Inspection·November 8, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fills his insulin pump and attaches the new pump himself. He stated he monitored his blood glucose with his monitor the on his left upper arm. During an interview on 11/08/2022 at 10:45 AM, Resident #177 stated he did not have his insulin pump on admission to the facility. He stated his family brought the insulin pump to him about a week after being admitted to the facility. He stated before he had his insulin pump, the nurses were checking his finger stick blood sugar and administering Lantus(insulin) every day. He stated now that he had the insulin pump, the nurses asked him what his blood sugar was each day. He stated no one at the facility had monitored him on the use of insulin pump. He stated he took care of it himself. During an interview on 11/08/2022 at 10:50 AM, LVN A stated Resident #177 did not have insulin pump on admission to the facility. LVN A was not able to find an order in resident record for Humalog insulin. She stated Resident #177 was on Lantus at time of admission. She stated Humalog the resident used in insulin pump was kept in the medication room refrigerator on back hall. She stated the resident brought Humalog from home. She stated she asked the resident what his blood glucose readings were each shift but did not record them anywhere in the resident's record. During an interview on 11/08/2022 at 11:20 AM, the DON stated she was not sure why there were no orders for Humalog for Resident #177. She stated she was not sure when Humalog was ordered, and Lantus discontinued. She stated she did not know why there was not a self-medication evaluation for Resident #177 for his use of insulin pump. She stated all residents who wish to self-medicate should be evaluated prior to them doing so, to be sure they were safe with self-medicating. She stated Resident #177's use of insulin pump and his continuous glucose monitor should have been in his baseline care plan. She stated the admission RN or herself initiated the baseline care plan within 48 hours of admission. She stated not knowing the resident need for insulin could affect his health in a negative way, such as blood glucose being too high or too low, not receiving insulin as needed. She stated not monitoring his blood glucose could affect his health in a negative way with resident blood glucose being too low or too high and could cause resident to be hospitalized . She stated the hospital discharge orders had Humalog and insulin pump on his list. S he stated she reviewed the baseline care plans. She stated she did not know what caused the failure to occur. During an interview on 11/08/2022 at 11:23 AM, LVN B stated she did the admission note for Resident #177. She stated the resident had his insulin pump on admission and that he showed her how it was used. She stated for new admissions, she would transcribe hospital orders to facility's Physician orders and then it was reviewed by an RN. She stated the potential for not having insulin pump on orders could be potential for missed doses, blood glucose being too high or too low and either of these could cause resident to be hospitalized . Review of facility's policy titled Base Line Care Plans (no date) The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- . Include the minimum healthcare information necessary to properly care for a resident including, but not limited toInitial goals based on admission orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 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 0655 Physician orders Level of Harm - Minimal harm or potential for actual harm Dietary orders Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transcribing provider Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 4 (Front Long Hall Cart and Back Long Hall Cart) Medication Carts. The facility failed to ensure that all medications and supplies stored in Back Long Hall Cart were properly labeled and not past their expiration date. The facility failed to ensure that all medications and supplies stored in Front Long Hall Cart were properly stored. These failures could place residents at risk of decline in health due to lack of potency of supplies, medications/biologicals, or misappropriation of medications. The findings included: Observation on [DATE] at 12:00 PM of Back Long Hall Cart revealed: 1) An opened bottle of Pro- Stat AWC without an open date, with a manufacture label stated item needed to be thrown out after 3 months of being open. 2) An opened bottle of Humulin R insulin with an open date of [DATE]. 3) An opened bottle of Insulin Lispro with an open date of [DATE] 4) An opened bottle of Humulin R insulin with an open date of [DATE] 5) 2 bottles of eye drops stored in same tray with oral medications. Observation on [DATE] at 12:15 PM of Front Long Hall Cart revealed: 2 loose pills located in the 2nd drawer of the medication cart. During an interview on [DATE] at 12:05 PM, LVN A stated eye drops should have been stored in a separate location from oral medications. LVN A stated Insulin should have been discarded 28 - 30 days after it had been opened. LVN A stated that using insulin after the recommended use by date could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 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 0761 Level of Harm - Minimal harm or potential for actual harm result in residents not receiving insulin correctly. LVN A stated the bottle of Pro-Stat AWC should have had an open date written on the bottle because manufacture label stated item needed to be thrown out after 3 months. LVN A stated nurses were responsible to ensure carts were kept clean and in order each shift. LVN A stated these failures could affect residents by medication not working like they should. LVN A did not provide a reason to what caused the failure. Residents Affected - Some During an interview on [DATE] at 12:15 PM, LVN C stated pills should not have been loose in the medication cart. LVN C stated if loose pills were found in the medication cart, they must be disposed of in the hazard box. LVN C stated each nurse was responsible for monitoring their cart. During an interview on [DATE] at 12:22 PM, the DON stated there should not have been loose pills or expired medication in the medication cart. The DON stated Insulin should be discarded either 28 days or 42 days, depending on type of insulin, after bottle had been opened. The DON stated that Humulin insulin and Insulin Lispro should have been discarded 28 days after opened, per policy. The DON sated that medication should have an open date written on bottle. The DON stated Pro-stat AWC should have an open date written on bottle and follow the manufacture label for discard of bottle. The DON stated items in medication carts should have been stored per method of use. The DON stated the failures could affect residents negatively, their diabetes could have been negatively affected because insulin may not have been affective or could have made residents sick from items not being discarded. The DON stated that the charge nurses were responsible for monitoring medication carts each shift and ultimately it was the DON's responsibility to ensure medication carts were in order. The DON stated what led to failure was the lack of continuity of facility staff. Record review of facility policy titled, Recommended Medication Storage, dated 07/2012 revealed: medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was open . Insulins Humulin R, N 70/30 and Mix . Expires 28 days after initial use regardless of product storage (refrigerated or room temperature). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for food service. The facility failed to label items in refrigerators and freezers with a received and/or opened date. The facility failed to discard items in refrigerators and freezers after expired and/or use by dates. The facility failed to seal items in refrigerators and freezers. The facility staff failed to perform hand hygiene when switching tasks while preparing and serving food. These failures placed all residents at risk of food borne illnesses. Findings included: During an observation and interviews on 11/06/22 at 10:06 AM Refrigerator #1 1 bottle of Grape Juice 1/3 full with an expiration date of 9/24/22. 1 bottle of Prune Juice with an opened date of 8/31(no year noted). 1 bottle of Beef broth with an opened date of 10/03(no year noted) 1 box of thickened Orange Juice with no opened date. Freezer #2 1 tub of Vanilla ice cream with no opened date. 3 packages of frozen waffles with ice crystals with no date to determine when placed in freezer or when to discard them. 1 package of frozen round brown balls that [NAME] described as hush puppies with no label that identified the item or when it was placed in freezer or when to discard them. 1 package of frozen hush puppies that did not have a date to determine when placed in the freezer or when to discard them. 1 package of frozen tater tots with ice crystals with no date to determine when placed in freezer or when to discard them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 4 packages of frozen breaded okra with no date to determine when placed in freezer or when to discard them. 1 package of frozen sweet potato tator tots with no date to determine when placed in freezer or when to discard them. Residents Affected - Many Refrigerator #2 1 clear plastic tube labeled ketchup that included 9 small plastic cups of white substance-DA said was Mayonnaise, 10 small plastic cups that had a yellow substance-DA said was mustard. No label to identify the substances or when placed in the refrigerator or when to discard the substances. 1 clear plastic tube of several small plastic cups of white substance. The label to the clear plastic tub identifies the cups to have sour cream. The date on the tub was 8/10(no year noted). 1 clear plastic bag with white substance inside-DA said it was low fat vanilla yogurt. It did not have a label to identify the substance or a use by or discard date. 1 bottle of chocolate syrup dated 8/18(no year noted) that had no lid to seal it closed. 1 tub of pimento cheese that was not sealed. Refrigerator #3 1 box of breakfast sausage patties that was opened to air with no date opened or use by discard date. Freezer #1 in storage room outside of kitchen 1 box of frozen mangoes with no opened, use by, or discard date. 1 box of cinnamon rolls that was open to air with no opened, use by, or discard date. 1 box of cheesy garlic sticks that was open to air with no opened, use by, or discard date. During an interview on 11/06/22 at 11:05 AM with DM, she said items in the refrigerators that had been prepared needed to be thrown out between 3 and 7 days after preparation. She said if a food item included mayonnaise in its preparation such as chicken salad, ham salad etc, it would need to be discarded after 3 days. Anything that was opened and placed in the refrigerators should have the date they were opened. Any time items were pulled out of their original shipping box and placed in either the refrigerators or freezers, then the items should have a label placed on them to identify them and have the date they were received on the label. DM said she trained all the staff that worked in the kitchen. During an observation on 11/06/22 from 11:27 AM to 12:22 PM, [NAME] did not perform hand hygiene prior to beginning preparation of altered food textured meal items of chicken tenders and okra. Then, [NAME] did not perform hand hygiene after preparing the altered texture meal items nor did [NAME] perform hand hygiene prior to obtaining temperature of all food items before meal service. Finally, [NAME] did not perform hand hygiene prior to start of meal service. At this same time DA did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 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 675537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brownwood Nursing and Rehabilitation 101 Miller Dr Brownwood, TX 76801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many perform hand hygiene prior to obtaining temperature of drinks for meal service. Afterwards, DA did not perform hand hygiene prior to start of meal service. At no time did [NAME] or DA wear gloves for preparation. During an interview on 11/06/22 at 12:22 PM, [NAME] said that hand hygiene should have been performed any time before switching tasks such as preparing altered textured food items, obtaining food item temperatures, and before starting meal service. Record review of facility policy labeled Food Storage and Supplies dated 2012 revealed: open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to market by circling it, so it is readily visible and noticeable . If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf stable items will be stored in a first in, first out manner, to be used within one year. Products without a dated shipping label should be dated when they received by the facility so there is a method to keep track of the age of the product . Perishable items that are refrigerated are dated once opened and used within seven days, but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date . frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within seven days . If a frozen food item does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging . Any frozen food more than one year old will be inspected for food quality and freezer burn before being used some frozen battered, breaded, or fry ready products are packaged with small slits in the interior bags to prevent ice crystal formation. Record review of facility policy labeled Hand Washing dated 2012 revealed: Employees are to frequently perform hand washing FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 8 of 8