Health inspection·December 8, 2022

F 0583 had gotten worse. Level of Harm - Minimal harm or potential for actual harm Interviews on 12/08/22 at 2:28 PM and 9:18 AM with Social Worker revealed Resident # 16 had diagnoses of depression and bipolar disorder. She stated she was currently being seen by a psychiatrist and psychologist for her mental illness. She stated Resident #16's psychologist should be meeting with Resident #16 privately. Residents Affected - Few Record Review of Resident #16's individual therapy notes from August to December 2022 revealed Resident had individual counseling on 08/09/22, 08/23/22, 09/13/22, 09/27/22, 10/11/22, 10/25/22, 11/15/22. The counseling forms reflected recommended therapy once a week. Record Review of Resident #16's individual therapy note completed by Consultant Psychologist G dated 11/15/22 reflected Resident #16 had symptoms of depression and anxiety. She stated feeling better after the therapy. Goals for therapy including reducing symptoms of anxiety and depression. Psychotherapy is recommended 1 time a week. Record Review of Resident #16's Psychiatric Evaluation/Management Visit note dated 11/22/22 completed by Consultant Psychiatrist F reflected Resident #16 was being seen for anxiety, depression/sadness and psychosis. Resident #16 had diagnoses of bipolar disorder, generalized anxiety disorder and major depressive disorder. Interview on 12/07/22 at 3:05 PM with the DON revealed Resident #16 loved attention. She stated she was unaware of Resident #16's therapy sessions with the Consultant Psychologist G not being done in a private setting. She stated Resident #16 should have therapy sessions in a private setting. Interview on 12/07/22 at 3:46 PM with Consultant Psychologist G revealed she was supposed to meet Resident #16 weekly as per therapy recommendations but only came to facility every 2 weeks to see Resident #16. She stated she had talked with Resident #16 when she was in dining room . She stated she would make sure from now on she met with Resident #16 privately. Interview on 12/08/22 at 12:55 PM with Consultant Psychiatrist F revealed she will go see Resident #16 today. She stated she visited with Resident #16 about twice a month for short amount of time for medication management. She stated Resident #16 should be asked if she would like to go somewhere more private to talk and if resident wants privacy, it should be followed. Record Review of facility's policy Behavioral Health Services last revised February 2019 reflected The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Behavioral health services are provided to residents as part of the Interdisciplinary, person-centered approach to care. 2. Residents who exhibit signs of emotional /psychosocial distress receive services and support that address their individual needs and goals for care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 2 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #7 and #16) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan to address Resident #7's WanderGuard and history of exit seeking behavior. 2. The facility failed to develop a comprehensive person-centered care plan to address Resident #16's bipolar disorder and interventions for depression. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of traumatic brain injury, hypertension, Parkinson's disease and seizures. Resident #7 required extensive assistance with transfers, dressing and toileting ADLs. Resident #7 had a BIMS of 10 indicating he was moderately cognitively impaired. He had no behaviors. Record Review of Resident #7's Current Physician Orders dated 12/08/22 reflected a physician order dated 01/12/20 to check WanderGuard and record activation and expiration date weekly. Record Review of Resident #7's Current Comprehensive Care Plan undated did not reflect Resident #7 had a WanderGuard and had history of exit seeking behavior. Observation on 12/06/22 at 10:08 AM revealed Resident #7 was in his room and had a WanderGuard around his right ankle. Interview on 12/07/22 at 2:28 PM with Social Worker revealed Resident #7 did have a WanderGuard placement and has tried to go out exit door before. Interview on 12/08/22 at 12:25 PM with Unit Manager E revealed Resident #7 did attempt to go out one of the back exit doors on hallway before. She stated Resident #7 verbalized he wanted to leave but no there was no recent exit seeking behavior. She stated Resident #7 had a WanderGuard for resident safety and because of his exit seeking behavior in the past. She was not aware WanderGuard and Resident's exit seeking behavior was not care planned. Interview on 12/08/22 at 1:05 PM with Patient Care Coordinator revealed Resident #7 did have a WanderGuard for resident safety due to history of exit seeking behavior. She stated Resident #7's WanderGuard and exit seeking behavior should be care planed. 2. Record Review of Resident #16's Annual MDS dated [DATE] reflected she was a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 3 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some female admitted to the facility on [DATE] with diagnoses of hypertension, dementia, Depression and bipolar disorder and chronic obstructive pulmonary disorder. Resident #16 had a BIMS of 12 indicating she was moderately cognitively intact. She had a mood score of 15 indicating she had moderately severe depression. She received antidepressant medications. Record Review of Resident #16's Quarterly MDS assessments dated 09/20/22 and 06/21/22 reflected she had diagnoses of bipolar disorder and depression. Resident #16's mood score was 0 indicating no mood issues. Resident #16 was receiving antidepressant medications. Record Review of Resident #16's Active Diagnoses List undated reflected she was admitted on [DATE] with diagnoses of Major Depression Disorder and Bipolar Disorder. Record Review of Resident #16's individual therapy notes from August to December 2022 revealed Resident had individual counseling on 08/09/22, 08/23/22, 09/13/22, 09/27/22, 10/11/22, 10/25/22, 11/15/22 for anxiety and major depression disorder. The counseling forms reflected recommended therapy once a week. Record Review of Resident #16's psychiatric evaluation/management nurse notes from June to October 2022 reflected Resident #16 was seen for management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. Resident #16 had diagnoses of bipolar disorder, generalized anxiety disorder and major depressive disorder. Record Review of Resident #16's Psychiatric Evaluation/Management Visit note completed by Consultant Psychiatrist F dated 11/03/22 reflected Resident #16 had diagnoses of Bipolar disorder, generalized anxiety disorder and major depressive disorder. It reflected Depression: managed with Cymbalta, Anxiety: stable and Bipolar disorder: stable Record Review of Resident #16's individual therapy note completed by Consultant Psychologist G dated 11/15/22 reflected Resident #16 had symptoms of depression and anxiety. She stated feeling better after the therapy. Goals for therapy including reducing symptoms of anxiety and depression. Psychotherapy is recommended 1 time a week. Record Review of Resident #16's Psychiatric Evaluation/Management Visit note dated 11/22/22 completed by Consultant Psychiatrist F reflected Resident #16 was being seen for anxiety, depression/sadness and psychosis. Resident #16 had diagnoses of Bipolar disorder, generalized anxiety disorder and major depressive disorder. Record Review of Resident #16's Comprehensive Care Plan last evaluated on 11/10/22 reflected Resident #16 was currently taking psychotropic medications as evidence by depression. Interventions included to monitor and record any displayed behavior or mood problems, monitor effectiveness of psychotropic medications and psych consult as needed. It did not address specific interventions for Resident #16's depression. The care plan did not address her bipolar disorder. Observation and Interviews on 12/06/22 at 10:19 AM and 11:45 AM with Resident #16 revealed she was in her room. She stated her depression was getting worse and talking to a professional like a counselor would help her. Resident #16 stated she had issues with her family member recently and that has made her depression much worse. She stated the psychologist did not meet with her privately the last two times she saw her and she was in the dining room. She stated it had been awhile since she last saw the Consultant psychologist G privately and did not see her that often. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 4 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and Interview on 12/07/22 at 2:13 PM with Resident #16 revealed she did not open up like she wanted to and able to be honest with Consultant Psychologist G if she could not have privacy to talk with her. She stated talking to someone like Consultant Psychologist G had helped her with her depression, but she needed to meet with her more often especially now since her depression had gotten worse. Resident #16 became tearful with tears coming down her face and said she felt like shit and was less social than usual not wanting to participate in group activities like she did before. Interview on 12/07/22 at 2:28 PM with Social Worker revealed this was the first time she saw Resident #16 crying and she was having issues with family. Resident # 16 had diagnoses of depression and bipolar disorder. She stated she was currently being seen by a psychiatrist and psychologist for her mental illness. She stated Resident #16 had depression and bipolar diagnoses for a long time but was not sure how long. She stated yesterday her not going to eat in dining room for lunch was out of her normal. Interview on 12/07/22 at 3:05 PM with DON revealed Resident #16 had depression and bipolar disorder. She was seeing a psychiatrist and psychologist to assist her with her mental illnesses. She stated Unit Managers and Patient Care Coordinator were responsible for care planning. Interview on 12/07/22 at 3:15 PM with Unit Manager D revealed she was not aware depression and bipolar disorder needed to be care planned for Resident #16. Interview on 12/07/22 at 3:20 PM with Patient Care Coordinator revealed Resident #16 only had a care plan for depression medications and care plan did not mention Resident #16's bipolar disorder. She was not aware depression and bipolar disorder should have been care planned for Resident #16. Interview on 12/07/22 at 3:46 PM with Consultant Psychologist G revealed she provided individual therapy to Resident #16 every 2 weeks for her bipolar, depression and anxiety. She stated she last saw Resident #16 on 11/29/22 but did not have it documented yet. Review of facility's policy Assessments dated November 2017 reflected: .6. A comprehensive, person-centered plan of care, consistent with the resident rights The policy did not specify what specific areas need to be care planned. Record review of facility's policy Behavioral Health Services last revised February 2019 reflected .Behavioral health services are provided to residents as part of the Interdisciplinary, person-centered approach to care. 2. Residents who exhibit signs of emotional /psychosocial distress receive services and support that address their individual needs and goals for care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 5 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #33) of two residents reviewed for incontinence care. The facility failed to ensure CNA C and CNA B provided appropriate perineal care for Resident #33 after assisting resident with the bed pan when CNA C failed to clean the resident's perineal area. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Review of Resident #33's quarterly MDS assessment, dated 10/28/22 reflected a [AGE] year-old female with an admission date of 04/29/19. She had a BIMS of 12, indicating she was moderately cognitively impaired. Resident #33 required extensive one person assistance with toileting and personal hygiene and was occasionally incontinent of urinary bladder and continent of bowel. Resident #33 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included coronary artery disease, dementia, and cerebrovascular disease. Review of Resident #33's Comprehensive Care Plan dated 07/28/22, reflected, . Toileting- [Resident #33] requires extensive assistance . [Resident #33] will have toileting needs met with the assistance of 1-2 people .Interventions .Provide hygiene after voiding/Bowel movements to prevent skin breakdown. Apply moisture barriers . Review of CNA C's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 10/19/22 and was competent to provide care. Review of CNA B's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 10/19/22 and was competent to provide care. In an observation on 12/06/22 at 10:30 a.m. revealed CNAs B and C entered Resident #33's room with mechanical lift. Both staff put on clean gloves without performing hand hygiene. CNA C asked Resident #33 if she needed to use the bed pan, which the resident said yes. CNA C rolled the resident over on her right side and placed a bed pan under the resident. When resident had finished, she rolled the resident off the bedpan revealing she had urinated. CNA C wiped the resident's anal area from front to back, revealing she also had some bowel movement. CNA C wiped a few times more and then emptied the bed pan. CNA C removed her gloves and put on clean gloves without performing hand hygiene and placed a clean brief under the resident and opened packages of barrier cream, which accidentally dropped on the floor. CNA C picked up with barrier cream with a wipe, removed her gloves and without performing hand hygiene left the room to retrieve more gloves and more barrier cream. CNA C re-entered the resident's room and placed a new box of gloves in the glove holder by the resident's sink and put on clean gloves without performing hand hygiene. CNA C then applied barrier cream, removed her gloves, and re-gloved without performing hand hygiene and rolled the resident back onto the brief without ever cleaning her perineal area. CNA B and CNA C fastened the resident brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 6 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 In an interview with CNAs B and C on 12/06/22 at 11:00 a.m. CNA C stated she was supposed to clean from front to back when providing perineal care and stated by failing to provide proper peri care it placed the resident at risk of infections. In an interview with the DON on 12/08/22 at 01:35 p.m. She stated anytime a staff member assisted a resident with a bed pan, they were to clean the resident from front to back. She stated by not cleaning a resident properly it placed them at risk for urinary tract infections and skin breakdown. Review of the facility's policy titled, Perineal Care Protocol, dated February 2022, reflected, Cleansing the perineal area between showers or baths, helps prevent irritations, infection, and skin breakdown as well as keeping the Patient comfortable .Wash hands; apply gloves .Assist patient to supine position and remove soiled clothing and/or brief, if needed to clean soiled areas first by wiping of fecal material with wipes .Remove gloves, sanitize hands and apply new gloves .Place a clean towel under patient's buttocks .Using a new wipe, wash, beginning from center of abdomen, and clean outwards from front to side .Wash from front towards rectum, front to back, and using clean stroke. Never wipe back and forth from the back to the top .Separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back .Using a new wipe, wash from vagina toward rectum with one stroke, front to back, repeat, if necessary, with a new wipe as all feces must be cleaned off .With new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock .Wash/sanitize hands. Apply clean gloves .apply barrier cream to perineal and buttock area, dispose of gloves, sanitize hands, and apply clean gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 7 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (Resident #16) of five residents reviewed for behavioral health services. The facility failed to ensure Resident #16 was receiving individual therapy once a week by Consultant Psychologist G. This failure could place residents at risk for not receiving behavioral healthcare services and a decrease in quality of life. Findings included: Record Review of Resident #16's Annual MDS dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, dementia, Depression and bipolar disorder and chronic obstructive pulmonary disorder. Resident #16 had a BIMS of 12 indicating she was moderately cognitively intact. She had a mood score of 15 indicating she had moderately severe depression. She received antidepressant medications. Record Review of Resident #16's Quarterly MDS assessments dated 09/20/22 and 06/21/22 reflected she had diagnoses of bipolar disorder and depression. Resident #16's mood score was 0 indicating no mood issues. Resident #16 was receiving antidepressant medications. Record Review of Resident #16's Active Diagnoses List undated reflected she was admitted on [DATE] with diagnoses of Major Depression Disorder and Bipolar Disorder. Record Review of Resident #16's Comprehensive Care Plan last evaluated on 11/10/22 reflected Resident #16 was currently taking psychotropic medications as evidence by depression. Interventions included to monitor and record any displayed behavior or mood problems, monitor effectiveness of psychotropic medications and psych consult as needed. The care plan did not address her bipolar disorder. Record Review of Resident #16's current physician orders reflected a physician order dated 10/14/21 for psychiatry/psychology referral and psychiatry and psychology care to evaluate and treat. Record Review of Resident #16's individual therapy notes from August to December 2022 revealed Resident had individual counseling on 08/09/22, 08/23/22, 09/13/22, 09/27/22, 10/11/22, 10/25/22, 11/15/22. The counseling forms reflected recommended therapy once a week. Record Review of Resident #16's Psychiatric Evaluation/Management Visit note completed by Consultant Psychiatrist F dated 11/03/22 reflected Resident #16 had diagnoses of Bipolar disorder, generalized anxiety disorder and major depressive disorder. It reflected Depression: managed with Cymbalta, Anxiety: stable and Bipolar disorder: stable Record Review of Resident #16' s individual therapy note completed by Consultant Psychologist G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 8 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 11/15/22 reflected Resident #16 had symptoms of depression and anxiety. She stated feeling better after the therapy. Goals for therapy including reducing symptoms of anxiety and depression. Psychotherapy is recommended 1 time a week. Record Review of Resident #16's Psychiatric Evaluation/Management Visit note dated 11/22/22 completed by Consultant Psychiatrist F reflected Resident #16 was being seen for anxiety, depression/sadness and psychosis. Resident #16 had diagnoses of Bipolar disorder, generalized anxiety disorder and major depressive disorder. Observation and Interviews on 12/06/22 at 10:19 AM and 11:45 AM with Resident #16 revealed she was in her room. She stated her depression was getting worse and talking to a professional like a counselor would help her. Resident #16 stated she had issues with her family member recently and that has made her depression much worse. She stated the psychologist did not meet with her privately the last two times she saw her, and she was in the dining room. She stated it had been a while since she last saw the Consultant psychologist G privately and did not see her that often. Observation and Interview on 12/06/22 at 12:05 PM revealed Resident #16 told LVN H she was going to stay in her room for lunch. Observation and Interview on 12/07/22 at 2:13 PM with Resident #16 revealed she did not open up like she wanted to and able to be honest with Consultant Psychologist G if she could not have privacy to talk with her. She stated talking to someone like Consultant Psychologist G had helped her with her depression, but she needed to meet with her more often especially now since her depression had gotten worse. Resident #16 became tearful with tears coming down her face and said, she felt like shit and was less social than usual not wanting to participate in group activities like she did before. Interview on 12/07/22 at 2:18 PM with Resident #16 revealed she told social worker she did not want to burden her, and social worker assured her she was available to talk to her. Resident #16 stated she was going to go to bingo now but that's only group activity she wanted to go to right now. Interview on 12/07/22 at 2:28 PM with Social Worker revealed this was the first time she saw Resident #16 crying and she was having issues with family. Resident # 16 had diagnoses of depression and bipolar disorder. She stated she was currently being seen by a psychiatrist and psychologist for her mental illness. She stated Resident #16 had depression and bipolar diagnoses for a long time but was not sure how long. She stated yesterday her not going to eat in dining room for lunch was out of her normal. Follow-up interview on 12/08/22 at 9:18 AM with Social Worker revealed she spoke with Resident #16 yesterday and today she's doing better. She stated she only saw Consultant Psychologist G come out to facility about every 2 weeks and was not aware Resident #16 was to be seen weekly by the Consultant Psychologist G per the therapy notes. She stated going forward the facility will meet with Consultant Psychologist G and review with her to ensure Resident #16 is seen as often as recommended once a week. She stated the Consultant Psychologist G will see Resident #16 next week. Interview on 12/07/22 at 3:05 PM with the DON revealed Resident #16 loved attention. She stated she was not aware yesterday that Resident #16 ate in her room during lunch and that was not like her. She stated she was not aware of Resident #16's depression getting worse. She stated if the nurse had not contacted physician today about increased anxiety and resident requesting some medication help she would have an issue. She stated she was unaware of Resident #16's therapy sessions with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 9 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Consultant Psychologist G not being done in a private setting. She stated she was unaware of Resident #16 not getting the recommended individual therapy sessions and did not know she should have been getting weekly therapy by Consultant Psychologist G. Interview on 12/07/22 at 3:46 PM with Consultant Psychologist G revealed she was supposed to meet Resident #16 weekly as per therapy recommendations but only came to facility every 2 weeks . She stated she had talked with Resident #16 when she was in dining room. She stated she would make sure from now on she met with Resident #16 privately. She said she was off this week and will be seeing Resident #16 next week. She stated she last saw Resident #16 on 11/29/22 but did not have it documented yet. She stated Resident #16's bipolar was stable and she was not aware of Resident #16 having increased depression or anxiety. She stated Resident #16 was compliant with her therapy and Resident #16 did tell her the individual therapy sessions did seem to help her with her depression and anxiety. Interview on 12/08/22 at 12:55 PM with Consultant Psychiatrist F revealed she will go see Resident #16 today. She stated she visited with Resident #16 about twice a month for short amount of time for medication management. She stated Resident #16 should be asked if she would like to go somewhere more private to talk and if resident wants privacy it should be followed. Record Review of facility's policy Behavioral Health Services last revised February 2019 reflected The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Behavioral health services are provided to residents as part of the Interdisciplinary, person-centered approach to care. 2. Residents who exhibit signs of emotional /psychosocial distress receive services and support that address their individual needs and goals for care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 10 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 observation, interview, and record review, the facility failed to 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 two (Resident #33 and Resident #56) of six residents observed for infection control in that: Residents Affected - Some 1. CNA B and CNA C failed to perform hand hygiene during perineal care for Resident #33 and failed to perform hand hygiene before leaving and re-entering Resident #33's room. CNA C failed to wipe Resident #33 from front to back during perineal care. 2. LVN A failed to prevent cross contamination of the bottle of testing strips used to obtain a fingerstick blood sugar on Resident's #56. These failures could place the residents at risk for infection and cross contamination. Findings included: 1. Review of Resident #33's quarterly MDS assessment, dated 10/28/22 reflected a [AGE] year-old female with an admission dated of 04/29/19. She had a BIMS of 12, indicating she was moderately cognitively impaired. Resident #33 required extensive one person assistance with toileting and personal hygiene and was occasionally incontinent of urinary bladder and continent of bowel. Resident #1 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included coronary artery disease, dementia, and cerebrovascular disease. Review of Resident #33's Comprehensive Care Plan dated 07/28/22, reflected, . Toileting- [Resident #33] requires extensive assistance . [Resident #33] will have toileting needs met with the assistance of 1-2 people .Interventions .Provide hygiene after voiding/Bowel movements to prevent skin breakdown. Apply moisture barriers . Review of CNA B's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 10/19/22 and was competent to provide care. Review of CNA C's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 10/19/22 and was competent to provide care. In an observation on 12/06/22 at 10:30 a.m. revealed CNAs B and C entered Resident #33's room with mechanical lift. Both staff put on clean gloves without performing hand hygiene. CNA C asked Resident #33 if she needed to use the bed pan, which the resident said yes. CNA C rolled the resident over on her right side and placed a bed pan under the resident. When resident had finished, she rolled the resident off the bedpan revealing she had urinated. CNA C wiped the resident's anal area and wiped back to front, revealing she also had some bowel movement. CNA C wiped a few times more and then emptied the bed pan. CNA C removed her gloves and put on clean gloves without performing hand hygiene and placed a clean brief under the resident and opened packages of barrier cream, which accidentally dropped on the floor. CNA C picked up with barrier cream with a wipe, removed her gloves and without performing hand hygiene left the room to retrieve more gloves and more barrier cream. CNA C re-entered the resident's room and placed a new box of gloves in the glove holder by the resident's sink and put on clean gloves without performing hand hygiene. CNA C then applied barrier cream, removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 11 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 - Some her gloves, and re-gloved without performing hand hygiene and rolled the resident back onto the brief without ever cleaning her perineal area. CNA B and CNA C fastened the resident brief. CNA B put on the residents' pants while CNA C removed her gloves and without performing hand hygiene, left the room again to retrieve a mechanical lift sling. CNA C re-entered the room put on clean gloves without performing hand hygiene, and she and CNA B placed the resident on the sling and transferred her to her wheelchair. CNA B removed her gloves and without performing hand hygiene, left the room to retrieve a pair of socks for the resident while. CNA C gathered the soiled linens and trash. CNA C removed the glove from her right hand but left the glove on her left hand and carried the trash and soiled linen bags out of the room down the hallway to the soiled linen room. CNA B re-entered the resident's room, put on clean gloves without performing hand hygiene and placed the socks on the resident. CNA C re-entered the resident's room and without performing hand hygiene put on gloves and retrieved a shirt out of the resident's closet and both CNAs changed the resident's shirt. Both CNAs removed their gloves and left the room without performing hand hygiene. In an interview with CNAs B and C on 12/06/22 at 11:00 a.m. Both CNAs stated they were supposed to perform hand hygiene after each glove change and before and after entering the room. Both acknowledged they had not performed hand hygiene during the entire process. CNA C stated she was didn't know why she had not performed hand hygiene, and CNA B stated she was nervous. CNA C stated she was supposed to clean from front to back when providing perineal care and stated by failing to provide proper peri care it placed the resident at risk of infections. In an interview with the DON on 12/08/22 at 01:35 p.m. she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. Review of the facility's policy titled, Perineal Care Protocol, dated February 2022, reflected, Cleansing the perineal area between showers or baths, helps prevent irritations, infection, and skin breakdown as well as keeping the Patient comfortable .Wash hands; apply gloves .Assist patient to supine position and remove soiled clothing and/or brief, if needed to clean soiled areas first by wiping of fecal material with wipes .Remove gloves, sanitize hands and apply new gloves .Place a clean towel under patient's buttocks .Using a new wipe, wash, beginning from center of abdomen, and clean outwards from front to side .Wash from front towards rectum, front to back, and using clean stroke. Never wipe back and forth from the back to the top .Separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back .Using a new wipe, wash from vagina toward rectum with one stroke, front to back, repeat, if necessary, with a new wipe as all feces must be cleaned off .With new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock .Wash/sanitize hands. Apply clean gloves .apply barrier cream to perineal and buttock area, dispose of gloves, sanitize hands, and apply clean gloves . 2. Record review of Resident #56's Face Sheet dated 12/07/22, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus, acquired absence of right leg above knee and chronic kidney disease. An observation on 12/06/22 at 11:30 a.m. revealed LVN A at the medication cart preparing to perform Resident #56's finger-stick blood sugar (FSBS). LVN A removed the glucometer and a bottle of testing strips with an open date of 12/05/22, from the medication cart and wiped down the glucometer with a 3x3 germicidal wipe. LVN A performed hand hygiene, donned gloves, and entered the resident's room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 12 of 13 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 - Some to perform the FSBS, carrying the glucometer, an alcohol wipe, a lancet, and the bottle of testing strips. LVN A opened the bottle of testing strips, pulled one strip out of the bottle, and placed the strip into the glucometer. LVN A then pricked Resident #56's finger and obtained a blood sample for FSBS. LVN A then gathered up the bottle of testing strips with her soiled gloves and returned to the medication cart, removed the test strip from the glucometer, and disposed of it and the lancet and placed the glucometer on a paper towel and placed the bottle of testing strips on top of the medication cart. LVN A removed her gloves, put on clean gloves and opened a single package of germicidal wipe which contained a 3x3 pre-moistened wipe and wiped the glucometer down. LVN A then removed her gloves and placed the contaminated bottle of testing strips into the top drawer of the medication cart and then performed hand hygiene. In an interview with LVN A 12/06/22 at 11:45 a.m., she stated she should not have carried the full bottle of test strips into the room and that by doing so she had contaminated the bottle of strips. She stated she would discard the bottle of test strips. Interview with the DON on 12/08/22 at 1:40 p.m. revealed staff were not to carry in the full bottle of test strips into a resident's room for FSBS. She stated by doing so, they had contaminated the entire bottle of test strips since it was used for multiple patients. She stated failure to follow the correct procedures could lead to infections and cross contamination. Review of the CDC guidelines obtained on 12/09/22 https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, reflected: .The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose ( blood sugar) monitoring and insulin administration .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put person at risk for infection include .Failing to change gloves and perform hand hygiene between fingerstick procedures .A simple rule for safe care .Blood glucose Meters .disinfected after every use .General .unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Do not carry supplies and medications in pockets .Hand hygiene .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other person's Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, reflected, .Place the equipment on the bedside stand or overbed table .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .Wear gloves .Obtain a blood sample .dispose of the lancet in the sharps disposal container .discard disposable supplies .Clean and disinfect reusable equipment between uses .remove gloves .wash hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 13 of 13