Health inspection·January 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39's MDS assessment dated [DATE] reflected a BIMS score of 2 which indicated severe impairment. ADL care reflected for transfers, toileting, and bathing, Resident #39 was totally dependent for assistance. Record review of Resident #39's comprehensive care plan dated 12/30/2024 reflected goals and approaches to include wheelchair mobility. Observation and attempted interview on 01/15/2025 at 9:20am with Resident #39 revealed resident sitting in his wheelchair in the common area and the wheelchair's left and right arm rests were cracked. There were no skin tears on his arms. Resident #39 was nonresponsive. Record review of Resident #15's face sheet dated 01/15/2025 reflected an [AGE] year-old female who was admitted to the facility 05/01/2024 with diagnoses which included: Dementia (condition characterized by loss of brain functions such as memory loss), hemiplegia and hemiparesis( weakness and paralysis) following cerebral infarction affecting left dominant side, hypertension, and lack of coordination. Record review of Resident #15's MDS assessment dated [DATE] reflected a BIMS score of 8 which indicated moderate impairment. ADL care reflected for transfers, toileting, and bathing, Resident #15 was totally dependent for assistance. Record review of Resident #15's comprehensive care plan dated 11/05/2024 reflected goals and approaches to include wheelchair mobility. Observation and attempted interview on 01/15/2025 at 9:22am with Resident #15 revealed resident sitting in her wheelchair in the common area. Resident #15's wheelchair left arm rest was cracked with exposed foam. The right arm rest was missing. There were no skin tears on her arms. Resident #15 was nonresponsive. Record review of Resident #10's face sheet dated 01/15/2025 reflected an [AGE] year-old female who was admitted to the facility 12/31/2010 with diagnoses which included: Alzheimer's disease with late onset, abnormalities of gait and mobility, muscle weakness, and lack of coordination. Record review of Resident #10's MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated intact cognitive abilities. ADL care reflected Resident is independent but for transfers, toileting, and bathing Resident #10 required supervision with setup. Record review of Resident #10's comprehensive care plan dated 01/06/2025 reflected goals and approaches to include wheelchair mobility. Observation and interview on 01/15/2025 at 10:29am with Resident #10 revealed resident sitting in her wheelchair in her room. Resident #10's wheelchair right and left armrest was cracked with exposed foam. There were no skins tears on her arms. Resident #10 stated when her wheelchair arm handle was loose, she went to one of the maintenance men and told one of the men. She stated the maintenance man tightened her handle right away. Resident #10 stated she never told staff about her right and left arm rest being cracked because she's not worried about it. She stated staff never mentioned anything to her about her wheelchair arm rests being cracked. In an interview on 01/15/2025 at 9:15am with CNA I stated when resident's wheelchairs needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 2 of 7 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 675402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockwall Nursing Care Center 206 Storrs Rockwall, TX 75087 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 - Some repairs, staff would make a note of the repairs in the maintenance log that is located at the nurse's station. She stated depending on the repair, maintenance resolved the issue in a timely manner. She stated wheelchairs not being repaired could cause skin tears. In an interview on 01/15/2025 at 9:25am with LVN J stated she's been employed at the facility for two months. She stated she is unsure of the procedure to report wheelchair repairs. In an interview on 01/15/2025 at 1:29pm with the ADM he stated wheelchairs inspections are completed routinely once a month and daily during angel rounds. He stated if staff identify a wheelchair that needed to be repaired, staff is expected to submit a request in the online maintenance portal, or the request is reported to a supervisor and discussed in the morning meeting. He stated there were no discussion from staff regarding Residents #19, #39, #15, and #10 wheelchair armrests needed to be repaired. He stated any request submitted in the portal went to the maintenance supervisor and the maintenance supervisor resolved all requests. He stated he could provide documentation of requests submitted to the online portal. However, he could not provide any documentation that reflected the quantity of wheelchairs being inspected daily. He stated wheelchairs not being repaired could put residents at fall risks and sharp edges could harm the residents. A policy regarding the maintenance of wheelchairs was requested. The ADM stated the facility does not have a policy regarding wheelchair maintenance but provided documentation of Resident's Rights . In an interview on 01/15/2025 at 3:07pm with the DON she stated when a wheelchair needed to be repaired staff is expected to report the repair to the nurse on duty, and the nurse notified the DON or ADM. She stated when the repair was reported to her, she notified the therapy department, and the therapy department ordered a new wheelchair. She stated wheelchairs not being repaired could cause the wheelchair not to function properly. She stated if the wheelchair's arm rests are cracked but the foam is still intact, there is no risks to residents. In an interview on 01/15/2025 at 3:19pm with the MS he stated when a wheelchair needed to be repaired, he would repair the wheelchair if he could. He stated if he was unable to repair the wheelchair, the facility purchased another wheelchair. He stated when staff identified a wheelchair repair, staff entered the request in the maintenance portal, and he reviewed and resolved the request. He stated because some staff is not tech savvy, some maintenance requests are noted in the maintenance log located at each nurse's station. He stated he completed routine wheelchair inspections every month and noted in the online maintenance portal. He stated lately, he hasn't received any maintenance request in the online portal or in the maintenance log binder. Record review of the facility's maintenance log binders dated August 2024-January 2025 revealed one wheelchair repair request dated 10/30/2024. Wheelchair brakes needed adjustment. The request was resolved, the brakes were adjusted, and the arm rest and side panel repaired. There was no resolved date noted. The maintenance log binder did not reveal any wheelchair repair request for Residents #19, #39, #15, and #10. Record review of the facility's online maintenance portal requests dated August 1, 2024- January 14, 2025, revealed routine wheelchair inspections on the entire building dated 08/02/2024, 10/15/2024, 11/19/2024, and 12/17/2024. The inspections did not reveal any wheelchair repair requests for Residents #19, #39, #15, and #10. Record review of State Long Term Care Ombudsman Program dated 2025 reflected: Your Rights in a Nursing Facility .Dignity and Respect: you have the right to live in safe, decent, conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 3 of 7 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 675402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockwall Nursing Care Center 206 Storrs Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were labeled and dated with the received or expiration date. 2. The facility failed to ensure expired whipping cream was disposed. 3. The facility failed to discard open items stored in the refrigerator that were not sealed. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of drink dispenser on 01/14/2025 at 9:14am revealed the following: -1 3 gallon drink dispenser of unidentified yellow liquid drink. There was no label description or preparation date. Observation of refrigerator #1 on 01/14/2025 at 9:22 am revealed the following: -2 quarts of heavy whipping cream with use by date 01/08/2025 . Observation of refrigerator #3 on 01/14/2025 at 9:28am revealed the following: -1 large zip top bag of ham dated 01/12/2025 exposed to the air . -1 large pack of unidentified chopped lunch meat. There was no label description or use by or expiration date. In an interview with the DM on 01/14/2025 at 9:36am he stated staff is expected to label and date all food items upon receival and daily as needed. He stated use by dates or expirations dates are checked before storing and daily as food items are used. He stated the ham exposed to air should be sealed tight. He stated the unidentified chopped lunch meat should be labeled identifying meat with an open date or us by date. He stated the risks of food items not properly labeled and dated, and stored past the expiration date could cause potential food poisoning. In an interview with DC H on 01/15/2025 at 11:28am, she stated all food items that are delivered to the facility should be labeled and dated before the food items are stored. She stated the risks of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 4 of 7 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 675402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockwall Nursing Care Center 206 Storrs Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some food items not labeled or dated correctly could cause allergic reactions and serving expired food could cause residents to become sick. Record review of the facility's Food Storage and Supplies Policy, no date, reflected Policy Statement: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dates as when opened. 6. Any product with a stamped expiration date will be discarded once that date passes. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form .], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food.Section 3-305.13 Vended Time/Temperature Control for Safety Food, Original Container: In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination . Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnable are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: . www.fda.gov FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 5 of 7 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 675402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockwall Nursing Care Center 206 Storrs Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews and record reviews the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 12 rooms (Residents #43's and #61's rooms) and 1 of 4 halls (the 300 wing (secure unit) hallway). The facility failed to ensure that there was running water in the sinks, the sinks had functioning drains, safety grab bars were secure to the walls, tiles had no gaps between them exposing the porous flooring beneath and safety handrails had no exposed sharp metal protrusions. These failures could result in residents experiencing falls, skin tears and unable to perform handwashing. Findings included: An observation on 01/14/2025 at 4:07 PM in the bathroom of Resident #43 revealed43 revealed that the safety grab bar facing the toilet was loose from the wall and offered significant movement when pulled upon. The water barrier (a plastic based sheeting designed to repel liquids) next to the toilet had separated from the wall next to the toilet revealing a large gap (approximately 6 inches by 4 inches) between the wall and the water barrier . The tiles around the base of the toilet had become separated revealing gaps ( approximately(approximately 5 tiles with ½ inch to 1/8 inch1/8-inch gaps) between the tiles that exposed the bare floor. Resident #43 was unable to answer any questions about his bathroom. An observation on 01/15/2025 at 10:11 AM in the bathroom of Resident #61 revealed that the sink had no running hot or cold water and the stopper for the sink was inoperable keeping the stopper closed. Resident #61 was not in his room at the time of the observation. An observation on 01/15/2025 at 10:50 AM in the 300 Wing (Secure Unit) a section of hand railhandrail was observed to be missing the plastic, curved endcaps exposing the sharp edges of sheet metal that residents could have access too. An observation on 01/15/2025 at 12:04 PM of a conversation between the ADON and Resident #61 revealed that Resident #61 asked the ADON where he could wash his hands, he stated that there was no water in his room. The ADON offered Resident #61 some Alcohol Based Hand Rub and instructed Resident #61 on how to use the hand sanitizer. The ADON said to Resident #61 that all of the water had been turned off to all of the bathrooms because they were fixing his sink. Resident #61 was unable to answer questions. In an interview on 01/15/2025 at 12:06 PM CNA B stated that the maintenance folder was located behind the nurses station. She stated that the facility had also started to use a phone app to report maintenance issues but that she had not used it yet. She stated that she would report clogged toilets, burnt out lights or beds that need to be fixed. She stated that she sometimes just tells the maintenance supervisor in person of maintenance issues. In an interview on 01/16/2025 at 12:12 PM CNA C revealed that the maintenance log was located behind the nurses station and that she is supposed to log anything that is broken there like lights, beds, and toilets. She stated that the facility was trying to use a new phone app to report things to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 6 of 7 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 675402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockwall Nursing Care Center 206 Storrs Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the maintenance supervisor. She stated that it was important to fix things around the facility that residents use so that their lives are better and that not having beds or toilets working could make life more difficult for residents. In an interview on 1/16/2025 at 12:23 PM CNA E revealed that she was aware of two maintenance logs, one behind the nursing station by the entrance to the facility and one at the nursing station near the entrance to the secure unit. She stated That she had written maintenance issues in both logs before and she was pretty sure they were still supposed to be using the maintenance logs but that there was a new phone App that the facility was wanting them to use. She stated that it was important to have issues fixed so that residents could do everyday things like use their toilets, shower rooms and other things. In an interview on 1/16/2025 at 3:26 PM the ADM revealed that he had been unaware of the safety grab rail in Resident #43's room, the lack of running water in Resident #61's room or the hand/guard rail with exposed sharp edges in the 300 [Secure Unit] hallway. He stated that the maintenance issues in the Secure unit could cause falls or skin tears and that all residents should have available hot water to wash their hands. He stated that he had reviewed both maintenance logs and the new phone App reporting system and he could find no reports about maintenance issues in the secure unit. In an interview on 01/16/2025 at 3:29 PM the Maintenance Supervisor revealed that he had not been aware of the maintenance issues in the secure unit. He stated that the safety grab bar in Resident #43's room was loose and that the spacers used to secure it to the wall had cracked and he would fix it that day. He stated that he had be had not seen any entries in either the maintenance log or the new phone App about the maintenance issues in Residents #43's and #61's rooms. He stated that he had no idea how long the sink in Resident #61's room was not functioning but explained that the shut off valves beneath the sink were not functioning and that the stopper in the sink would not open. He stated that it needs to be fixed immediately so the residents could wash their hands when they want to. He stated that he was unaware of the handrail in the 300-hall missing its end caps, and that the ends of the handrail were not extremely sharp but that it was sheet metal and could be sharp. He stated that he would find new endcaps for the handrail as soon as possible. He stated that he prefers to use the old maintenance logbooks over the new maintenance phone App as he had not seen many entries in the phone App. In an interview on 01/16/2025 at 3:38 PM the DON revealed that she had not been aware of the maintenance issues on the 300-Hall [Secure Unit]. She stated that if the safety grab bar in a resident's bathroom fell off a resident could fall and possibly injure themselves. She stated that if residents could not wash their hands with hot water and soap it could lead to possible infection control issues or affect the mental state of residents if unable to attend to daily hygiene needs. She stated that the exposed edges handrail in the hallway of the 300-Hall Secure Unit could pose a skin tear risk to residents using the handrail for balance or going past the handrail in wheelchairs. Record review of both maintenance logs in the facility found no evidence of maintenance issues being reported for the 300-Hall Secure Unit x 3 months. Record review of the facility policy, Homelike Environment, revised February 2021, reflected: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675402 If continuation sheet Page 7 of 7