11:52 a.m., revealed Resident #4 was in a motorized wheelchair, in the facility's hallway. Resident #4 was operating the motorized wheelchair with his right hand. Resident #4's left arm contracted, and his hand was clenched into a fist. Resident #4's lower extremities appeared to have shortened and his knees contracted. No contracture management tools such as hand rolls or a carrot hand splint (positions the finger away from the palm to protect the skin from moisture, pressure, and nail puncture) was noted in Resident #4's left hand. During an observation on 04/18/23 at 2:22 p.m., revealed Resident #4 was in a motorized wheelchair, in his room. Resident #4 was operating the motorized wheelchair with his right hand. Resident #4's left arm contracted, and hand clenched into a fist. Resident #4 lower extremities appeared shortening and knees contracted. No contracture management tools such as hand rolls or carrot hand splint (positions the finger away from the palm to protect the skin from moisture, pressure, and nail puncture) was noted in Resident #4's left hand. 2. Record review of a face sheet dated 04/18/23 revealed Resident #19 was [AGE] year-old female and admitted on [DATE] with diagnoses including muscle wasting and atrophy (shortening), rheumatoid arthritis (a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints), and spondylosis (a degenerative process affecting the vertebral disc and facet joints that gradually develops with age). Record review of the annual MDS assessment dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS of 15 which indicated intact cognition and required supervision for eating, limited assistance for dressing, extensive assistance for bed mobility, transfer, toilet use, and personal hygiene, and total dependence for bathing. The MDS revealed Resident #19 required total dependence for locomotion on (moves between locations in her room and adjacent corridor on same floor) and off (moves to and returns from off-unit locations such as dining, activities, or treatment) unit by wheelchair. The MDS revealed Resident #19 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS of 14 which indicated intact cognition and required extensive assistance for bed mobility, transfer, locomotion off unit, dressing, eating, and total dependence for locomotion on unit toilet use, personal hygiene, and bathing. The MDS revealed Resident #19 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. The MDS revealed Resident #19 required increased assistance with ADLs for previous MDS assessment on 05/11/22. Record review of Resident #19's care plan dated 06/10/21 revealed she had Parkinson's disease, potential for impaired mobility, fall, and a decline in cognitive status. Interventions included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 18 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 0688 adaptive devices as recommended by therapy or MD and to give medications as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #19's care plan dated 08/15/19 revealed she had an ADL self-care performance deficit related to pain, Parkinson's diseases, RA, multiple cardiac diagnosis, history of falling, muscle wasting and atrophy multiple sites. Interventions included to ensure all articles needed to maintain/perform good oral/personal hygiene. The care plan did not reveal Resident #19's functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremities on both sides. Residents Affected - Some Record review of Resident #19's consolidated physician orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. During an observation 04/17/23 at 11:39 a.m., revealed Resident #19 was in the dining room sitting in her wheelchair at a table. Resident #19's left, and right hands were clenched into fists. Resident #19 was assisted with her meal by staff members. During an observation and interview on 04/18/23 at 9:57 a.m., revealed Resident #19 was sitting in her recliner with a touch pad call light within reach. Resident #19's left, and right hands were clenched into fists. She said she had rheumatoid arthritis in her hands, and it had progressively gotten worse over the years. Resident #19 said she needed help with her hygiene and eating. She said occasionally staff members placed the carrot hand splints in her hands at night, but they always fell out, so it did no good. During an observation on 04/18/23 at 2:25 p.m., revealed Resident #19 was sitting in her recliner watching television. Resident #19's left, and right hands were clenched into fists. No hand splints were noted in Resident #19's hands. During an observation on 04/18/23 at 3:45 p.m., revealed Resident #19 was sitting in her recliner watching television. Resident #19's left, and right hands were clenched into fists. No hand splints were noted in Resident #19's hands. 3. Record review of a face sheet dated 04/18/23 revealed Resident #33 was [AGE] year-old female admitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #33's quarterly MDS assessment dated [DATE] revealed she was rarely/never understood and rarely/never understood others. The MDS revealed Resident #33 BIMS was unable to be completed due to being rarely/never understood. The MDS revealed Resident #33 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #33 was totally dependent for all ADLs. The MDS revealed Resident #33 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremity on one side and lower extremities on both sides. Record review of care plan dated 04/05/23 revealed Resident #33 had ADL self-care performance deficit related to dementia and Parkinson's disease. Interventions included assist of one staff member for locomotion while in Geri chair and assist of one staff member to feed her each meal, bedfast all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 19 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or most of the time, and not ambulatory. The care plan did not reveal Resident #33 had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to her upper extremity on one side and lower extremities on both sides. Record review of Resident #33's consolidated physician orders dated 04/18/23 did not reveal limited range of motion/contracture management orders. During an observation on 04/17/23 at 11:39 a.m., revealed Resident #33 was sitting in a Geri chair with a positioning wedge on her right side. Resident #33 lower half of her body was covered with a blanket, so the Surveyor was unable to visualize limited range of motion or contractures, and tremors were noted. During an observation on 04/18/23 at 09:58 a.m., revealed Resident #33 was asleep, sitting in a Geri chair with her right arm hanging outside of the chair. Resident #33 lower half of her body was covered with a blanket, so the Surveyor was unable to visualize limited range of motion or contractures, and tremors were noted. During an interview on 04/19/23 at 11:52 a.m., the DOR said she had been in this position since 03/15/23 but had worked for the facility in another capacity. She said the facility ran an activities of daily living significant change report and if a resident had a decline, but therapy was not recommended then the ADON decided which resident received restorative care. The DOR said Resident #4 received OT and ST six months at a time for maintenance, not so much for improvement. She said according to the therapy notes, Resident #4's goals were to tolerate passive ROM to the upper extremities, wear a left-hand roll for up to 5 hours, sit up in the Geri chair for 4 hours, and complete bed mobility with moderate assistance. She said nurses were responsible for doing those tasks, and therapy was responsible for increasing the tolerance time. The DOR said she did not know if or where staff documented implementing those goals and how long he tolerated the tasks. The DOR said when she looked in the system, Resident #33 had never been evaluated or treated by therapy and was not on restorative services. She said Resident #19 had been on OT from January-February 2023 but did not show much improvement from therapy. She said Resident #19 had been on restorative services but did not know if she currently was. The DOR said Resident #19's OT discharge summary did not mention hand rolls/splints, but nurses were responsible for placing those on the resident. During an interview on 04/19/23 at 1:49 p.m., LVN A said Resident #4 did have contractures, but she could not recall how the facility managed them. She said sometimes the treatment administration record would have an order for splint devices but Resident #4 did not have an order for splints. LVN A said she had not put splints in Resident #4 left hand. She said she did not know if CNAs or restorative did passive ROM with him. She said Resident #33 did have limited ROM but did not recall seeing her receive therapy or restorative services. LVN A said Resident #19 had carrot splints in her room and after she reviewed the chart, Resident #19 did not have an order for them. She said she did not know who was on the restorative or contracture list. LVN A said providing services to residents with limited range of motion or contractures was important to maintain their quality of living, movement, independence, ADL assistance level, and circulation. She said it could affect their mentality and quality of life. LVN A said if there was an order for placement of contracture tools, then it was the nurse's responsibility to do it. During an interview on 04/19/23 at 3:51 p.m., the DON said the facility did not have a process in place to ensure residents with limited range of motion or contractures received services to prevent further restriction. She said now the CNAs would be responsible for keeping resident's hands clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 20 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and placement of hand rolls. The DON said before the survey, there were no orders for CNAs to follow and they were currently putting those orders in the system. She said CNAs probably were not doing those interventions because they did not know what to do without an order. The DON said even if a resident was on restorative services, the CNAs were responsible for contracture orders. She said the facility was going to add a place in the computer system to chart that the contracture orders were getting done by the CNAs. The DON said management would do follow throughs to make sure the hand cleaning and hand roll placement was getting done. She said nurses would be primarily responsible overseeing the CNAs. The DON said it was important to provide contracture management to ensure high function mobility. She said not managing contractures or limited range of motion increased contractures and decreased mobility. During an interview on 04/19/23 at 4:46 p.m., the Administrator said he had to refer to the nursing management regarding contractures and limited range of motion. Record review of the facility's Contracture list dated 04/17/23 revealed the list included Resident #4, Resident #19, and Resident #33. Record review of a facility Resident Mobility and Range of Motion policy dated 07/17 revealed .residents will not experience an avoidable reduction in range of motion .residents with limited range of motion will receive treatment and service to increase and/or prevent a further decrease in ROM .residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .the care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed .the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .intervention may include therapies, the provision of necessary equipment, and/or exercises .documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 21 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 - Few 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 interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #204) reviewed for psychotropic medications. The facility failed to ensure Resident #204 had an appropriate diagnosis for usage of Olanzapine (antipsychotic). This failure could place residents at risk of being over-medicated or experience undesirable side effects. Findings included: Record review of a face sheet dated 04/18/23 revealed Resident #240 was [AGE] year-old female admitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that interferes with daily life), anxiety (persistent and excessive worry that interferes with daily activities), hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste). Record review of Resident #204's quarterly MDS assessment dated [DATE] revealed she was understood and understood others. The MDS revealed Resident #204 had a BIMS of 03 which indicated severely impaired cognition and required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS revealed Resident #204 did not have an acute change in mental status from the resident's baseline. The MDS revealed Resident #204 did not show signs of inattention (distraction), disorganized thinking (speak very quickly and stumble over your words so that other people may find it difficult to understand what you're saying) and altered level of consciousness (a state of reduced alertness or inability to arouse due to low awareness of the environment). The MDS revealed Resident #204 did not have hallucination or delusions. The MDS revealed Resident #204 did not have physical, verbal, or other behavioral symptoms. The MDS revealed Resident #204 received an antipsychotic, antianxiety, and antidepressant in last 7 days. Record review of Resident #204's care plan dated 03/09/22 revealed the resident had a diagnosis of hallucinations unspecified and currently took Olanzapine. Interventions reflected to monitor/record/report new onset signs/symptoms of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout day, communication decline, disorientation, lethargy, restlessness, and agitation. Altered sleep cycle, dehydration, infection, delusion, and hallucination. Provide medications to alleviate agitation as ordered by MD. Record review of Resident #204's consolidated physician's order dated 04/18/23 revealed Olanzapine tablet 5MG, 1 tablet by mouth at bedtime related to hallucinations, unspecified dated 01/10/23. Record review of Resident #204's Consent for Antipsychotic or Neuroleptic Medication Treatment dated 02/02/22 revealed .[MD E] .Internal Medicine Specialty .treating this individual since 02/02/22 .has following psychiatric condition and/or maladaptive behavior: Hallucinations .diagnosis is based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 22 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Panola County Nursing & Rehabilitation 501 Cottage Rd Carthage, TX 75633 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 - Few on the following dominant characteristics exhibited: hallucinations .course of therapy with antipsychotic medication: Olanzapine 5MG tablet by mouth at night .need for, and benefit of, the proposed treatment: decreased hallucinations . Record review of Resident #204's Consent for Psychoactive Medication Therapy dated 02/02/22 revealed . Olanzapine .specific condition to be treated .other: hallucinations .antipsychotic .prolonged treatment . Record review of a pharmacy recommendation by the consultant pharmacist, dated 10/01/22-10/31/22 revealed Resident #204 was currently receiving Olanzapine tablet 5MG, 1 tablet by mouth at bedtime related to hallucinations, Unspecified. Diagnosis was needed to support therapy. Please assist. No follow-through noted after recommendation. During an interview on 04/19/23 at 2:41 p.m., LVN A said she did not know if hallucination was an appropriate diagnosis for Olanzapine. LVN A said Resident #204 did not hallucinate, that she could recall. She said a diagnosis needed to match the correct medication. LVN A said if she received a medication with an incorrect diagnosis, she notified the ADON or MDS coordinator. She said having the correct diagnosis for use of a medication was important to know why you are giving the medication. During an interview on 04/19/23 at 2:58 p.m., the MDS coordinator said a diagnosis of hallucinations only was not an appropriate diagnosis for usage of Olanzapine. She said she got diagnoses from hospital records and other facility paperwork to add to the resident's record. The MDS coordinator said the DON added the diagnosis of hallucinations on Resident #204 when she admitted on [DATE]. She said the ADON, and DON reviewed admission orders to ensure appropriate diagnoses with medications. The MDS coordinator said she only assigned a primary diagnosis on admission and hallucination was not Resident #204's primary diagnosis. During an interview on 04/19/23 at 3:51 p.m., the DON said diagnosis of hallucinations only, was not appropriate to prescribe Olanzapine. She said she added hallucination as an indication for use for Olanzapine due to it being the only diagnosis on admission paperwork. The DON said she believed Resident #204 was on Olanzapine prior to admission to the facility. The DON said Resident #204 hallucinated. She said she knew nursing staff were not charting when Resident #204 hallucinated. The DON said Resident #204 was not on psychiatric services and her primary doctor managed the antipsychotic. She said she would talk to family and resident about being seen by psych services. The DON said it was important to have an appropriate diagnosis to make sure they treated the indication of use or reason for the medication. She said she, the DON, was responsible for overseeing this process. Record review of a facility Antipsychotic Medication Use policy dated 12/16 revealed .resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident .antipsychotic medication shall generally be used for the following conditions .Schizophrenia .Schizo-Affective disorder .Schizophreniform disorder .Delusional disorder .Mood disorder .Psychosis in the absence of dementia .medical illness with psychotic symptoms and/or treatment-related psychosis or mania .Tourette's Disorder .Huntington Disease .Hiccups .Nausea and vomiting associated with cancer or chemotherapy .diagnoses alone do not warrant the use of antipsychotic medication FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675387 If continuation sheet Page 23 of 23