Inspection·January 15, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate assessments were completed for 2 of 6 residents (Residents #3 and #41) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Residents #3 and #41's MDS assessments were accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. A review of Resident #3's face sheet for January 2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder and major depressive disorder. A review of Resident #3's PASRR Form 1012 (used to determine whether an individual has a primary dementia diagnosis or if they have a mental illness diagnosis) done 12/05/2023 indicated she now had a primary diagnosis of dementia and would not qualify for specialized services. A review of Resident #3's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression and bipolar disorder. During an interview on 01/15/2025 at 1:30 p.m., MDS RN H said during an audit they discovered a PASRR Level 1 screening was not done for Resident #3. She said they completed Form 1012 (used to determine whether an individual has a primary dementia diagnosis or if they have a mental illness diagnosis) for Resident #3 because she had a primary diagnosis of dementia. 2. A review of Resident #41's face sheet for January 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder and schizophrenia. A review of Resident #41's PASRR Level 1 screening done 01/25/2024 indicated she was positive for MI. A review of Resident #41's PASRR Evaluation done 02/02/2024 indicated she was positive for MI. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #41's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had bipolar disorder and schizophrenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 2 of 8 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 01/15/2025 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 0641 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 01/15/2025 at 11:15 a.m., MDS RN B said the facility did not have a policy and used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said if she had any questions regarding the MDS assessment she went directly to the RAI manual. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said she had been taught if the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and she was told to answer no because they were negative. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. Event ID: Facility ID: 675424 If continuation sheet Page 3 of 8 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 01/15/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were completed and accurately documented for 1 of 4 residents (Resident #59) reviewed for medical records accuracy. The facility failed to ensure the physician's orders for Resident #59 to received hemodialysis treatment related to renal failure, to be performed three days a week via left upper arm shunt at a dialysis care group facility. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record reviewed of Resident #59's face sheet dated (01/14/2025), and physician's orders dated (01/14/2025), indicated she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included, End Stage Renal Disease (A condition in which the kidneys lose the ability to remove waste and balance fluids), Acute Respiratory Failure with Hypoxia (An absence of enough oxygen in the tissues to sustain bodily functions), Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), and Hypertension. Record review of Resident# #59 MDS dated [DATE] revealed, section C0500 BIMS summary score was 15 which, indicated she was cognitively intact. On 01/13/2025 at 10:30a.m. Observed Resident # 59 (Interview-able), in her room sitting in bed watching TV, C/D & well groomed, bed in low position, water at bedside, call light was in reach, no signs of abuse/neglect. The resident's room was clean and homelike and there were no physical environment hazards identified. Resident said staff assisted her with transfers and ADL care. Resident denied A/N, said she had been on hemodialysis for seven years, and was scheduled on Tuesday, Thursday, and Saturday's every week at a local dialysis unit. She voiced no concerns, and said she was satisfied with her care. Record review of Resident # 59 physician's active orders dated (01/14/2025), indicated there was no orders for Resident #59 to receive hemodialysis treatment to be performed. Record review of Resident #59 care plans dated 12/19/2024, indicated focus plan: 1. Dialysis (M-W-F) three days a week, Resident #59 receives dialysis related to renal failure. Hemodialysis treatments to be performed via left upper arm shunt at a dialysis care group. 2. Auscultate shunt site for bruit and palpate for thrill as ordered. Notify physician for absence of bruit/thrill. 3. Obtain lab work per physician orders and report results when available. Record review of the dialysis communication form dated 01/09/2025, indicated Resident #59 vital signs: blood pressure (137/75), respirations (22), and Pulse (74). Resident #59 refused to go to dialysis due to bad weather. Dialysis communication form dated 01/11/2025 indicated vital signs: blood pressure (148/76), respirations (16), and Pulse (64). Sack lunch sent with Resident #59. Communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 4 of 8 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 01/15/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from dialysis: before dialysis weight 74.5kg, after dialysis weight 70.8kg, total fluid removed 3.7kg. Post dialysis assessment vital signs: blood pressure (158/70), respirations (18), and Pulse (68). Dressing to shunt dry, intact, and no concerns. Observations resident up in wheelchair transferred back to facility. During an interview on 01/14/2025 at 9:30a.m., LVN E said, Resident #59 was scheduled for hemodialysis on Tuesday, Thursday, and Saturday. She said the CNA's will get Resident #59 dressed and ready for dialysis, the resident had agreed to go to her appointment which is scheduled for 11:00am today, and a sack lunch will be sent with Resident #59. During an interview on 01/15/2025 at 11:15a.m., ADON B said, the two facility's ADON's were responsible for checking and reviewing all new admissions, re-admissions, check lists, and physician orders to ensure orders were put in accurately. She said, the ADON's were responsible for ensuring medication administration orders, and dialysis treatments were entered into the Electronic Health Record (EHR). ADON B said, Resident #59 was re-admitted to the facility from the hospital on [DATE]), and the dialysis set orders was not re-entered into EHR. During an interview on 01/15/2025 at 11:30a.m., DON said, the two facility's ADON's were responsible for checking and reviewing all new admissions, re-admissions, check lists, and physician orders to ensure orders were put in accurately. She said, the ADON's were responsible for ensuring medication administration orders, and dialysis treatments were entered into the EHR for the correct patient, correct time, correct route, correct dose, correct medication, and the correct documentation accurately. Review of the facility's Nursing Service Policy Maintenance of Electronic Clinical Records dated 08/13/2019, reviewed on 01/15/2025 indicated, a complete, and accurate electronic clinical record will be maintained on each resident and kept accessible for appropriate personnel to deliver the appropriate level of care for each resident. The electronic clinical records will contain at least, the resident's identification, Physician's orders, Physician documentation, Nursing documentation, and the necessary documents and required assessments. Review of the facility's Following Physician Orders Policy dated 09/28/2021, reviewed on 01/15/2025 indicated guidance on receiving and following physician orders guidelines in writing or via fax, the nurse in a timely manner will document the orders by entering the orders, the times, dates, and signature on the physician order sheet. Follow the facility procedure, including noting the orders, submitting to pharmacy, and transcribing to medication or treatment administration record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 5 of 8 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 01/15/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #42 and #76) reviewed for Enhanced Barrier Precautions. Residents Affected - Few LVN E failed to cleanse the injection site prior to administering an insulin injection to Resident #76. LVN F failed to don appropriate PPE (a gown) prior to administering medications via Resident #42's feeding tube. These failures could place residents under their care at risk for the transmission of communicable diseases and infections. Findings include: 1.Record review of a face sheet dated 01/14/2025 indicated Resident #76 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included Type II Diabetes Mellitus (a condition wherein the pancreas does not make enough insulin resulting in the body having trouble controlling blood sugar and using it for energy). Record review of the quarterly MDS dated [DATE] noted Resident #76 had a BIMS score of 15 which indicated her cognition was intact. The MDS also indicated Resident #76 received insulin injections for the treatment of Diabetes Mellitus. Record review of the Resident #76's physician orders indicated an order dated 11/06/2024 for Resident #76 to be given sliding scale insulin pen injections 4 (four) times a day before meals and at bedtime (The term sliding scale refers to the pre-meal and bedtime dose of insulin based on the blood sugar level before the meal and at bedtime). During an observation and interview on 01/13/2025 at 11:30 AM, LVN E prepared to administer insulin using an insulin pen (a small, lightweight pen that is pre-filled with insulin). She obtained the prescribed insulin pen from her nurse's cart, sanitized her hands, and donned a pair of gloves. LVN E entered Resident #76's room and told Resident #76 she was going to administer insulin. LVN E used her left hand to pull up the sleeve on Resident #76's right arm and hold it in place while she used her right hand to administer the insulin injection into the right upper arm. LVN E did not have an alcohol pad nor did she use anything else to cleanse Resident #76's injection site prior to administering the insulin injection. LVN E said she forgot to cleanse the injection site prior to administering the insulin. LVN E said she should have used an alcohol wipe pad to cleanse the site prior to administering the insulin injection. LVN E said cleansing the injection site prior to giving an injection was important to reduce the risk of infection. A record review of the facility's policy dated 03/12/2015, revised on 02/10/2020, and titled Insulin Pen Administration indicated the following: Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 6 of 8 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 01/15/2025 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 0880 The purpose of the policy is to provide safe practice guidelines during insulin pen administration to avoid transmission of microorganisms that put patients at risk for infection. Level of Harm - Minimal harm or potential for actual harm Procedure . Residents Affected - Few Clean the skin at the injection site with sterile alcohol swab Inject dose . 2. Record review of a face sheet dated 01/14/2025 indicated Resident #42 was a [AGE] year-old male who was admitted to the facility on [DATE] and was re-admitted on [DATE]. He had diagnoses which included dysphagia (difficulty swallowing) related to cerebrovascular accident (stroke), vascular dementia (brain damage caused by multiple strokes), protein calorie malnutrition, and PEG tube (a feeding tube placed through the skin and abdominal wall in to the stomach for nutrition). Record review of the admission MDS dated [DATE] noted Resident #42 had a BIMS score of 00 (zero) which indicated his cognition was severely impaired. The MDS also indicated Resident #42 had a feeding tube by which he received nutrition. Record review of Resident #42's care plan dated 01/14/2025 indicated Resident #42 required EBP due to having a feeding tube. The care plan specified interventions for EBP which including ensuring an EBP sign was posted on the door to Resident #42's door and on the wall above his bed and ensuring PPE was available for use. During an observation and interview on 01/14/2025 at 8:40 AM, LVN F prepared Resident #42's morning medications for administration through his feeding tube. She donned gloves and entered Resident #42's room. Resident #42 had a sign on his room door facing the hallway which indicated EBP was required. The sign also said that all providers and staff must wear gloves and a gown for high-contact activities which included feeding tube care or use and a second EBP sign with the same information was noted on the wall above the head of Resident #42's bed. There was a 3-drawer plastic container outside the doorway which contained PPE that included gloves and gowns. LVN F did not put on a gown. LVN F told Resident #42 that she was going to give him his medications through his feeding tube. LVN F attempted to obtain an unsealed plastic bag containing a 60 mL syringe that was hanging from the portable pole at Resident #42's bedside. During her attempt to release the bag from the pole, the bag with the syringe in it fell to the floor. Using her gloved hands, LVN F picked the bag and syringe up from the floor, removed the syringe from the unsealed bag, and laid the plastic bag on the bedside nightstand. Without changing her gloves, sanitizing her hands, nor obtaining a new syringe, LVN F used the syringe that was obtained from the bag that fell to the floor to check for tube placement and administer water flushes and medications through the feeding tube. LVN F re-capped the tube when she finished with the medication administration. LVN F then placed the syringe back inside the plastic bag and hung it back on the pole. LVN F removed her gloves, disposed of them in the trash, and left the room. LVN F performed hand hygiene and said she was done. During an interview on 01/14/2025 at 9:20 AM, LVN F said she was not sure exactly what the letters EBP stood for but knew it had to do with infection control. She said EBP meant staff were supposed to wear a mask, gown, and gloves when handling catheters and wounds. When asked if she should have donned a gown prior to handling Resident #42's feeding tube, LVN F said she was not sure. When surveyor asked LVN F to review the EBP sign on Resident #42's door, LVN F read the sign aloud, saying that a gown and gloves were to be used during high-contact resident care activities which included feeding tubes. LVN F said she should have put a gown on in addition to her gloves before handling Resident #42's feeding tube. LVN F said she should have gotten a new syringe instead of using the one that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 7 of 8 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 01/15/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was dropped on the floor. She said microorganisms on the floor could have transferred to the bag containing the syringe. She said she may have contaminated her gloves when she picked the bag from the floor and transferred microorganisms to the syringe when she withdrew it from the bag and possibly spread infection when she handled Resident #42's feeding tube with her contaminated gloves. During an interview on 01/15/2025 at 1:30 PM, ADON D said she was the Infection Preventionist for the facility. She said she expected the nurses to follow the facilities policies on infection control and prevention including the policies on insulin pen use and EBP. She said she expected the nurses to cleanse all injection sites prior to administering injections to reduce the risk for transmission of infection. ADON D said the purpose of EBP was to reduce the risk of spreading infection. ADON D said LVN E should have cleansed the injection site with an alcohol pad prior to administering the injection. ADON D said LVN F should have donned a gown prior to handling Resident #42's feeding tube. ADON D said LVN F should have discarded the dropped syringe and bag and gotten a new one. Record review of the facility's policy dated10/24/2022 and titled Infection Prevention and Control Program indicated the following: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per national standards and guidelines. 6. Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices (e.g.feeding tube .) regardless of MDRO status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675424 If continuation sheet Page 8 of 8