Inspection·July 14, 2023

F 0677 indicated Resident #3 did receive showers on 6/1/23, 6/6/23, 6/9/23, 6/19/23, 6/20/23, and 6/26/23. Level of Harm - Minimal harm or potential for actual harm Record review of the Documentation Survey Report dated July 2023 indicated Resident #3 was scheduled to receive his showers on Tuesdays, Thursdays, and Saturday during the 6:00 a.m. to 2:00 p.m. shift. The Documentation Survey Report indicated Resident #3 did not receive a shower on 7/1/23, 7/8/23, and 7/11/23. The Documentation Survey Report indicated Resident #3 did receive showers on 7/2/23, 7/3/23, 7/4/23, 7/5/23, and 7/6/23. Residents Affected - Some During an interview on 7/12/23 at 10:24 a.m. the DON said if the Bathing Task had NA on it that meant the bath/shower was not performed. During an interview on 7/12/23 at 11:09 am the DON said Resident #3 was care planned to be resistive to care and yells at staff to get out of his room. The DON said they had finally gotten Resident #3 into a routine regarding showers and he had been better most of June and July 2023. During an interview and observation on 7/12/23 beginning at 12:25 p.m. Resident #3 said he did not receive his scheduled showers. Resident #3 said he did not refuse his showers. Resident #3 said he had never refused showers. Resident #3 said it made him feel dirty when he did not receive his scheduled showers. Resident #3 was clean and well-groomed during the interview. During an interview on 7/12/23 at 1:32 p.m. LVN B said she had worked back at the facility for about 2 weeks. LVN B said she worked the 6:00 a.m.-6:00 p.m. LVN B said Resident #3 had not refused showers to her knowledge. During an interview 7/12/23 at 1:59 p.m. MA H said she was working on the floor as a CNA today, 7/12/23. MA H said she was familiar with Resident #3. MA H said Resident #3 required assistance with transferring to the bathroom. MA H said she was not aware of Resident #3 refusing showers. During an interview on 7/12/23 at 2:22 p.m. MA H said CNAs were responsible for giving the residents their scheduled showers. MA H said if a resident refused a shower the CNA should report the refusal to the charge nurse. MA H said the charge nurses should chart refusals. MA H said the CNAs were able to chart refusals in the POC system (system that informs staff regarding patient care including bathing, transfer status, and toileting). During an interview on 7/12/23 at 2:26 p.m. the DON said CNAs were responsible for providing the residents their scheduled showers. The DON said if a resident refused their shower the CNA should notify the charge nurse and document the refusal in the POC system. The DON said the charge nurse should then go ask the resident again if they would take their scheduled shower. The DON said the charge nurse is not required to document shower refusals. The DON said the importance of ensuring residents received their scheduled showers was for them to be clean and have good hygiene. Record review of the facility's Activities of Daily Living Care Guidelines dated 1/23/2016 indicated, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .Resident participate in and receive the following person centered. Bathing: includes grooming activities such as shaving and brushing teeth and hair . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 2 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 reviewed for pain. Residents Affected - Few The facility failed to contact the physician in a timely manner regarding Resident #1's pain medication. The facility failed to provide Resident #1 with pain medication for 20 hours after admitting with pain at a 9 out of 10 (0 being no pain at all and 10 being the worst pain you have ever experienced). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/13/23 at 11:40 a.m. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health, behaviors, and quality of life. Findings Included: Record review of the consolidated physician orders dated 7/12/23 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] at 9:13 p.m. with a diagnosis including gastric ulcer with hemorrhage (internal bleed of a stomach ulcer), hypertension (high blood pressure), chronic pain syndrome, overactive bladder, and gastroesophageal reflux disease (heart burn). The physician orders indicated Resident #1 had orders for Morphine Sulfate (medication for pain) by mouth every morning and at bedtime starting 7/06/23 and Hydrocodone (medication for pain) 10-325mg by mouth every 6 hours as needed for pain starting 7/06/23. Record review of the MAR dated July 2023 indicated Resident #1 received her first dose of Morphine Sulfate on 7/06/23 at 7:00 p.m. and was experience pain of 7 out of 10 (0 being no pain and 10 being severe pain) The MAR indicated Resident #1 received her first dose of Hydrocodone on 7/06/23 at 7:30 p.m. and was experience pain of 9 out of 10. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #1 had moderate pain occasionally. Record review of the care plan dated 7/06/23 indicated Resident #1 was on a pain management regimen and takes analgesics routinely or as needed. The care plan indicated interventions included administer medications as ordered, monitor for side effects and effectiveness, and attempt non-pharmacological pain interventions when not contraindicated. Record review of the Admit/Readmit Evaluation dated 07/05/23 at 10:10 p.m. indicated Resident #1 had pain of 9 out of 10 with non-verbal pain indicator of restlessness. The Admit/Readmit Evaluation indicated interventions implemented were narcotics and quiet/relaxation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 3 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the Pain assessment dated [DATE] at 11:39 p.m. indicated Resident #1 reported having pain in her hip and back daily and times it was horrible or excruciating. The Pain Assessment indicated Resident #1 rated her pain as very severe. Record review of the nursing progress noted dated 7/06/23 at 3:06 p.m. indicated, The skilled nurse contacted [the physician] in regards for the need of ordered controlled medications. [The physician] reports ordered medications have been sent to the pharmacy at this time, awaiting arrival . Record review of pain level summary dated 7/06/23 at 7:30 p.m. indicated Resident #1 had a pain level of 9 out of 10. Record review of the pain level summary dated 7/06/23 at 9:24 p.m. indicated Resident #1 had a pain level of 7 out of 10. Record review of pharmacy packing slips dated 7/06/23 indicated Resident #1's morphine sulfate and hydrocodone had been delivered. During an interview on 7/07/23 at 1:20 p.m. Resident #1 said she had been in pain when she admitted to the facility on [DATE]. Resident #1 said did not receive any pain medication until 7/06/23 at 10:50 p.m. During an interview on 7/12/23 at 1:32 p.m. LVN B said she had worked at the facility 2 weeks. LVN B said she worked the 6:00 a.m.-6:00 p.m. shift. LVN B said Resident #1 in pain when she came in for her shift on 7/06/23. LVN B she was told in report about Resident #1' pain medications not being at the facility. LVN B said the order for Resident #1's pain medications had not been sent to the pharmacy. LVN B said she contacted the physician regarding Resident #1's pain medications. LVN B said she had text the physician regarding Resident #1's pain medication on 7/06/23 at 10:02 a.m. but did not chart that she had contacted him at that time. LVN B said she told Resident #1 that she could administer her some Tylenol. LVN B said Resident #1 refused the Tylenol. LVN B said without documentation there was no way to prove medications were given, communication with the physician had taken place, or that Resident #1 had refused Tylenol. During an interview on 7/12/23 at 1:43 p.m. the pharmacy staff said there was not time of delivery for Resident #1's medication on 7/06/23 documented. The pharmacy staff said they did not have the time the controlled medication order was received from the physician. During an interview on 7/12/23 at 2:26 p.m. the DON said when a new admit was coming from the hospital she expected staff to ask the hospital nurse during report to have the hospital doctor send a triplicate with the resident if they have an order for narcotics. The DON said she expected staff to ask the hospital nurse to administer pain medications to a resident with pain prior to them transferring to the facility. The DON said if a resident was admitted with pain 9 out of 10 she expected the nurse to reach out to the physician regarding sending in a controlled medication order if needed and get an order for an as needed pain medication until the pain medication requiring a controlled medication order was available. The DON said if it was after hours the nurses had access to on-call physicians to request an order for pain medication. The DON said the facility's Medical Director had standing ordered for all residents for Tylenol for pain. The DON said when she came into work on 7/06/23 Resident #1 was complaining of pain. The DON said she was called to the Resident #1's room. The DON said Resident #1 complained that she had not yet received any pain medication since she had admitted to the facility on [DATE] and was in pain. The DON said the nurse had been working on getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 4 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1's pain medication all day on 7/06/23. The DON said it was important to manage resident's pain so the residents were pain free. The DON said if something was not charted the only way to prove it had been done would be ask the physician. During an interview on 7/12/23 at 3:41 p.m. the Medical Director said he was familiar with Resident #1. The Medical Director said he had not seen Resident #1 in person yet. The Medical Director said the facility had notified him on 7/06/23 regarding Resident #1's pain. The Medical Director said he could not verify what time he was notified of Resident #1's pain. The Medical Director said he sent the controlled medication order to the pharmacy for Resident #1's morphine sulfate and hydrocodone on 7/06/23. The Medical Director said he could not verify the time the controlled medication orders for these medications was sent to the pharmacy. The Medical Director said the facility had standing orders from him for residents to receive Tylenol for pain. During an observation and interview on 7/13/23 beginning at 12:15 p.m. Resident #1 was lying in the hospital bed resting. Resident #1 said she did not feel good at all. Resident #1 said she did not remember speaking to the surveyor last week or her admission to the facility. During an interview on 7/13/23 at 2:32 p.m. LVN G said she was the nurse who admitted Resident #1 on 7/05/23. LVN G said Resident #1 complained of pain of 9 out of 10. LVN G she had 3 admissions the night that Resident #1 was admitted to the facility. LVN G said the ADON had assisted with inputting orders on 7/05/23. LVN G said her admission assessments for Resident #1 were not completed until 7/6/23, but she had dated them for the night Resident #1 admitted on [DATE]. LVN G said she gave Resident #1 pain medication on 7/06/23. LVN G said the night that she admitted Resident #1 had said she was in pain around midnight and asked for her pain medicine. LVN G said Resident #1 said she was always in pain. LVN G said on 7/05/23 she offered Resident #1 Tylenol and that Resident #1 accepted the Tylenol, but that she did not document giving her Tylenol. LVN G said LVN B gave her report on 7/06/23. LVN G said the LVN B told her in report that she had to contact the pharmacy after the first pharmacy run regarding Resident #1's pain medication and reached out to the physician regarding sending the controlled medication order to the pharmacy. LVN G said that she assumed in the facility's EMR it could be seen when the assessments had been completed. LVN G said she actually never completed the admission evaluation and locked it due to not having Resident #1's height and weight. LVN G said there was no way to prove she had administered Tylenol to Resident #1 due to it not being charted. LVN G said when she came on shift 7/05/23 at 6:00 p.m. the day shift nurse had already taken report from the hospital on Resident #1. LVN G said the report sheet it indicated Resident #1's narcotics order had already been sent to the pharmacy. LVN G said she did not contact the physician regarding Resident #1's pain medication due to being told in report it had been sent to the pharmacy. LVN G said she did not call the pharmacy to verify the narcotics orders were there because she had 3 admissions (3 new residents transferred to the facility from home, the hospital, or another nursing facility) and did not have the time. LVN G said it was important to administer scheduled pain medication to help keep their pain under control and not let it get to an excruciating level. Record review of the facility's Pain Management Policy dated 10/24/2022 indicated, The facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences .The facility will utilize a systemic approach for recognition, evaluation, treatment, and monitoring of pain. Pain evaluation are completed on admission, quarterly, with a significant change of condition, and as needed .Based on professional standards of practice, an assessment or evaluation by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 5 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few information, as applicable to the resident: History of pain and its treatment .Asking the patient to rate the intensity of his/her pain using a numeric scale, a verbal or visual indicator that is appropriate and preferred by the resident .Reviewing the resident's current medical conditions .Impact of pain on quality of life .Current prescribed pain medications .Based on the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission . The Administrator was notified on 7/13/2023 at 11:55 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/13/2023 at 11:57 a.m. The facility's Plan of Removal was accepted on 7/14/2023 at 7:35 a.m. and included: 1. Immediately Resident # 1 discharged to hospital on 7/11/23. A Pain User defined assessment will be completed on 100% of all residents in center by the DON/designee to identify if any other residents are experiencing pain. This will be completed today 7/13/23 at 6:00 pm. DON or designee will notify the physician of any resident experiencing unrelieved pain with current pain regimen. This will be completed 7/13/2023 at 6:00 pm if applicable DON or designee will provide all license nurses education on Pain Management Policy this will be completed 7/13/23 at 6:00 pm. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Notification of Change in Condition Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Medication Administration Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. 2. Identification of Residents Affected or Likely to be Affected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 6 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON/Designee will complete a Pain assessment on 100% of all residents in center to identify if any other residents experiencing pain. This will be completed 7/13/2023 at 6:00 pm, and Physician notification will be completed by charge nurse of resident, for any resident identified with pain. 3. Actions to Prevent Occurrence/Recurrence: DON/Designee will Provide all nurses with education on Pain Management Policy. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. DON/Designee will Provide all nurses with education on Notification on Change of Condition. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. DON/Designee will Provide all nurses with education on Medication Administration Guidelines. This will be completed by 7/13/2023 at 6:00 pm. No nurse will be allowed to work until this education has been completed. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. DON/Designee completed 100% audit on 7/13/2023 at 4:00 pm and validated that all residents who receive pain medication, have medication available. DON/Designee started education with all license nurses on Control Substance Prescriptions Guidelines (which includes back up procedures for new admissions, including notifying physician and telehealth physician after hours for orders.). This education will be completed on 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. 4. Monitoring: DON or designee will monitor daily the 24hr sheets to identify any residents with unrelieved pain with physician notified of any identified. DON or designee will complete the QAPI pain monitor tool daily x 30 days, to validate no resident are experiencing unrelieved pain. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 7/13/2023 The facility's Medical Director was notified of the immediate jeopardy at 1:41pm on 7/13/23 by the administrator. On 7/13/23 4:00 pm an ad hoc QAPI meeting was conducted including medical director to discuss findings and sustained compliance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 7 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 7/14/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 7/14/23 between 10:53 a.m. and 11:25 am (LVN A, LVN B, RN C, LVN D, LVN E, LVN F) were performed. All staff interviewed were able to name types of non-verbal pain indicators, non-pharmacological pain interventions, when to notify the physician, how to obtain pain medication for newly admitted residents, what information should be documented in the resident EMR, and proper medication administration and documentation. A random sample of resident EMR's were reviewed to ensure pain assessments had been completed on 7/13/23. Record review of QAPI meeting sign-in sheet dated 7/13/23 indicated appropriate staff in attendance. Record review of the DON's signed statement indicated pain medication audit and verification had been completed on all residents receiving pain medication. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 8 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 2 of 5 residents reviewed for pharmacy services. (Resident #1 and Resident #2) The facility failed to ensure Resident #1 was administered her morning doses of atorvastatin (medication for high cholesterol), metoprolol succinate (medication for high blood pressure), cefdinir (an antibiotic), Namenda (medication for dementia), gabapentin (medication for nerve pain), and oxybutynin (medication for overactive bladder) that were available in the facility's e-kit (emergency medication kit) on 7/6/23 The facility failed to ensure Resident #2 was administered his night doses of Flomax (medication for urinary retention), metformin (medication for diabetes), protonix (medication for heart burn), and simvastatin (medication for high cholesterol) that were available in the facility's e-kit (emergency medication kit) on 7/6/23. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: 1. Record review of the consolidated physician orders dated 7/12/23 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis including gastric ulcer with hemorrhage (internal bleed of a stomach ulcer), hypertension (high blood pressure), chronic pain syndrome, overactive bladder, and gastroesophageal reflux disease (heart burn). The physician orders indicated Resident #1 had orders for atorvastatin 40mg by mouth in the morning starting 7/06/23, metoprolol succinate 25mg by mouth in the morning starting 7/06/23, cefdinir 300 mg by mouth twice a day starting 7/06/23, Namenda 10mg by mouth in the morning starting 7/06/23, gabapentin 100mg by mouth three times a day starting 7/06/23, and oxybutynin 5mg by mouth three times a day starting 7/06/23. Record review of the medication administration record (MAR) dated July 2023 indicated Resident #1 was not administered her atorvastatin 40mg, metoprolol succinate 25mg, cefdinir 300mg, Namenda 10mg, gabapentin 100mg, and oxybutynin 5mg on the morning of 7/06/2023. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 13 and was cognitively intact. Record review of the Inventory Expiration Report dated 4/10/23 for the facility's e-kit/automated medication dispensing system had the following medication and quantities available: Atorvastatin 40mg-8 tablets Cefdinir 300mg-6 capsules Metoprolol Succinate 25mg-10 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 9 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0755 Oxybutynin 5mg-5 tablet Level of Harm - Minimal harm or potential for actual harm Gabapentin 100mg-8 capsules Namenda 5mg-5 tablets Residents Affected - Few During an interview on 7/7/23 at 1:20 p.m. Resident #1 said she did not remember if she received routine medications the morning of 7/6/23. During an interview on 7/12/23 at 1:32 p.m. LVN B said that the nurses were responsible for giving the resident the initial doses of medication. LVN B said the medication can be pulled from e-kit/ automated medication dispensing system if they had not arrived from the pharmacy. LVN B said Resident #1's medication had come in from the pharmacy. LVN B said she initial dosed all of Resident #1's morning medication on 7/06/23 but did not document the administration. LVN B said without documentation there is no way to prove medications were given. 2. Record review of the consolidated physician orders dated 7/12/23 indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including diabetes, hyperlipidemia (elevated cholesterol), gastroesophageal reflux disease, and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). The physician orders indicated Resident #2 had orders for Flomax (medication for urinary retention) 0.4mg by mouth at bedtime starting 7/06/23, metformin (medication for diabetes) 500mg by mouth at bedtime starting 7/06/23, protonix (medication for gastroesophageal reflux disease) 40mg by mouth at bedtime starting 7/06/23, and simvastatin (medication for high cholesterol) 10mg by mouth at bedtime starting 7/06/23. Record review of the medication administration record (MAR) dated July 2023 indicated Resident #2 was not administered his Flomax 0.4mg, metformin 500mg, protonix 40mg, and simvastatin 10mg at bedtime starting 7/06/23. Record review of the MDS dated [DATE] indicated Resident #2's MDS had not been completed. Record review of the Inventory Expiration Report dated 4/10/23 for the facility's e-kit/automated medication dispensing system had the following medication and quantities available: Metformin 500mg-10 tablets Protonix 40mg-6 capsules Simvastatin 10mg-5 tablets Flomax 0.4mg-6 capsules During an interview on 7/12/23 at 12:20 p.m., the Administrator said LVN G was in the hospital and not available for interview. During an interview on 7/12/23 at 12:32 p.m. the DON said LVN J and LVN B were the nurses who administered all medications to newly admitted residents on 7/6/23. During an interview on 7:12 at 12:38 p.m. the DON said a nurse would be required to initially dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 10 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0755 medications for residents that are newly admitted . Level of Harm - Minimal harm or potential for actual harm During an interview on 7/12/23 at 1:43 p.m. a pharmacy staff member said there was not a time of delivery documented for Resident #1 or Resident #2's medication that was documented delivered on 7/06/23. Residents Affected - Few During an interview on 7/12/23 at 1:57 p.m. LVN J said she had worked at the facility since May 2020. LVN J said with a new admission they try to call in medications to the pharmacy after receiving report from the hospital. LVN J said the pharmacy delivered to the facility twice a day. LVN J said if the pharmacy has not delivered and medications were due the nurse should pull them from the e-kit/automated medication dispensing system. LVN J said nurse were required to initial dose medications and were the only staff able to access the e-kit/automated medication dispensing system. LVN J said it was important to get what routine medications were available out of the e-kit/automated medication dispensing system to ensure the residents medication stayed regulated. LVN J said if something was not charted or charted at the wrong time there was no way to prove that it happened or happened at a different time. During an interview on 7/12/23 at 2:26 p.m. The DON said nurses should pull available medications from the e-kit/automated medication dispensing system to administer to newly admitted residents until their medications arrive from the pharmacy. The DON said she worked remotely and inputs orders when a resident is admitted to the facility. The DON said when orders were input into the EMR they were electronically forwarded straight to the pharmacy. The DON said it was important for routine medication to be administered when available from the pharmacy or in the e-kit/automated medication dispensing system for continuation of care. The DON said if something was not charted the only way to prove it had been done would be ask the physician. The DON said when a medication was got out of the e-kit/automated medication dispensing system the pharmacy was notified and replaced that medication. During an interview on 7/12/23 at 3:41 p.m. the Medical Director said for routine medications that were non-narcotic, the staff could get what was available out of the e-kit/automated medication dispensing system. The Medical Director said he would expect the nurses to get medications that were available out of the e-kit/automated medication dispensing system to administer to the residents especially newly admitted residents so they did not go without their medications. Record review of the facility's Medication-Treatment Administration and Documentation Guidelines policy revised 2/02/14 indicated, .Medication-Treatment Administration and Documentation Guidelines applies to licensed nurses and certified medication aides according to licensure or certification scope of practice .Administer the medication according to the physician order .Circle initials for those medication or treatment that were not administered and document reason for the non-administration on the back of the MAR .Check the E Box list for medication not available. If medication not available verify availability with the pharmacy. Notify the physician when medication or treatment will be available, provide information regarding medications in E Box and document physician response . Record review of the facility's Emergency Pharmacy Service & Emergency Kits policy revised 8/2020 indicated, Emergency pharmacy service is available 24 hours a day. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in portable, sealed containers in compliance with applicable state regulations .When accessing medications from the emergency kit or electronic interim box secondary to a new order, or when medication for which there is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 11 of 12 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 675424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm current prescription is not readily available, the nurse should not take a medication from the e-kit or electronic interim box without checking allergies on the medical record and possible drug-drug interactions with the pharmacist . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 12 of 12