Health inspection·September 20, 2023

F 0578 During an interview on [DATE] at 3:47 PM, Resident #16 verified he had signed the DNR. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 9:46 AM, the DON stated Resident #16 should have been coded as a DNR. The DON stated the social worker would have been responsible for taking care of the DNR and she no longer worked at the facility, so it would fall on nursing staff now. The DON stated the process was for the social worker to talk to the resident and have them fill out a request and sign it. Residents Affected - Few The social worker would then give the form to the DON and the DON would reveal it to the family and get the physician order. The DON stated the importance of having the correct code status was so the facility could honor the residents wishes and staff could follow through with their wishes. The DON stated Resident #16 was admitted to the facility already on hospice services from the hospital and the admitting nurse would have been responsible for putting in the hospice order. The DON stated she was responsible for auditing the code statuses on charts monthly and during care plan meetings. The DON stated there was no DNR in Resident #16's folder, so she did not know Resident #16 was a DNR. During an interview on [DATE] at 1:43 PM, the ADM stated he expected residents to have the correct code status on their charts. The ADM stated the importance of the correct code status was to follow the patient's wishes and measures adequately. Record review of the facilities policy on Do Not Resuscitate Order, last revised on [DATE], indicated . the DNR order takes effect at the time the order is issued, provided the order is placed in the patient's medical record as soon as practicable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 2 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 interviews, and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents (Residents #16) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately code the ostomy status on Resident #16. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #16's face sheet, dated 09/19/2023, indicated Resident #16 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depression (loss of interest in activities) and osteoarthritis (flexible tissue at the end of bones wear down). Record review of Resident #16's order summary report, dated 1215/2021, indicated Resident #16 had a foley catheter. The order summary did not indicate Resident #16 had an ostomy. Record review of the quarterly MDS dated [DATE], indicated Resident #16 understood others and made himself understood. The assessment indicated Resident #16 was cognitively intact with a BIMS score of 15 that indicates intact cognition. Section H of the MDS indicated Resident #16 had a indwelling catheter and an ostomy (pouching system that collects waste diverted from the biological system). Record review of Resident #16's care plan, with a revision date of 06/20/2022, indicated Resident #16 had an indwelling catheter. The care plan did not indicate Resident #16 had an ostomy. During an observation and interview on 09/18/23 at 9:56 AM, Resident #16 was in his bed watching TV. Resident #16 did not have an ostomy. Resident #16 stated he had never had an ostomy. During an interview on 09/20/23 at 9:46 AM, the DON stated the MDS nurse was responsible for completing the MDS and she was currently on vacation. The DON stated Resident #16 does not have an ostomy and it should not have been checked. The DON stated the process was for regional to spot check and complete quarterly reviews on the MDS. The DON stated she does not know why Resident #16 was marked to have an ostomy, unless the MDS nurse marked the wrong line. The DON stated the importance of having the MDS coded correctly was so it would provide an accurate picture of the resident's care. The DON stated if the MDS was not coded accurately then inaccurate care could have been provided to Resident #16. During an interview on 09/20/23 at 1:43 PM, the ADM stated he expected the MDS to be correct. The ADM stated the importance of the MDS was to make sure the facility was transmitting to CMS accurately. During an interview on 09/20/23 at 11:29 AM, the facility's policy was requested on MDS and not provided. The Regional nurse stated there was no policy, and they are to follow the RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 3 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was updated and revised to reflect she was on PASRR services. This failure could cause the resident to not receive the correct care impacting the patient's health and/or serious illness. Findings include: Record review of Resident #43's face sheet dated 09/20/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had a diagnoses which included paraplegia (damage to the trunk, legs, and pelvic organs), hydrocephalus (fluid on the brain that causes damage) and lumbar spina bifida without hydrocephalus (spinal cord does not form properly). Record review of Resident #7's Comprehensive MDS dated [DATE] indicated Resident #43 made herself understood and had the ability to understand others. Resident #43 had a BIMS score of 13 which indicated intact cognition. Record review of Resident #43's care plan initiated on 05/31/23 did not indicate PASRR services. Record review of Resident #43's PASRR level I screening dated 05/05/23 indicated she had an Intellectual Disability. Record review of Resident #43's PASRR II evaluation dated 07/27/23 indicated specialized services were recommended for self-monitoring and coordinating of medical treatments. Record review of Resident #43's PASRR Comprehensive Plan indicated an IDT meeting was completed on 08/29/23 to discuss all specialized services and supports and agreed on physical therapy, occupational therapy, habilitation coordination, independent skills training, and behavioral support. During an interview on 09/20/23 at 9:46 AM, the DON stated PASRR services should have been care planned on Resident #43 and the MDS coordinator was responsible. The DON stated the MDS coordinator was currently on vacation. The DON stated the process in place was for staff to review care plans during the quarterly IDT meetings and update them. The DON stated Resident #43 was admitted to the facility on [DATE], and the facility had not completed a quarterly meeting yet. The DON stated Resident #43 had monthly PASRR meetings and the importance of care planning PASSR was for the resident to receive adequate care. The DON stated if PASRR services were not care planned then the resident could be at risk of not getting the services she needed. During an interview on 09/20/23 at 1:43 PM, the ADM stated the MDS coordinator was responsible for care planning PASRR services on Resident #43 and he expected care plans to be done correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 4 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 Record review of the facility's policy titled, Comprehensive Care Planning (no date) indicated, .The facility will 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, and mental and psychosocial needs that are identified in the comprehensive assessment . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 5 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 15 (Resident #26) residents reviewed for accidents hazards and supervision. The facility failed to properly store wound cleanser leaving it on Resident #26's bedside table. The facility failed to properly store wound cleanser leaving it in Resident #'26's dresser. This failure could place residents at an increased risk for injury. The findings included: Record review of Resident #26's face sheet dated 09/21/2023 revealed, Resident #26 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (plaque buildup in the arteries), lumbago (low back pain) and unspecified diastolic congestive heart failure (heart muscle does not pump enough blood). Record review of Resident #26's Quarterly MDS dated [DATE] indicated he was able to make himself understood and he had the ability to understand others. The MDS indicated Resident #26 had a BIMS score of 15 for intact cognition. Record review of the safety data sheet for Medline Skintegrity wound cleanser indicated to take proper precautions to ensure your own health and safety before attempting rescue and providing first aid. Consult a physician and show this safety data sheet to the doctor in attendance. For Ingestion: Never give anything by mouth to an unconscious person. Consult a physician if necessary. For prolonged exposure, use appropriate goggles, protective clothing, and gloves. Eye Protection: None required for normal use. For prolonged exposure, use appropriate goggles, protective clothing, and gloves. Handle in accordance with good industrial hygiene and safety practices. Wash thoroughly with soap and water after handling and before eating, drinking, or using tobacco. Safety shower and eye wash should be available close to work areas. During an observation and interview on 09/18/23 at 9:16 AM, Resident #26 had a bottle of wound cleaner sitting on his bed side table labeled Medline Skintegrity wound cleanser. Wound cleaner did not reveal it was medicated. Resident #26 stated it was for a wound on his buttock. During an observation and interview on 09/18/23 at 2:19 PM, Resident #26 stated a staff member had picked up his wound care spray, but he had an additional bottle in his dresser that he revealed. During an interview on 09/20/23 at 9:46 AM, the DON stated Resident #26 was not allowed to have wound care spray in his room. The DON stated other residents could have picked up the wound care spray and misused it, then it would have caused a reportable. During an interview on 09/20/23 at 1:43 PM, the ADM stated residents were not allowed to have wound care spray in their room. The ADM stated wound care spray was a combustible and could result in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 6 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 harm if not used correctly. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy on, Items Not Allowed in Resident Room:, no date, indicated A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled Keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 7 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #9) of 15 residents reviewed for urinary incontinence. The facility failed to provide timely treatment of Resident #9's Urinary Tract Infection. This failure could place residents with Urinary Tract Infections at increased risk of not receiving appropriate treatment, which could result in severe illness or hospitalization. Findings included: Record review of the undated face sheet indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of the physician's orders dated 9/19/23 indicated Resident #9 had with diagnoses that included: Diabetes Mellitus 2 (a chronic condition that affects the way the body processes sugar, the body either does not produce enough insulin, or it resists insulin), Urinary Tract Infection (an infection in the urinary system, kidneys, bladder, or urethra), quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down), dementia (impairment in memory and judgement). The physician's orders did not indicate she was on antibiotic or treatment for a UTI. The physician's orders indicated: 9/6/23 May have UA with C&S one time only for burning/odor with urination Record review of the admission MDS dated [DATE] indicated Resident #9 had clear speech, was understood by others, and understood others. Her BIMs score was 15 indicating she was cognitively intact. Resident #9 required the extensive assistance of two or more staff for bed mobility and transfer, and the extensive assistance of 1 staff for toilet use. Record review of the care plan dated 7/6/23 indicated Resident #9 had Diabetes Mellitus and hemiplegia/hemiparesis (paralysis on one side of the body) related to a stroke (damage to the brain from interruption of blood supply). Resident #9 had bladder incontinence and bowel incontinence. The care plan indicated she refused showers and bed baths at times. Resident #9 required 2 staff for bed mobility and bathing. Record review of the progress notes indicated: 9/8/23 Pending UA/CS results and will notify oncoming nurse for follow up. This note was signed by LVN A Record review of PCC on 9/19/23 did not have the lab results of the UA or CS for Resident #9. During an interview and record review on 9/19/23 at 11:37 AM, the DON said she found the lab UA result for Resident #9. The UA dated 9/7/23 (with a collection date of 9/6/23) indicated positive for bacteria. The DON said the lab was positive for a UTI. The DON provided the C&S dated 9/7/23 (with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 8 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0690 Level of Harm - Minimal harm or potential for actual harm collection date of 9/6/23) that indicated positive for Eschericia Coli (a bacteria that is found in the lower intestine of warm-blooded organisms). Record review on 9/19/23 at 11:39 AM, of the physician's orders for Resident [NAME] indicated no new antibiotic or treatment for UTI. Residents Affected - Few During an interview on 9/19/23 at 11:40 AM, the DON said she would check the IPAD to see if the UA and C&S result was sent to the NP or MD. She looked at the facility IPAD and the communication on the IPAD. She said the lab should have been sent to the NP and/or MD on 9/8/23 or 9/9/23 and it was not, according to her checking the messages on the IPAD. She said she was going to call the nurse for Resident #9 that day and see if she called the MD. During an interview on 9/19/23 at 11:44 AM, the DON and Regional Nurse said they did not see any orders for an antibiotic for Resident #9 or any treatment for her for her UTI (positive UA on 9/8/23) in her orders. The DON said it did not appear she was being treated for her UTI. During an interview on 9/19/23 at 11:56 AM, Resident #9 said she felt fine. She said felt pretty good today and had no pain, and no pain with urination. She said her urine had a bad smell to it. During an interview and record review on 9/19/23 at 12:48 PM, the DON showed this surveyor the order for Resident #9's UA/CS. She showed this surveyor it was dated 9/6/23 and put in by NP for PPHP (Provider Partner's Health Plan). She said PPHP was a managed care that provided a RN and NP. She the NP put in the order for the UA and C&S for Resident #9 on 9/6/23. She said she called the NP while ago and the NP said a nurse told her the UA and C&S was negative for Resident #9. She said the labs were received in the facility 9/8/23 and were received by LVN B. She said LVN B told her she did not remember calling the NP. She said the failure or breakdown was when the results were received, they were not given to the NP. She said normally the nurse would let the NP for PPHP and the facility NP know of the results. During an interview on 9/19/23 at 12:51 PM, the Regional Nurse said Resident #9 was not treated for her UTI because the physician or NP were not notified of the positive results. She said that was a problem. She said the NP or the MD should have been notified of Resident #9's positive labs. During an interview on 9/19/23 at 1:08 PM, LVN B said Resident #9 had a UA and C&S. She said she did not remember why that lab was ordered but she thought maybe because Resident #9 complained of itching. She said the NP for PPHP wrote an order for UA and C&S on 9/6/23. She said the ADON told her she gave her the results of the UA and C&S on 9/8/23, but said she did not remember receiving it. She said LVN A told her a UA and C&S were pending for Resident #9 on 9/8/23. She said somehow she did not call the NP with the results but did not know why. She said she would always send a picture of the lab on the facility IPAD but she must not have called the NP or sent the results to the NP on the IPAD. She said their process was when they received a critical lab they would immediately call the NP. She said if it was not a critical lab, she would send a picture of the lab result on the IPAD to the NP. She said if she did not get a response, she would call the NP. She said the nurse that receives the lab back with the results was responsible for notifying the NP or MD and that day (9/8/23) it was her. She said not notifying the NP or MD could result in Resident #9 getting a more serious UTI or getting septic (infected with microorgamisms). She said she did not know if anyone checked behind her to make sure she did completed notifying the NP and receiving new orders. During an interview on 9/19/23 at 1:34 PM, the ADON said she was just now aware that Resident #9's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 9 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few UTI had not been treated and the NP had not been notified. She said the UTI should have been called in to the NP on 9/8/23 because it was a positive lab. She said she printed labs every morning from the day before and gave them to the nurses to make sure all nurses had them, so they were not missed. She said she gave LVN B the initial UA that showed positive for bacteria, the initial UA result that comes before the C&S. She said at that point she expected the nurse to call the NP (for PPHP) or send pictures of the lab on the telehealth (the IPAD) to her. During an interview on 9/19/23 at 2:26 PM, the ADON said the person responsible to make sure the labs were called into NP/MD was the nurse that received the result. She said she and the DON will double check at times, usually monthly, but nothing was documented. She said Resident #9's positive UA was missed because the nurse did not notify the NP/MD. The ADON said evidently the process did not work, so she would do a lab log, and she would start that now because the process they were using did not work. She said if nurses were not working on the floor, they had morning meeting and they discussed the 24- hour report. She said the UA was back on 9/8/23 for Resident #9. She said the 24-hour report for 9/9/23 and 9/10/23 indicated the UA was pending and that was not correct. She said the night nurses usually updated the 24-hour report. She said LVN B should have updated the 24-hour report to indicate the UA for Resident #9 was back and it was positive. She said Resident #9 not getting the treatment she needed could result in confusion, sepsis, or altered mental status. She said without surveyor intervention Resident #9 could have gotten really sick. The ADON said Resident #9 started an antibiotic for her UTI today. Record review of the 24-hour reports indicated: 9/6/23 Resident #9 needs UA/C&S 9/7/23 Resident #9 sending UA/C&S results 9/8/23 Resident #9 pending UA/C&S results 9/9/23 Resident #9 pending UA/C&S results 9/10/23 Resident #9 pending UA/C&S results Record review of the physician's orders for Resident #9 dated 9/19/23 at 12:15 PM indicated: Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet by mouth one time a day for bacterial infection for 7 days. Record review of the progress notes for Resident #9 dated 9/19/23 at 12:35 PM indicated: Initial dose of Augmentin 875 and probiotic was given po (by mouth) for an active UTI without any adverse reaction to medication at this time. Resident was encouraged to drink more water . This note was signed by LVN B. During an interview on 9/19/23 at 2:43 PM, the DON said they did not have a lab policy. During an interview and record review on 9/19/23 at 2:49 PM, the ADON showed this surveyor a Plan of Action lab log that she was in-servicing the staff on. The in-service indicated to enter each lab ordered and information, then check daily for follow-up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 10 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/19/23 at 3:17 PM, LVN B came into the work room visibly upset and crying. She said she had apologized to Resident #9 for not letting the NP know she needed treatment and said she felt terrible for it. She said Resident #9 was on antibiotics now. During an interview and record review on 9/19/23 at 3:23 PM, the ADON provided another in-service that indicated: Check doctors labs multiple times during shift to print and send to MD/NP. make sure to document labs that need follow up on 24-hour report. make sure to check 24-hour report for labs that need follow-up. During an interview on 9/20/23 at 7:30 AM, the DON said regarding Resident #9 or labs in general, her expectations were that all nurses had access to the lab results. She said in the morning meeting she and the ADON provided the nurses with results from the prior day of the labs. She said on the weekend the weekend supervisor looks at the labs and the DON, ADON, or the Treatment Nurse was present on the weekend to give out the lab results. She said that was when staff went over the 24-hour report. She said on 9/8/23 the ADON gave the results of Resident #9's UA/C&S to LVN B and expected her to notify the NP. She said ultimately she was responsible for everything that happened in the building. She said she should have double checked to make sure it was done. She said she would be overseeing labs from now on instead of the ADON doing it. She said the ADON was double checking that labs and making sure antibiotics were put in if needed. She said the ADON worked the floor 3 out of 5 days and the week that happened it was not a good week. She said the ADON did not document that she double checked the labs and results. She said the 24-hour report continued to indicate on 9/9/23 and 9/10/23 kept indicating labs were pending when labs were already back. She said 9/9/23 and 9/10/23 was the weekend and none of the nurses looked in the website to see if the lab had resulted. She said the ball dropped when LVN B did not indicate the UA positive for Resident #9 on the 24-hour report. She said, or the ball could have dropped if the ADON never printed out the positive UA lab for Resident #9 and gave it to LVN B. She said she was not sure what really happened. She said the process they were using failed regarding Resident #9's labs. She said their process had been working until now and then it failed. She said the risks of Resident #9 not being treated for her UTI were her infection worsening, sepsis, and other health conditions. She said they had not had a problem like this before since she had been here (January 2023). She said the current lab process could affect every resident. She said they were currently doing in-services regarding improvement in lab processes. She said she started a lab log for nurses to check, and she will be responsible for making sure that was done. She said the night nurses were responsible for updating the 24-hour report and they will be in-serviced regarding verifying labs were back and anything on the 24-hour report that has been done documented on the 24-hour report. During an interview on 9/20/23 at 7:57 AM, the ADON said she had in-serviced the night staff by phone on the new lab logs and making sure the 24-hour report was correct. She said she instructed them how to log into the lab website, even though they already knew how. The ADON said the lab log should prevent missing another lab. She said she will get with the RN weekend supervisor and in-service her. During an interview on 9/20/23 at 10:50 AM, the ADM said the charge nurse, for that resident was responsible for making sure the NP/MD was called with the lab results. He said in the case of Resident #9 it was LVN B. He said the ADON was supposed to follow up to make sure it had been completed. He said in the case of Resident #9 the charge nurse did not notify the NP/MD and the ADON apparently did not follow up to make sure it was completed. He said somehow it had fallen through the cracks during the morning meetings in that it was not discussed on 9/8/23. The administrator said Resident #9 could have gotten sepsis. He said his expectation was that the Charge Nurse would notify the NP/MD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 11 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the results of a positive lab once the lab was received. He said the NP should have been notified on 9/8/23 of Resident #9's positive UA/CS. He said this mistake could affect any resident that had labs drawn. During a phone interview on 9/20/23 at 1:16 PM, the NP for PPHP said she was not notified until 9/19/23 that Resident #9's UA/CS was positive. She said Resident #9 was new to PPHP services as of 9/1/23. She said PPHP was an extra set of eyes. She said she saw her for the first time on 9/5/23 and said she could not really remember, but Resident #9 must have told her she had signs or symptoms of a UTI because she ordered a UA and C&S. She said she saw Resident #9 in the facility again on 9/11/23 and a nurse (unknown who) told her the UA and was negative. She said the C&S would not have been back yet because it took a few days. She said she did not know who the nurse was that told her the UA was negative. She said she was not notified until 9/19/23 that the UA and C&S was positive. She said she called in an antibiotic for Resident #9 on 9/19/23. She said the lab results were usually put in the Primary Care Folder and she asked for it on 9/11/23 and on 9/15/23 but was told both times no one knew where the results were. She said not getting the results of a positive UA or C&S timely could be a problem in that the resident could get sepsis, altered mental status, and a lot of other things. A Physician's Orders Policy provided by the DON on 9/19/23 indicated: Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. .4.The receiving nurse will contact any other department or external facilities as required . The policy did not address notifying the MD/NP of lab values. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 12 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 33 opportunities, resulting in an 12% percent medication error involving 2 of 4 residents reviewed for medication administration (Residents #11and #36). Residents Affected - Few MA A failed to verify the dose of eye drops to be administered and administered an inaccurate dose of 2 (two) drops instead of the ordered 1 (one) drop of Dorzolamide/Timolol eye drop solution (used to treat glaucoma by reducing pressure in the eye) to Resident # 36's right eye. MA A failed to administer 3 (three) scheduled medications including Isosorbide (used to prevent chest pain in patients with heart disease), Metformin (used to treat and manage high blood sugar levels), and Latuda (used to treat depression (a mental illness) to Resident #11 as ordered by the physician. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: Resident #11 Record review of the face sheet dated 09/19/2023 indicated Resident #11 was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), and major depression (a mental illness that involves a depressed mood or loss of pleasure or interest in activities for a long period of time.) During observation and interview on 09/19/2023 at 08:32 AM, MA A administered medications to Resident #11. Prior to administering any medications, MA A checked Resident #11's blood pressure (BP) and pulse (P). The BP was 138/79 and the P was 64. MA A administered medications including Acidophilus, omeprazole, gabapentin, ariprazole, glipizide, furosemide, metoprolol, lisinopril, and potassium. Record review of the physician orders dated for September 2023 indicated Resident #11 was also to receive the following 3 (three) medications in the AM (6:30-10:30 AM) daily: isosorbide mononitrate ER (extended release) 30mg daily to help treat high blood pressure, metformin 500 mg 2 (two) times daily to treat diabetes, and Latuda 160 mg (2 tablets of 80 mg to equal 160 mg) 2 (two) times daily to treat major depression. These three medications were not administered during the observed medication pass at 08:32 on 09/19/2023. During an interview of MA A said she did not give Resident #11 his isosorbide, metformin, nor Latuda because they were not available. She said she had ordered the metformin and isosorbide that morning (09/19/2023) and said the Latuda had been ordered on 09/13/2023. MA A said she should tell the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 13 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few charge nurse when a medication was not available for administration and the charge nurse could see if the medication(s) needed were in the facility's emergency drug container (ER box). When asked, MA A said she had not told the charge nurse that she did not have the medications. MA A was then observed to tell the charge nurse what medications were needed. During an interview on 09/19/2023 at 11:50 AM, the ADON said Resident #11's metformin and isosorbide medications had been retrieved from the facility's emergency drug container and had been given to the resident. She also said the Latuda medication had been delivered on 09/13/2023 and had been found in another resident's section of the medication cart and the resident had been given this medication also. During an interview on 09/20/2023 at 12:45 PM, the DON said the MA should have asked the charge nurse to see if the missing medications were available in the facility's emergency drug container. The DON said she had in-serviced MA A on this process. Resident #36 Record review of the face sheet dated 09/19/2023 indicated Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dementia and glaucoma (damage to the eye caused by increased pressure in the eye) of the right and left eyes. During observation and interview on 09/19/2023 at 08/15 AM, MA A place 2 drops of Dorzolamide/Timolol eye solution into Resident #36's right eye. MA A then brought the bottle containing the eye drop solution back to the cart and placed it in the package it came in. MA A looked at the prescribing information on the package and said she thought the resident was supposed to get 2 drops but she was supposed to get one drop. MA A then said she would tell the DON about the mistake. Record review of the physician's orders dated for September 2023 indicated Resident #36 was to receive 1 (one) drop of Dorzolamide/Timolol 22.3-6.8 mg per milliliter solution in the right eye 2 (two) times daily. During an interview with the DON at 12:45 PM on 09/19/2023, the DON said the doctor had been notified about the Resident #36 receiving the wrong dose of eye medication and a medication error report had been initiated. DON said she had in-serviced the Med A on administration of the right dose of medications. Review of the facility's policy titled Medication Administration Procedures' indicated the following: 14. 20. The five rights of medication should always be adhered to 1. Right drug 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 14 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 Right dose Level of Harm - Minimal harm or potential for actual harm 3. Right resident Residents Affected - Few 4. Right time 5. Right route. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 15 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents (Resident #11) reviewed for significant medication errors, in that: Residents Affected - Few MA A failed to administer 2 scheduled medication, isosorbide mononitrate (to high blood pressure and metformin (to treat high blood sugar). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. for a lower than desired blood pressure and/or pulse. Findings included: Resident #11 Record review of the face sheet dated 09/19/2023 indicated Resident #11 was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included hypertension (elevated/high blood pressure) and diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar). During observation and interview on 09/19/2023 at 08:32 AM, MA A administered medications to Resident #11. MA A administered medications including Acidophilus, omeprazole, gabapentin, ariprazole, glipizide, furosemide, metoprolol, lisinopril, and potassium. Record review on 09/19/2023 at 11:10 AM of the physician orders dated for September 2023 indicated Resident #11 was also to receive the following 2 (two) medications in the AM (6:30-10:30 AM) daily: isosorbide mononitrate ER (extended release) 30mg daily to help treat high blood pressure and metformin 500 mg 2 (two) times daily to treat diabetes.(two) times daily to treat major depression. These medications were not administered during the observed medication pass at 08:32 on 09/19/2023. During an interview on 09/19/2023 at 11:45 AM, MA A said she did not give Resident #11 his isosorbide and metformin because they were not available. She said she had ordered the metformin and isosorbide that morning (09/19/2023). MA A said she should tell the charge nurse when a medication was not available for administration and the charge nurse could see if the medication(s) needed were in the facility's emergency drug container (ER box). When asked, MA A said she had not told the charge nurse that she did not have the medications. MA A was then observed to tell the charge nurse what medications were needed. During an interview on 09/19/2023 at 11:50 AM, the ADON said Resident #11's metformin and isosorbide medications had been retrieved from the facility's emergency drug container and had been given to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 16 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 09/20/2023 at 12:45 PM, the DON said MA A should have notified the charge nurse of the missing medications and the charge nurse would then check the emergency drug supply to see if the drugs were available. The DON said she had in-serviced MA A on the process for what to do if a medication is not available for administration. Review of the facility's policy titled Medication Administration Procedures' did not indicate what to do if a medication was not available for administration. Event ID: Facility ID: 675390 If continuation sheet Page 17 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility failed to promptly notify the physician of laboratory results 1 of 15 residents reviewed for laboratory services (Resident #9). The facility did not notify Resident #9's physician about the results of her urinalysis. This failure could place residents with infections at risk of a delay in medical evaluation and treatment. Findings included: Record review of the undated face sheet indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of the physician's orders dated 9/19/23 indicated Resident #9 had with diagnoses that included: Diabetes Mellitus 2 (a chronic condition that affects the way the body processes sugar, the body either does not produce enough insulin, or it resists insulin), Urinary Tract Infection (an infection in the urinary system, kidneys, bladder, or urethra), quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down), dementia (impairment in memory and judgement). The physician's orders did not indicate she was on antibiotic or treatment for a UTI. The physician's orders indicated: 9/6/23 May have UA with C&S one time only for burning/odor with urination Record review of the admission MDS dated [DATE] indicated Resident #9 had clear speech, was understood by others, and understood others. Her BIMS score was 15 indicating she was cognitively intact. Resident #9 required the extensive assistance of two or more staff for bed mobility and transfer, and the extensive assistance of 1 staff for toilet use. Record review of the care plan dated 7/6/23 indicated Resident #9 had Diabetes Mellitus and hemiplegia/hemiparesis (paralysis on one side of the body) related to a stroke (damage to the brain from interruption of blood supply). Resident #9 had bladder incontinence and bowel incontinence. The care plan indicated she refused showers and bed baths at times. Resident #9 required 2 staff for bed mobility and bathing. Record review of the progress notes indicated: 9/8/23 Pending UA/CS results and will notify oncoming nurse for follow up. This note was signed by LVN A Record review of PCC on 9/19/23 did not have the lab results of the UA or CS for Resident #9. During an interview and record review on 9/19/23 at 11:37 AM, the DON said she found the lab UA result for Resident #9 . The UA dated 9/7/23 (with a collection date of 9/6/23) indicated positive for bacteria. The DON said the lab was positive for a UTI. The DON provided the C&S dated 9/7/23 (with a collection date of 9/6/23) that indicated positive for Eschericia Coli (a bacteria that is found in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 18 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0773 the lower intestine of warm-blooded organisms). Level of Harm - Minimal harm or potential for actual harm Record review on 9/19/23 at 11:39 AM, of the physician's orders for Resident #9 indicated no new antibiotic or treatment for UTI. Residents Affected - Few During an interview on 9/19/23 at 11:40 AM, the DON said she would check the IPAD (a computer tablet) to see if the UA and C&S result was sent to the NP or MD. She looked at the facility IPAD and the communication on the IPAD. She said the lab should have been sent to the NP and/or MD on 9/8/23 or 9/9/23 and it was not, according to her checking the messages on the IPAD. She said she was going to call the nurse for Resident #9 that day and see if she called the MD. During an interview on 9/19/23 at 11:44 AM, the DON and Regional Nurse said they did not see any orders for an antibiotic for Resident #9 or any treatment for her for her UTI (positive UA on 9/8/23) in her orders. The DON said it did not appear she was being treated for her UTI. During an interview on 9/19/23 at 11:56 AM, Resident #9 said she felt fine. She said she felt pretty good today and had no pain, and no pain with urination. She said her urine had a bad smell to it. During an interview and record review on 9/19/23 at 12:48 PM, the DON showed this surveyor the order for Resident #9's UA/CS. She showed this surveyor it was dated 9/6/23 and put in by NP for PPHP (Provider Partner's Health Plan). She said PPHP was a managed care that provided a RN and NP. She said the NP put in the order for the UA and C&S for Resident #9 on 9/6/23. She said she called the NP awhile ago and the NP said a nurse told her the UA and C&S was negative for Resident #9. She said the labs were received in the facility 9/8/23 and were received by LVN B. She said LVN B told her she did not remember calling the NP. She said the failure or breakdown was when the results were received, they were not given to the NP. She said normally the nurse would let the NP for PPHP and the facility NP know of the results. During an interview on 9/19/23 at 12:51 PM, the Regional Nurse said Resident #9 was not treated for her UTI because the physician or NP were not notified of the positive results. She said that was a problem. She said the NP or the MD should have been notified of Resident #9's positive labs. During an interview on 9/19/23 at 1:08 PM, LVN B said Resident #9 had a UA and C&S. She said she did not remember why that lab was ordered but she thought maybe because Resident #9 complained of itching. She said the NP for PPHP wrote an order for UA and C&S on 9/6/23. She said the ADON told her she gave her the results of the UA and C&S on 9/8/23, but said she did not remember receiving it. She said LVN A told her a UA and C&S were pending for Resident #9 on 9/8/23. She said somehow she did not call the NP with the results but did not know why. She said she would always send a picture of the lab on the facility IPAD but she must not have called the NP or sent the results to the NP on the IPAD. She said their process was when they received a critical lab they would immediately call the NP. She said if it was not a critical lab, she would send a picture of the lab result on the IPAD to the NP. She said if she did not get a response, she would call the NP. She said the nurse that receives the lab back with the results was responsible for notifying the NP or MD and that day (9/8/23) it was her. She said not notifying the NP or MD could result in Resident #9 getting a more serious UTI or getting septic (infected with microorganisms). She said she did not know if anyone checked behind her to make sure she did completed notifying the NP and receiving new orders. During an interview on 9/19/23 at 1:34 PM, the ADON said she was just now aware that Resident #9's UTI had not been treated and the NP had not been notified. She said the UTI should have been called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 19 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0773 Level of Harm - Minimal harm or potential for actual harm in to the NP on 9/8/23 because it was a positive lab. She said she printed labs every morning from the day before and gave them to the nurses to make sure all nurses had them, so they were not missed. She said she gave LVN B the initial UA that showed positive for bacteria, the initial UA result that comes before the C&S. She said at that point she expected the nurse to call the NP (for PPHP) or send pictures of the lab on the telehealth (the IPAD) to her. Residents Affected - Few During an interview on 9/19/23 at 2:26 PM, the ADON said the person responsible to make sure the labs were called into NP/MD was the nurse that received the result. She said she and the DON will double check at times, usually monthly, but nothing was documented. She said Resident #9's positive UA was missed because the nurse did not notify the NP/MD. The ADON said evidently the process did not work, so she would do a lab log, and she would start that now because the process they were using did not work. She said if nurses were not working on the floor, they had morning meeting and they discussed the 24- hour report. She said the UA was back on 9/8/23 for Resident #9. She said the 24-hour report for 9/9/23 and 9/10/23 indicated the UA was pending and that was not correct. She said the night nurses usually updated the 24-hour report. She said LVN B should have updated the 24-hour report to indicate the UA for Resident #9 was back and it was positive. She said Resident #9 not getting the treatment she needed could result in confusion, sepsis, or altered mental status. She said without surveyor intervention Resident #9 could have gotten really sick. The ADON said Resident #9 started an antibiotic for her UTI today. Record review of the 24-hour reports indicated: 9/6/23 Resident #9 needs UA/C&S 9/7/23 Resident #9 sending UA/C&S results 9/8/23 Resident #9 pending UA/C&S results 9/9/23 Resident #9 pending UA/C&S results 9/10/23 Resident #9 pending UA/C&S results Record review of the physician's orders for Resident #9 dated 9/19/23 at 12:15 PM indicated: Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet by mouth one time a day for bacterial infection for 7 days. Record review of the progress notes for Resident #9 dated 9/19/23 at 12:35 PM indicated: Initial dose of Augmentin 875 and probiotic was given po (by mouth) for an active UTI without any adverse reaction to medication at this time. Resident was encouraged to drink more water . This note was signed by LVN B. During an interview on 9/19/23 at 2:43 PM, the DON said they did not have a lab policy. Record review on 9/19/23 at 2:49 PM, the ADON showed this surveyor a Plan of Action lab log that she was in-servicing the staff on. The in-service indicated to enter each lab ordered and information, then check daily for follow-up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 20 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review on 9/19/23 at 3:23 PM, the ADON provided another in-service that indicated: Check doctors labs multiple times during shift to print and send to MD/NP. make sure to document labs that need follow up on 24-hour report. make sure to check 24-hour report for labs that need follow-up. During an interview on 9/20/23 at 7:30 AM, the DON said regarding Resident #9 or labs in general, her expectations were that all nurses had access to the lab results. She said in the morning meeting she and the ADON provided the nurses with results from the prior day of the labs. She said on the weekend the weekend supervisor looks at the labs and the DON, ADON, or the Treatment Nurse was present on the weekend to give out the lab results. She said that was when staff went over the 24-hour report. She said on 9/8/23 the ADON gave the results of Resident #9's UA/C&S to LVN B and expected her to notify the NP. She said ultimately, she was responsible for everything that happened in the building. She said she should have double checked to make sure it was done. She said she would be overseeing labs from now on instead of the ADON doing it. She said the ADON was double checking that labs and making sure antibiotics were put in if needed. She said the ADON worked the floor 3 out of 5 days and the week that happened it was not a good week. She said the ADON did not document that she double checked the labs and results. She said the 24-hour report continued to indicate on 9/9/23 and 9/10/23 kept indicating labs were pending when labs were already back. She said 9/9/23 and 9/10/23 was the weekend and none of the nurses looked in the website to see if the lab had resulted. She said the ball was dropped when LVN B did not indicate the UA positive for Resident #9 on the 24-hour report. She said, or the ball could have dropped if the ADON never printed out the positive UA lab for Resident #9 and gave it to LVN B. She said she was not sure what really happened. She said the process they were using failed regarding Resident #9's labs. She said their process had been working until now and then it failed. She said the risks of Resident #9 not being treated for her UTI were her infection worsening, sepsis, and other health conditions. She said they had not had a problem like this before since she had been here (January 2023). She said the current lab process could affect every resident. She said they were currently doing in-services regarding improvement in lab processes. She said she started a lab log for nurses to check, and she will be responsible for making sure that was done. She said the night nurses were responsible for updating the 24-hour report and they will be in-serviced regarding verifying labs were back and anything on the 24-hour report that has been done documented on the 24-hour report. During an interview on 9/20/23 at 7:57 AM, the ADON said she had in-serviced the night staff by phone on the new lab logs and making sure the 24-hour report was correct. She said she instructed them how to log into the lab website, even though they already knew how. The ADON said the lab log should prevent missing another lab. She said she will get with the RN weekend supervisor and in-service her. During an interview on 9/20/23 at 10:50 AM, the ADM said the charge nurse, for that resident was responsible for making sure the NP/MD was called with the lab results. He said in the case of Resident #9 it was LVN B. He said the ADON was supposed to follow up to make sure it had been completed. He said in the case of Resident #9 the charge nurse did not notify the NP/MD and the ADON apparently did not follow up to make sure it was completed. He said somehow it had fallen through the cracks during the morning meetings in that it was not discussed on 9/8/23. The administrator said Resident #9 could have gotten sepsis. He said his expectation was that the Charge Nurse would notify the NP/MD with the results of a positive lab once the lab was received. He said the NP should have been notified on 9/8/23 of Resident #9's positive UA/CS. He said this mistake could affect any resident that had labs drawn. During a phone interview on 9/20/23 at 1:16 PM, the NP for PPHP said she was not notified until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 21 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/19/23 that Resident #9's UA/CS was positive. She said Resident #9 was new to PPHP services as of 9/1/23. She said PPHP was an extra set of eyes. She said she saw her for the first time on 9/5/23 and said she could not really remember, but Resident #9 must have told her she had signs or symptoms of a UTI because she ordered a UA and C&S. She said she saw Resident #9 in the facility again on 9/11/23 and a nurse (unknown who) told her the UA and was negative. She said the C&S would not have been back yet because it took a few days. She said she did not know who the nurse was that told her the UA was negative. She said she was not notified until 9/19/23 that the UA and C&S was positive. She said she called in an antibiotic for Resident #9 on 9/19/23. She said the lab results were usually put in the Primary Care Folder and she asked for it on 9/11/23 and on 9/15/23 but was told both times no one knew where the results were. She said not getting the results of a positive UA or C&S timely could be a problem in that the resident could get sepsis, altered mental status, and a lot of other things. A Physician's Orders Policy provided by the DON on 9/19/23 indicated: Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. .4.The receiving nurse will contact any other department or external facilities as required . The policy did not address notifying the MD/NP of lab values. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 22 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Few The facility failed to ensure food items were dated and labeled. These failures could place residents at risk for foodborne illness. Findings include: During an observation and interview with the Dietary Manager of the refrigerators on 09/18/2023 starting at 8:32 AM revealed 6 cartons of strawberries with no date, 3 cartons of mixed fruit with no label or date, a white container labeled chili beans dated 9/10/23 and the Dietary Manager stated it was peanut butter and jelly, and 1 bag of ham with no label or date. During an interview on 09-19-23 at 12:13 PM, the Dietary Manager stated whoever puts away the food items were responsible for dating and labeling the items. The Dietary Manager stated he was responsible for checking the refrigerator and freezer daily and making sure the items were labeled and dated. The Dietary Manger stated he does not work on the weekends, and it was his first day back and does not check the freezer and refrigeration until 9:30 AM. The Dietary Manager stated he had not been able to check the refrigerators and freezers prior to walk through. The Dietary Manger denied having a sign in sheet for making sure items were labeled and dated and there were no other processes in place. The Dietary Manager stated the importance of making sure items were labeled and dated was to make sure the food was still good, and residents did not get sick. During an interview on 09/20/23 at 1:43 PM, the ADM stated he expected kitchen items to be labeled and dated. The ADM stated the importance of labeling and dating was to ensure food items were not expired and they were the correct items. The ADM stated unlabeled items could cause adverse effects and cause residents to have an upset stomach due to bacteria. Record review of the facility's policy on Storage Refrigerators Storage, dated 2012, indicated . Food must be covered when stored, with a date label identifying what is in the container . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 23 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #16 and Resident #28) reviewed for hospice services. The facility did not ensure Resident #16's hospice records were a part of their records in the facility. The facility did not ensure Resident #28's hospice records were a part of their records in the facility. The facility did not ensure Resident #16 had a physician order for hospice. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1.Record review of Resident #16's face sheet, dated 09/19/2023, indicated Resident #16 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depression (loss of interest in activities) and osteoarthritis (flexible tissue at the end of bones wear down). Record review of Resident #16's order summary report, dated 12/15/2021, did not indicate hospice services. Record review of the quarterly MDS dated [DATE], indicated Resident #16 understood others and made himself understood. The assessment indicated Resident #16 was cognitively intact with a BIMS score of 15 which indicates intact cognition. Section O of the MDS indicated hospice care. Record review of Resident #16's care plan, revised on 08/25/23, indicated Resident #16 had a terminal prognosis COPD and was receiving hospice services. The interventions included to respect resident wishes and to work cooperatively with the hospice team to ensure the residents spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #16's hospice binder, accessed on 9/19/23 at 3:56 PM, revealed no updated Plan of Care since 6/7/23 or updated nursing notes. 2. Record review of Resident #28's face sheet, dated 09/20/2023, indicated Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Alzheimer's (memory loss), major depressive disorder (depressed mood) and contractures (fixed tightening of muscles, tendons, and ligaments). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 24 of 25 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 675390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunflower Park Health Care 1803 Highway 243 East Kaufman, TX 75142 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the quarterly MDS dated [DATE], indicated Resident #28 sometimes understood others and rarely made himself understood. The MDS assessment indicated Resident #28 did not have a BIMS score. Section O of the MDS indicated hospice care. Record review of Resident #28's care plan, revised on 12/14/21, indicated Resident #28 required hospice services related to senile degeneration of the brain (decreased ability to think, concentrate or remember). The interventions included hospice staff to assist with resident care. Record review of Resident #28's hospice binder, accessed on 9/19/23 at 4:00 PM, revealed no updated Plan of Care since 7/15/23 or updated nursing notes since 6/6/23. During an interview on 09/19/23 at 10:37 AM, the hospice secretary stated she sent out the updated plan of care and skilled nursing visits with the nurse after each IDT meeting to update the resident folders. The secretary stated Resident #16 had an IDT meeting last week and the nurse should have updated the folder on 9/14/23 when she visited the facility. During an attempted telephone interview on 09/19/23 at 10:37 AM to gather more information, the Hospice nurse did not answer. No phone call was returned upon exit of the facility. During an interview on 09/20/23 at 9:46 AM, the DON stated she was responsible for making sure hospice was signing the folders that visits were being made. The DON stated she did not know she was responsible for making sure they had the updated plan of care or nursing notes in the folder and she agreed that the folder did not have the current information in it. The DON stated the importance of communication with hospice was to keep all staff that was caring for the resident updated on care and for continuation of care. During an interview on 9/20/23 at 1:43 PM, the ADM stated he expected hospice folders to be up to date. The ADM stated the importance of having the folders up to date was to provide care related to the patient's current condition. Record review of the facility's policy on Hospice Services, revised 02/13/2007, revealed The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include Hospice Plan of Care Current interdisciplinary notes to include nurses' notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675390 If continuation sheet Page 25 of 25