Inspection·January 25, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were the resident will maintain or improve their independence with ADLs and will not be injured related to bed rail use, and resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Record review of Resident #33's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of obesity, heart failure, arthritis, respiratory failure, high blood pressure, difficulty sleeping, and depression. Resident #33's MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. Record review of Resident #33's Comprehensive Care Plan reviewed and revised 12/29/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will display optimal breathing pattern daily . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The Resident will cooperate with care . , The resident will not have any complications r/t bowel incontinence . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score . Record review of Resident #37's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken left arm, Type 2 diabetes, heart disease, high blood pressure, weakness, heartburn, stroke, and malnutrition. Resident #37's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 8 out of 15 indicating moderate cognitive impairment. Record review of Resident #37's Comprehensive Care Plan reviewed and revised 01/09/2024 revealed objectives lacking ability to be evaluated or quantified were: The resident will have complications of cardiac problems kept to a minimum . , The resident will have complication related to hypertension kept to a minimum . , The resident will have complication related to diabetes kept to a minimum . , The resident will show decreased episodes of s/sx of depression . , The resident will be able to make basic needs known verbally on a daily basis ., The resident will not have discomfort related to side effects of analgesia . , and Resident will not show a decline in psychosocial well-being or experience adverse effects . , Record review of Resident #44's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety. Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. Record review of Resident #44's Comprehensive Care Plan reviewed and revised 12/12/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will have complications related to Diabetes kept to a minimum . , The Resident will have no indications of acute [sudden onset] eye problems . , The Resident will not have discomfort related to side effects of analgesia ., The Resident will show decreased episodes of s/sx of Anxiety . , The Resident will have discomfort or adverse reactions related to antidepressant therapy kept to a minimum . , The Resident will be able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 2 of 11 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 01/25/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The resident will receive daily opportunities for social contact . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters. Record review of Resident #46's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken right upper leg, Parkinson's disease (a disorder of the nervous system), heart disease, Type 2 diabetes, Alzheimer's disease (a disease that affect memory and thought processes), chronic pain, history of falling, and high blood pressure. Resident #46's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. Record review of Resident #46's Comprehensive Care Plan reviewed and revised 01/23/2024 revealed objectives lacking ability to be evaluated or quantified were: The Resident will be offered encouraged and assisted to accept adequate hydration . , The resident will not have any complications r/t bowel incontinence . , Resident will maintain the highest level of communication for this resident . , , The Resident will be able to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The resident will demonstrate effective coping skills . , Dignity will be maintained and the resident will be kept comfortable and pain free with in one hour of intervention . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was The resident will not have any cardiac complications related to Antiarrhythmic [drug that regulates the heart's rhythm] use. Record review of Resident #51's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, weakness, heartburn, dizziness, cardiac pacemaker, high cholesterol, and hearing loss. Resident #51's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 15 out of 15 indicating intact cognition. Record review of Resident #51's Comprehensive Care Plan reviewed and revised 12/14/2023 revealed objectives lacking ability to be evaluated or quantified were: The resident will have discomfort or adverse reactions related to anticoagulant use kept to a minimum . , The resident will have drug related complications, including movement disorder, discomfort, hypotension [low blood pressure], gait [walking]disturbance, constipation/impaction or cognitive/behavioral impairment kept to a minimum . , The resident's safety will be maintained . , The resident will demonstrate effective coping skills . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use ., The resident will be compliant with thyroid replacement therapy . , The resident will have s/sx of complications of cardiac problems kept to a minimum . , The resident will improve current level of cognitive function . , and The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene and will be clean, dry, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 3 of 11 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 01/25/2024 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 0656 and free from odors with dignity maintained. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2024 at 2:45 PM MDS B stated that care plans should have incorporated all areas of patient care. MDS B stated minimum was not a measurable goal. MDS B stated the negative affect on residents could have affected their plan of care. MDS B stated what led to failure was new staff not knowing how to enter data into care plan and a lack of communication. Residents Affected - Some During an interview on 01/25/2024 at 3:05 PM the DON stated her expectation was that care plan would incorporate all areas of care for residents. The DON stated minimum was not a measurable goal. The DON stated MDS nurses were responsible to ensure that care plans were accurate and complete. The DON stated the residents could have been affected by residents may not have received conducive or accurate care. The DON stated the failure was caused by staff not being properly trained on initiating and entering data into care plan. Record review of facility policy titled, Comprehensive Care Planning undated revealed, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 4 of 11 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 01/25/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 2 residents (Resident #44) reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #44's medication regimen review which had pharmacy recommendations. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Resident #44 Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety. Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. Record review of Resident #44's physician orders on 01/25/2024 revealed mirtazapine oral tablet 30mg give 1 tabled by mouth at bedtime for insomnia. Record review of Resident #44's November 2023 MAR revealed mirtazapine was administered every day in November at 7:00 p.m. Record review of Resident #44's December 2023 MAR revealed mirtazapine was administered every day in December at 7:00 p.m. Record review of the Medication Regimen Review note written by consulting pharmacy with review date 11/08/2023 revealed Resident #44 had an order for Mirtazapine 30mg give 1 tablet at bedtime for Insomnia with recommendation of gradual dose reduction. Physician disagreed with recommendation and signed note on 12/01/2023 which was 24 days after recommendation. During an interview on 01/25/2024 at 5:01 p.m., the DON stated that she was responsible for ensuring pharmacy recommendations were completed. The DON stated that the physician's office was faxed the MRR, but that facility never received the completed form. She stated that on 01/25/2024 facility sent someone to physician's office to receive MRR form with physician signature on 12/01/2023. The DON stated she did not know if the facility had a time frame in which to get MRR completed, and she asked the RCN. The DON stated that the failure occurred due to her being busy and overlooked the follow up part of the process. The DON stated that effect to patient could be detrimental depending on medication and resident. During an interview on 01/25/2024 at 5:04 p.m., the RCN stated that it was the DON's responsibility to follow up on MRR recommendations. She stated that it was her expectation the DON would send MRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 5 of 11 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 01/25/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete to physician within 72 hours of receiving recommendations then follow up with physician after no response in 5 days. She stated that the effect failure could have on residents was that they would be on unnecessary medication or dosage. Record review of facility policy titled Consultant Pharmacist revised on 10/25/17 revealed: The pharmacist will provide a separate written report of irregularities to the attending physician, medical director, and director of nursing after their review .The attending physician will be notified of irregularities within 2 business days. The facility will deliver the reports either by email, fax, or hand delivery .If the facility has not received any communication from the physician regarding the irregularity within 5 business days, the facility staff will call the physician. Event ID: Facility ID: 675537 If continuation sheet Page 6 of 11 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 01/25/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 (Resident # 6, #4, #8, #42, #17 and #41) residents who received a pureed meal reviewed during the lunch meal. The facility failed to ensure Residents recieving a puree texture diet were provided the food according to the menu, incuding potato salad and a roll. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #6's Quarterly MDS dated [DATE] revealed: Section A- Identification Information Resident #6 was an [AGE] year old male admitted on [DATE]; Section C- Cognitive Patterns Resident #6 had a BIMS of 12 (moderate cognitive impairment); Section K- Swallowing/Nutritional Status Resident #6 had a mechanically altered diet. Record review of facility documents, titled, Resident Roster Diet Type dated 01/23/2024 revealed that Resident # 6, #4, #8, #42, #17 and #41 had texture type of puree for all meals. During an observation on 01/23/2024 at 10:30 AM of the dining room revealed a posted menu on the dining room wall that stated Tuesday Lunch Menu: Barbeque Ribs, Baked Beans, Potato Salad, Honey Kissed Roll and Fried Apple pie. During an observation and interview on 01/23/2024 starting at 11:30 AM of the kitchen, [NAME] A was observed pureeing the lunch meal. [NAME] A pureed barbeque meat and baked beans she did not puree potato salad or a roll . [NAME] A started lunch plate service and served a puree meal, that consisted of pureed barbeque meat, fortified mashed potatoes, pureed baked beans, and pureed fried pie. When questioned the DM stated the puree diets should have received potato salad and a roll not the fortified mashed potatoes. The DM asked [NAME] A if she had pureed the potato salad and roll, [NAME] A stated she had forgotten to puree the potato salad and roll. [NAME] A continued to serve the rest of the puree diets with fortified mashed potatoes and did not puree the potato salad and the roll. During an interview on 01/23//2024 at 12:30 PM, the DM stated her expectation was residents who received pureed diets should have received the same meal as regular diets. The DM stated the effect on residents could have been not receiving the correct number of calories their meal was budgeted. The DM stated the cooks and herself were responsible for ensuring the menu was followed. The DM did not have an explanation to what led to the failure. During an interview on 01/24/2024 at 9:11 AM, Resident #6 stated he had gotten potato salad once since he had been there and would like it more often and that he was usually served mashed potatoes. During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that all residents were served the same menu. The ADO stated the purred meal should have received the potato salad and the roll. The ADO stated the effect on residents could have been residents might not have received the correct nutrient values their diet required. The ADO stated the DM was responsible to ensure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 7 of 11 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 01/25/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm menu was followed. The ADO stated she was not able to provide a response to why the menu was not followed for the puree diet. During exit conference on 1/25/204 at 6:30 PM the ADO stated they did not have any other policies to provide. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 8 of 11 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 01/25/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: Refrigerator #1 1. One open container of cottage cheese with an use by date of 01/06/2024. 2. One unopened container of cottage cheese with an use by date of 01/06/2024. 3. One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. 4. One plastic container with a seal contained canned black olives and was not labeled with a food item description or an use by date. Dry Storage 1. Ten packages of flour tortillas out of the original box not labeled with a food item description or date. 2. One package of green tortillas out of the original box was not labeled with a food item description or date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 9 of 11 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 01/25/2024 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 During an interview on 01/23/2024 at 10:30 AM, the DM stated items that were passed their use by date should have been discarded. The DM stated food items should have label of item and dated. The DM stated residents could have been affected by getting food that was not flavorful. The DM stated the cooks and herself were responsible to ensure items were discarded and labeled correctly. The DM did not have a reason for the failure. Residents Affected - Some During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that food should have been labeled with a use by 'date and food item description. The ADO stated food should have been thrown out when past the use by date. The ADO stated the DM was responsible to monitor. The ADO stated what led to failure was the DM just missed them. Record review of facility policy title, 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. Record review of facility policy title, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/25/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD. (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 10 of 11 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 01/25/2024 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 Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675537 If continuation sheet Page 11 of 11