Inspection·October 18, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initiated 09/25/25 and revised 10/08/25 reflected the following care areas all initiated on 10/08/25: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously. Res frequently pulls wound vac off despite education. May use wet to moist dressing if dislodged; B. Focus: The resident is on anticoagulant therapy.D. Focus: The resident has Intravenous (IV) Access. Resident #1's care plan did not reflect the use of a catheter. Record review of pertinent nursing notes related to Resident #1's change of condition reflected:-A nursing progress note by LVN A on 09/24/25 at 9:45 PM reflected Resident #1 pulled her PICC line out on her own and it was found next to her bed with no active bleeding at insertion site. There was no documentation to reflect the RP was notified. -A nursing progress note by LVN D the next morning on 09/25/25 at 8:45 AM reflected Nurse called [RP] for consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-A nursing progress note by LVN A on 10/03/25 at 9:45 AM reflected Resident #1 pulled out her foley catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder) with the balloon (anchors the catheter in the bladder, preventing it from slipping out) intact and was found by the CNAs. Nurse assessment reflected there was no bleeding or obvious trauma noted. There was no documentation to reflect the RP was notified of the removal.-A nursing progress note by LVN A on 10/06/25 at 8:40 PM reflected, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line (An IV line is used to deliver medicines, fluids, blood products, or nutrition into a patient's bloodstream) and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders. There was no documentation to reflect the RP was notified of the PICC line issue.-A nursing progress note by LVN E dated 10/07/25 at 12:01 AM reflected, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. There was no documentation the RP was notified at the time of the new order implementation. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed Resident #1 missed several IV antibiotic doses while at the facility. She said the nurses told her the pharmacy had not sent the medication yet. The RP said days later, the facility switched Resident #1 to oral antibiotic medication without notice to the RP. She stated, They just said, ‘We're giving her pills now'. The RP also stated she was never informed that IV therapy had been discontinued or that doses were missed. The RP stated she was never notified of major changes in Resident #1's condition or treatment. The RP said no one told her the PICC line was no longer going to be used. The RP stated she learned about each incident only when she visited. The RP stated she was never told Resident #1 pulled out her catheter. She stated she remembered visiting the resident and did not see the catheter bag hanging on the side of her bed or wheelchair. The RP stated she did not recall any concerns being voiced by the hospital post-fall on 10/08/25 of any vaginal trauma. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled at her catheter quite a bit and would itch around the area and LVN D felt it irritated the resident's skin, but she never saw her pull it out. She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. She said she did contact [MD C] to get an oral antibiotic approved. LVN D stated Resident #1 would take oral medications much easier but she did not notify the RP of the order change. LVN D said the change of dose from IV to oral happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change. LVN D stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 2 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. An interview with LVN A on 10/15/25 at 3:55 PM revealed she provided antibiotics though Resident #1's IV but did not provide wound care. She stated the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial admission and sent her out on day two (09/25/25) and did her subsequent re-admission on [DATE]. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP . LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because it was clotted in the PICC line due to being exposed to air and she notified MD C and the RP. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated Resident #1 did have a catheter and pulled it out, but she was not sure when and thought it was night two of admission. LVN A stated a CNA notified her the catheter was found on the floor. When she went to assess, she saw the catheter with a 10-cc [NAME] intact (a flexible tube-foley catheter, that is inserted into the bladder to drain urine with the 10-cc referring to the balloon's capacity of 10 cubic centimeters or milliliters) had been removed. LVN A stated, She ripped it out. She said Resident #1 showed no pain and there was no blood. LVN A said she notified MD C and nursing administration, assessed and placed Resident #1 in a brief and got her cleaned up. LVN A stated the potential harm of pulling out a catheter, I mean anything pulled out the size of a straw there could be internal trauma. I think it was a 22 French (a large-diameter urinary catheter used in specific situations where a larger size is needed to prevent blockage. The 22 French refers to the catheter's external diameter, which is approximately 7.3 mm). She stated the catheter removal happened at the end of her shift, so it was turned over to the night shift. LVN A said she did not consider the catheter removal to be a change in condition. LVN A stated, In hindsight, [RP] should have been notified by the nursing staff. I gave report the next shift, it had just happened. LVN A said the event happened on her shift and she should have been the nurse to notify the RP about it. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall on 10/08/25 at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated when she called, she stated, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO said she did verify via Resident #1's chart that, She declined so much and I don't think it mattered what lines she had, she would have pulled on any of them due to her dementia and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 3 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete it was a sad situation. The ADO stated maybe Resident #1's RP was not contacted about the catheter removal because the nurse did not think there was a medical change of condition. She stated, If it happens on your shift, you own it. The oncoming nurse isn't responsible because they weren't there. An interview with the VPCO on 10/16/25 at 10:40 AM revealed when she reviewed Resident #1's nursing documentation and chart, she did not see where the RP was notified of the catheter removal. An interview with the DON on 10/16/25 at 1:00 PM revealed he had heard Resident #1's catheter had been pulled out and the RP should have been notified by the nurse on the hall at the time. He stated it was important because we always want to keep families up to date with any changes. Review of the facility's policy titled, Notifying the Physician of Change in Status (revised 03/11/2013) reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilized the INTERACT tool, ‘Change in Condition-When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify he physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work Day notification of the physician.5) The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 7) The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's order and the resident's status and response to interventions. Event ID: Facility ID: 675550 If continuation sheet Page 4 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to make prompt efforts to resolve grievances regarding the resident's care and treatment for one (Resident #1) of five residents reviewed for care concerns. The facility failed to document a grievance, respond and follow through on Resident #1's RP concerns when she voiced them to multiple management staff about poor nursing care and issues with her PICC line, wound vac, antibiotic medication and falls. This failure could place residents at risk for harm by allowing ongoing care concerns-including missed medications, PICC line and wound care issues, to go unaddressed, delaying necessary interventions and oversight.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously (a treatment that uses suction to aid healing in chronic or non-healing wounds), B. Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25), C. Focus: The resident has Hip Fracture. (Date Initiated: 10/08/25), D. Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25) and E. Focus: The resident is risk for falls (Date Initiated: 10/08/25).Record review of Resident #1's medication order summary for September 2025 and October 2025 reflected she required extensive wound care and IV therapy following her readmission with a right hip infection and sepsis. Resident #1's physician orders directed that the surgical wound to the right hip be cleaned with normal saline, packed with gauze and draped daily with a negative pressure wound therapy vac (a medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 5 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some device that uses suction to promote wound healing) to remain in place continuously at 125 mmHg. Resident #1 also had standing orders for IV antibiotics, including Cefazolin every eight hours and Bactrim DS for bacterial infection and Lovenox for prevention of blood clots. Additional physician instructions included daily saline flushes to maintain IV line patency (the state of being open or unobstructed, allowing for the free flow of fluids, air, or blood) and wet-to-moist dressing changes if the vac became dislodged.An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed she was not notified when the resident's PICC line was not able to be flushed and used to administer the IV medications. She stated when she saw the PICC line tubing, it appeared black and crusted, and she became aware of the issue only during a visit. The RP also stated staff did not contact her to inform her that Resident #1's IV antibiotic therapy had been stopped and change to oral medications until after the change was made. The RP stated the nursing staff told her she would be fine taking oral medications, but she was concerned Resident #1 would not be able to swallow them safety due to being on a pureed diet. The RP further stated she was not notified when the resident's urinary catheter immediately after it had been dislodged and not replaced. The RP stated she expected to be informed of any change to IV therapy or catheter status, as she was the responsible party for the resident's care decisions. Review of the facility's documented grievances from 09/25/25 through 10/18/25 revealed none for Resident #1. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated on the call she told the RP, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO then stated she notified the RP that an incident report to HHSC would be initiated for the fall with a major injury and the RP responded, ‘You have plenty of time to falsify the chart. An interview with the VPCO on 10/16/25 at 10:40 AM revealed she was not aware about the issues with Resident #1's PICC line, wound vac or two falls until after Resident #1 was transferred to the hospital on [DATE] The VPCO said the ADO had notified her Resident #1's RP was upset after the second fall on 10/08/25 and the facility had initiated a self-reported incident to HHSC based upon the concern that she was upset with care. She thought the ADO also completed a grievance for the RP's care concerns and they were important because any concerns needed to be addressed appropriately and reported back to whoever made the concern.An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay if she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he did not complete a grievance form related to Resident #1's RP concerns but he told her he would talk to the insurance company about the coverage for oral versus IV medication. He also said the RP had concerns about the wound vac but when he saw it on Resident #1, it was working and told her it was on her now. The DON stated looking back, he probably could have done a grievance for the RP's concerns, but when he was talking to her, he thought they were on the same page and she was satisfied with their conversation. An interview with ADON G on 10/18/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 6 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 12:26 PM revealed she had recently learned that any staff member could enter a grievance into their e-charting system. She said once those were entered online, they were routed to the appropriate department for review. ADON G stated, It takes the burden off one person. Typically, our social worker did them before. ADON G added that when families made multiple or serious complaints, the determination whether it qualified as a formal grievance depended on the grievance and what was involved. If the issue was complex, ADON G said it could require additional resources and multiple department members. ADON G stated staff were expected to check with a supervisor or management before deciding not to initiate a grievance so they could ensure every concern was documented.A follow up interview with the ADO on 10/18/25 at 12:43 PM revealed when a resident had a concern or complaint, she expected anyone with PCC access (a cloud-based software platform for the senior and long-term care industry that helps manage electronic health records, billing, and resident engagement)-with the exception of CNAs-to open a grievance and start it. The ADO stated grievances were entered electronically and management reviewed them daily and during monthly QAPI meetings. The ADO stated her expectation was that any concern was documented, and If there's frustration, anger, or genuine concerns-it's a grievance. She said if a resident/family member were emotionally attached or anxious about a concern, that was when staff should recognize something is wrong and initiate a grievance. The ADO said when Resident #1's RP raised concerns about wound care and supervision, the ADO and the DON reviewed documentation and determined whether a grievance was warranted. The ADO stated, Looking through the chart, it looked like communication had been happening through the PICC line issue and staff were documenting. I didn't think a grievance was needed at that time, but I did a self-report for the fall with injury and the RP's concern that the facility was not caring for her [Resident #1]. The ADO confirmed that a self-report was submitted to the State and that she and a corporate clinical RN investigated it that same evening and discovered Resident #1's PICC line was clotted and that an oral antibiotic was subsequently obtained. She stated she saw that the resident's antibiotics were changed and the wound vac was replaced. When asked if the RP's concerns fit the definition of a grievance under the facility's policy, the ADO replied, Personally, I do not, because we addressed it with a self-report.Review of the facility's Provider Investigation Report to HHSC for Resident #1 dated 10/08/25 reflected the incident category listed was Other and the description of the allegation by the ADO who reported it was, Resident stood up at the nurses station and fell. The self-report did not indicate any concerns of abuse/neglect of Resident #1 or concerns that the RP felt the resident's care was a concern.Review of the facility's policy titled, Grievances (Revised 11/02/2016) reflected, The resident has a right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.Procedure:.2. The grievance official of this facility if the administrator or their designee. 3. The grievance official will: Oversee the grievance process, Receive and track grievances to their conclusion.Issue written grievance decisions to the resident.6. All written grievances decisions will include: 1) The date the grievance was received, 2) A summary statement of the resident's grievance, 3) The steps taken to investigate the grievance, 4) A summary of the pertinent findings or conclusions regarding the resident's concern(s), 5) A statement as to whether the grievance was confirmed or not confirmed, 6) Any corrective action taken or to be taken by the facility as a result of the grievance and 7) The date the written decision was issued. Event ID: Facility ID: 675550 If continuation sheet Page 7 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 - Few 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time-frames to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to revise Resident #1's care plan after she fell on [DATE] to include updated fall prevention interventions and nursing management's identification of 1:1 supervision needs. The failure could place residents at risk for additional falls and injury by delaying the implementation and documentation of required supervision and safety interventions following a known fall event. Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of a nursing progress note dated 10/07/25 at 12:15 PM by ADON G reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be on the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's (assesses the nervous system through a combination of tests on mental status, cranial nerves, motor and sensory function, coordination and balance, and reflexes) initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall were documented as, 1 on 1 supervision (involves a dedicated caregiver providing constant, undivided attention to prevent falls and ensure safety due to cognitive impairment). Record review of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 8 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 - Few #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses' station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses' station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses' station and landed on left side of body. No LOC noted and mentation (the overall mental activity of the mind, including thinking, memory, reasoning, perception, and consciousness) remained at baseline. VS assessed. Neuros assessed. Attempted to locate wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. T Record review of Resident #1's care plan initiated 09/25/25 reflected a focus area/interventions for falls was initiated on 10/08/25 by the CCN and reflected, Focus: The resident is risk for falls (Date Initiated: 10/08/25)- Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove [sic]any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25). An interview with CNA H on 10/15/25 at 1:02 PM revealed she worked with Resident #1 and assisted her with all ADLs including feeding, changing and transfers. CNA H stated Resident #1 could not stand or ambulate safely on her own and required hands-on help at all times. CNA H stated that staff had discussed Resident #1 needing a one-on-one person to be with her because she could not be left alone without risk of falling. She said the ADONs and charge nurses were aware Resident #1 needed constant monitoring and that she tried to keep the resident within sight while on duty, especially during meals and rounding the hall. CNA H stated Everyone knew she couldn't be left by herself. An interview with LVN D on 10/15/25 at 12:32 PM revealed she was aware Resident #1 was a high-risk for falls and that staff were expected to keep her within eyesight. She said she knew from change of shift report and staff discussion that Resident #1 required close monitoring and should not attempt to get up unassisted. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 required increased supervision following her initial fall. She said she kept Resident #1 near the nurses' station in her wheelchair, So I could keep an eye on her. LVN A stated Resident #1 was confused and impulsive but pleasant, and she understood that nursing staff were expected to monitor her closely even though no one-on-one supervision was formally ordered. An interview with ADON G on 10/16/25 at 1:20 PM revealed she knew Resident #1 was a high fall risk and that increased supervision had been discussed after the first fall. She said she believed staff were keeping the resident near the nurses' station to maintain visual supervision but admitted she did not know whether she updated the care plan to reflect the need for 1:1 supervision. An interview with the ADO on 10/17/25 at 9:26 AM revealed when she reviewed the 10/07/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 9 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete fall incident report, it reflected 1:1 supervision had been selected as the intervention. She said ADON G entered the intervention but was unsure whether it had been communicated clearly to all shifts. The ADON said she assumed staff were aware of the supervision expectation but acknowledged that it may not have been documented in the care plan. An interview with ADON G was conducted on 10/18/25 at 12:26 PM and revealed the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift. ADON G stated the charge nurse was responsible for those updates with the assistance of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. A follow-up interview with the ADO on 10/18/25 at 12:43 PM revealed her expectation was that care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. The ADO stated, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to intervene and make it right. I try to communicate to my nurses to put a plan in place. She said new interventions post falls should be communicated to CNAs by updating the Kardex (a online documentation system, originally a brand name for a paper-based system, used primarily by nurses to keep a quick, organized summary of essential patient information) and through verbal handoff. She said the Kardex was the CNAs' quick look for what residents needed. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care; reassessment will occur after each fall. Interventions will be resident centered. Record review of the facility's Comprehensive Care Plan Policy (not dated) reflected, Each person 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.Interventions are the specific care and services that will be implemented.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS Assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Event ID: Facility ID: 675550 If continuation sheet Page 10 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's wound vac was providing the proper suction and failed to have her infected surgical wound assessed by the wound care physician or attending physician to determine the proper course of action, despite reports of complications. 2. The facility did not ensure proper management of Resident #1's clotted PICC line when it became clotted. Additionally, there was no dressing assessment documented for the PICC line. As a result of the PICC line not flushing, IV antibiotics were discontinued for the right hip surgical wound on 10/06/07 and oral antibiotics were started without addressing the central line's compromised condition. 3. Resident #1 had an unwitnessed fall on 10/07/25 with no noted injuries. After the fall, neurochecks were not completed per protocol from 10/07/25 to 10/08/25. On 10/08/25, Resident #1 fell again at the nurses' station and sustained a head injury. She was sent to the ER where it was determined she also had a left hip fracture.An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. While the IJ was removed on 10/18/25, the facility remained out of compliance at a scope of no actual harm and a severity level of pattern because the facility continued to monitor the implementation and effectiveness of their Plan of Removal and all nursing staff had not been trained on PICC line, neurochecks and wound vac therapy.These failures could result in could place residents at risk of not receiving care and treatment needed which could lead to avoidable decline and life-threatening complications.Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high-risk medications: anticoagulant (blood thinner), antibiotic and Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 11 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously. Res frequently pulls wound vac off despite education. May use wet to moist dressing if dislodged (Date initiated: 09/25/25); Interventions/Tasks: 1) Surgeon follow up as needed. Assist resident/RP with scheduling/transportation as needed (Date Initiated: 09/25/25), Observe for s/s of infection-increased redness, increased pain, drainage. Report to physician if noted (Date Initiated: 09/25/25), Observe for s/s of pain during treatment and medicate PRN per physician's orders (Date Initiated: 09/25/2025), negative pressure therapy continuously (a treatment that uses continuous or intermittent negative pressure to promote wound healing. It involves applying a special dressing to the wound that creates a vacuum, removing fluid, debris, and bacteria from the wound bed )(added 10/03/25), Remove staples or sutures as ordered (added 10/08/25).B. Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25); Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025)C. Focus: The resident has Hip Fracture. (Date Initiated: 10/08/25); Intervention/Task: 1) Change surgical incision dressing as per order and PRN (Date Initiated: 10/08/25).D. Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25); Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm; change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025).E. Focus: The resident is risk for falls (Date Initiated: 10/08/25); Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25) Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of Resident #1's order summary reflected the prescribing physician was MD C and he ordered the following:- Clean wound to right hip with NS change granufoam and apply drape one time a day every Tue, Fri for wound (Start Date 09/24/25) -Clean wound to right hip with NS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 12 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some place granufoam and drape one time a day every Mon, Wed, Fri for wound (Ordered 10/03/2025 with start date 10/06/25)-Negative pressure wound therapy to right hip at -125 continuously every shift for wound (Start Date 10/03/25)-Negative pressure wound therapy to right hip continuous at -125 every shift for wound (Start date 09/24/25)-Bactrim DS Tablet 800-160 MG Give 1 tablet by mouth three times a day for bacterial infection for 10 Days (Start Date 10/06/25)-Bactrim DS Tablet 800-160 MG Give 2 tablet by mouth two times a day for bacterial infection for 10 Days (Start Date 10/07/25)-Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25) -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25)-Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25)-Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 1 syringe intravenously every shift for IV antibiotics related to SEPSIS (start date 10/03/25)-Sodium Chloride Solution 0.9 % Use 10 ml intravenously every 8 hours for Flush 10 ml after each medication for 14 Days (Start Date 10/04/25)-Wet to moist dressing if dislodged every 4 hours as needed for wound (Start Date 10/03/25) Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused), 9:00 AM (refused) and 5:00 PM (away from facility). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25. Record review of Resident #1's admission Nursing Note by LVN A dated 09/24/25 reflected she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered. Resident #1 was documented as non-mobile/bedfast and could not bear weight, required one person assistance for bed mobility and two-person assist for transfers. Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of a Transfer Notification Progress Note by LVN A on 09/25/25 reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place. Record review of Resident #1's pertinent nursing progress note reflected:- (by WCRN B) 09/24/25 at 6:37 PM- Non-Ulcer Wound Assessment- Location of Area: Trochanter-Right, Type of Wound: Surgical, Length(cm):16, Width(cm):6, Depth(cm):4, Describe the wound appearance: Expose muscle, moderate exudate that is tan in color, No negative surrounding wound findings, No negative surrounding skin color findings, Odor: None, No pain associated with the wound. Interventions: Current wound treatment: granufoam; Frequency of wound treatment: 3 times a week, Other device: NA-Resident is non-compliant with treatment. Non-compliance consists of: confused and has no recall.-Record review of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 13 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #1's nursing progress note by LVN A on 09/24/25 at 8:46 PM reflected the Ertapenem was not administered due to awaiting delivery from pharmacy.-Record review of a nursing progress note by LVN A on 09/24/25 at 9:45 PM reflected Resident #1 pulled her PICC line out on her own and it was found next to her bed with no active bleeding at insertion site and MD C was notified via text. There was no documentation to reflect the RP was notified. -Record review of Resident #1's nursing progress note dated 09/25/25 at 12:14 AM by LVN E reflected Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-Record review of Resident #1's nursing progress note by LVN E dated 09/25/25 at 3:55 AM reflected the infusion company was contacted to schedule PICC replacement. -Record review of Resident #1's nursing progress note by LVN D on 09/25/25 at 9:15 AM reflected the PICC line was in place and an x-ray confirmed placement. -Record review of Resident #1's nursing progress note by LVN D on 09/25/25 reflected the Cefazolin was not administered due to Waiting on pharmacy. Record review of hospital records dated 09/25/25 reflected Resident #1's principal admission diagnosis was upper GI bleed and aspiration pneumonia and her hospital labs revealed her white cell blood count was 14.4. At her time of hospital discharge, the documentation reflected she had an unsteady gait, high fall risk and weakness and was confined to a bed, was unable to get up from bed without assistance, unable to ambulate and unable or sit in a chair or a wheelchair. During the hospital stay, documentation reflected Resident #1 had her foley removed, however, she continued to retain urine so the foley was replaced. She was discharged to the facility with a new order for Pantoprazole 40 mg po twice a day for 8 weeks for reflux esophagitis. Record review of Resident #1's pertinent nursing progress notes after the hospital re-admission reflected:-WCRN B's nursing note on 10/03/25 at 11:20 AM reflected the resident pulled at the wound vac dressing and dislodged it and had no recall of doing it. It was replaced by WCRN B at that time. -WCRN B's nursing note dated 10/06/25 (recorded as a late entry) reflected, Wound vac dressing replaced at this time resident dislodged it.-LVN A's nursing note on 10/06/25 at 8:40 PM reflected, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-LVN E's nursing note dated 10/07/25 at 12:01 AM reflected, N/O per MD C, D/C Cefazolin IV and start Bactrim DS po TID x 10days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted.-Record review of Resident #1's nursing progress note dated 10/07/25 at 8:16 AM (recorded as a late entry) reflected, Wound vac replaced at this time resident pulled suction dome off.-ADON G's nursing note reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be in the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall was documented as, 1 on 1 supervision. -Record review of Resident #1's neurological assessments reflected they were initiated and completed on 10/07/25 at 12:15 PM, 12:30 PM, 12:45 PM, 1:00 PM, 1:20 PM, 2:00 PM, 2:43 PM, 3:00 PM and 4:00 PM. There were no other neurological assessments documented for Resident #1 after 4:00 PM into the next day on 10/08/25. -Record review of a fall follow-up nursing progress note dated 10/07/25 at 6:00 PM by LVN A reflected Resident #1 appeared to be in no pain and interventions were a floor mat and low bed. -Record review of Resident #1's nursing progress note dated 10/07/25 by WCRN B at 9:43 PM reflected, Wet to dry dressing applied to right hip, resident has pulled wound vac dressing loose numerous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 14 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some times today.-Record review of Resident #1's nursing progress note dated 10/07/25 at 9:44 PM by LVN A (entered as a late entry) reflected, I spoke with [RP] earlier about resident pulling wound vac dressing off several times a day, I explained that she may not be appropriate for wound vac. She asked what she would be appropriate for, I told her a wound treatment that is recommended to be changed numerous times a day. She said then how will we pull the infection out, I told her that wound vacs don't pull infection out that they pull drainage out and help granulate the wound for healing.- Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses station and landed on left side of body. No LOC noted and mentation remained at baseline. VS assessed. Neuros assessed. Attempted to locate wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed multiple areas of concerns:1) The RP stated she had been trying for days to get help with [Resident #1's] wound vac which had stopped working after discharge from the hospital. She called who she thought was the administrator on Friday 09/26/25 and told her the wound vac wasn't pulling anything out. She said the administrator told her to bring the wound vac back on Saturday 09/27/25 and the nurse on duty would exchange it. The RP described arriving at the facility with the wound vac in her hands. She said she walked straight to the medication cart because she saw the nurse standing there and explained that the vac had alarms and wasn't functioning. The RP stated the nurse told her to just leave it there and walked off. Nobody even looked at it, the RP said. Wanting to be sure someone was accountable, she went to the DON's office. The RP said she told him directly, I brought this because it's not working-[Resident #1] still needs wound suction. She stated the DON replied that it was not his department and advised her to leave it with the floor nurse. The RP said she never received any call-back, paperwork or update and that no one from management followed up that weekend. They acted like I was bothering them, she said. The RP said the wound vac sat silent for days and no changes were made to the plan or nurses' notes to address the failure. She also said she never saw anyone check the tubing or document wound measurements after readmission. The RP stated that on several visits she found [Resident #1] in poor condition, describing unclean wound care and neglected hygiene. The RP stated during one observation at the facility, Resident #1 was sitting in a wheelchair and her wound flap had stool and drainage stuck to it. She saw the wound vac was disconnected, the tubing coiled on the floor and the unit covered in dried fluid. 2) The RP also stated Resident #1's PICC line had not been flushed or used for several days and that the site dressing was black and crusted. She said staff gave oral antibiotics instead of IV doses and that the pills were large even though [Resident #1] was on a puree diet. The RP stated nursing staff told her the resident would be fine taking oral medication, but the RP was concerned she could not swallow them. The RP did not indicate that she observed the resident taking medications orally or observed her struggle, it was just a concern. 3) The RP said she believed [Resident #1's] reinfection and worsening condition resulted from the facility's failure to clean the wound, use the vac, and maintain IV therapy as ordered. 4) The RP stated she also discovered the PICC line unprotected and soiled after a fall that she had not been notified about. It was dirty and dried out-it hadn't been touched, she said. She said she alerted the nurse, who said they were short-staffed and would clean it later. The RP said no one checked vital signs or assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 15 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the wound for hours afterward. She added that she repeatedly asked for the resident to be monitored more closely because she was weak and at risk for falls, but no supervision plan was implemented. 5) The RP stated Resident missed several IV antibiotic doses while at the facility. Nurses told her that the pharmacy had not send the antibiotics yet but a few days later, the RP said she found out the facility switched her to oral medication. The RP felt the facility made the choice without physician consultation or notice to the RP. They just said, ‘We're giving her pills now,' the RP said. The RP said the large tablets were inappropriate for [Resident #1's] swallowing restrictions and that she witnessed coughing and choking during administration. She said she was never informed that IV therapy had been discontinued or that doses were missed.6) The RP stated she was never notified of major changes in condition or treatment. She said no one told her the wound vac had been removed, that the PICC line was no longer used, or that the resident had fallen. She learned about each incident only when she visited. No one ever called me-I just kept finding things on my own, she said. She described repeatedly calling the facility afterward and receiving inconsistent explanations. She stated on 10/08 after Resident #1's fall where she fractured her other hip, she called the DON because she was boiling mad and she ended up getting ADON G and told her all of the things going on with Resident #1 and her concerns. The RP stated ADON G suggested a care plan meeting. The RP stated, I was like why wasn't there a care plan meeting done from the very beginning? So much switching around and disorganization, you would think that bringing a new resident into the facility would have been the very first thing. 7) The RP then stated, [Resident #1] is going to die now. She has to go on hospice, the doctors cannot do anything else to treat her. I have no other options left. We are trying to get her some skilled days in this new facility to give one last chance to see if any sign of improvement but every doctor at [hospital] said unfortunately nothing more we can do, too much trauma from breaking right and left hip.GI issues and trauma to the head- there is nothing more we can do at this point and we strongly suggest hospice now. So I am trying to give her a couple more weeks (at the new SNF) to see. and then if not, I have no choice because she is so much pain, two broken hips, head trauma, internal bleeding. [Previous SNF] put the right foot in the grave and [current SNF] put the left. The RP stated ADO contacted her after the fall on 10/08/25 at 6:12 PM and she told the ADO everything that had happened, what was going on with wound vac, PICC not running and dirty and the infection in right hip, the left hip now broken. The RP stated, She (ADO)was speechless. She didn't say anything except I will have to get back to you. An interview with WCRN B on 10/15/25 at 11:51 AM revealed Resident #1 was the only resident in the facility who received wound vac therapy and required it applied to her right hip but she would not leave the wound vac on, dislodged and pulled it off daily. She stated within two days, Resident #1 was sent back to the hospital for a GI bleed and re-admitted on [DATE] but did not get the wound vac until the next day. WCRN-B stated she remembered because she had to change the wound vac dressing twice that day because it was dislodged and had peeled off. She said the tape used was very secure and wound vacs were supposed to stay in place for a number of days up to a week. WCRN-B stated Resident #1 would not just unhook the wound vac tubing, somehow the whole suction dome itself would be loose, so she had to patch and change it multiple times. WCRN-B stated when there was an order for a wound vac, there was an accompanying facility standing order that reflected if the wound vac dressing was dislodged, a wet to dry dressing (a type of wound dressing that consist of a moist layer of gauze or other material placed directly on the wound, followed by a dry layer to absorb drainage) could be used. She stated, As the wound care nurse, I can replace, but other staff cannot replace, that is why a wet to dry dressing is done when I am not here and it becomes dislodged. WCRN-B stated most of the nurses that worked at the facility knew how to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 16 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some work the wound vac machine but did not necessarily know how to do the dressing change. She stated the weekend supervisor, one other nurse and [RN F] knew how to do the dressing change. WCRN-B stated she did not know if nurses had been in-serviced on how to use a wound vac. She said the machine was rented and there was a QR code that the nurse could scan on the machine, And that is how I figured out how to work it. WCRN-B stated on 10/07/25 around 9:30 PM, she had already done a wound vac dressing change twice for Resident #1, At that point, I did a wet to dry and it was likely going to pull loose again. She said the wound vac dressing already had to be changed twice the day before and three times on the current day. The WCRN-B stated Resident #1's wound was on her right hop, had typical drainage moderate for a wound vac, nothing wrong with it, pink tissue, probably four centimeters deep. The WCRN-B said Resident #1's RP thought there were issues with the wound vac when the resident first admitted because when WCRN-B placed it on the resident, it would show numerous error messages and I would have to mess with it, I could not say for certain if it was because [Resident #1] had messed with or pulled on it, [Resident #1] was all over the place. WCRN -B stated the wound vac was difficult to change because Resident #1 did not want to roll onto her side and when staff moved her, the resident thought she was going to fall. WCRN-B also thought the tape used for the dressing may have itched which would cause Resident #1 to try and peel it off. She said Resident #1 grabbed at staff, their clothing and they would give her a fidget [NAME], but she was still very confused and had no recall. WCRN-B stated the wound vac was new when Resident #1 admitted and it was corporate staff who were in charge of providing them or a person from central supply. WCRN-B stated Resident #1 ended up going to the hospital right after she admitted for a GI bleed and she should have gone with a wet to dry dressing, But I guess the nurse was in a panic but she went with a wound vac, not the plug. So after we got it back (wound vac), the [RP] was saying there was an issue with it and she wanted a different one, that two doctors had tried it and it didn't work. And I was like how could they if they didn't have a plug for power? WCRN-B stated when Resident #1 re-admitted from the hospital, she placed the wound vac on her and it worked fine. WCRN-B stated she did not think Resident #1 needed a wound vac in her opinion and felt it did not stay on her long enough to know if it was working good. She said the way to know if there was good suction was if there were no error messages on the machine and when it was turned onto negative pressure, the foam hardened and became rigid. The WCRN-B stated she did initial measurements when Resident #1 admitted but not when she re-admitted on [DATE]. She said Resident #1 was not at the facility long enough the first time for the wound care doctor to see her and the second time, I was not clear if she had a follow up with the surgeon that did her surgery because if she did, she didn't need to see the wound doctor here. WCRN-B said the wound doctor that rounded at the facility came on Tuesdays but had not seen Resident #1 when she was at the facility on 10/07/25. Additionally, WCRN-B said she did not know if Resident #1 had a follow-up appointment to the surgeon but stated, Our wound doctor does not see residents still under the care of a surgeon. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled her wound vac dressing off frequently, even though she never saw her do it. She said Resident #1 also pulled at her catheter quite a bit and would itch around the area and felt it irritated her skin but she never saw her pull it out. She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 17 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family of changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial, sent her out on day two and did her subsequent re-admission. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because i Event ID: Facility ID: 675550 If continuation sheet Page 18 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accident hazards/supervision . The facility failed to implement and maintain 1:1 supervision for Resident #1 as was recommended by nursing management following a fall on 10/07/25. On 10/08/25, Resident #1 fell at the nurses' station while not under 1:1 supervision and sustained another fall, striking her head on the counter and fracturing her left hip. An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. While the IJ was removed on 10/18/25, the facility remained out of compliance at a scope of no actual harm and a severity level of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal and because all nursing staff had not been trained on fall and supervision protocols related to enhanced and 1:1 supervision needs of high-fall risk residents. This failure placed residents at risk for significant injury, hospitalization or death due to not having adequate supervision to prevent accidents. Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year-old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnosis was sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by othersability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 reflected E. Focus: The resident is risk for falls (Date Initiated: 10/08/25); Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 19 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25). Record review of Resident #1's admission Nursing Note by LVN A dated 09/24/25 reflected she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered. Resident #1 was documented as non-mobile/bedfast and could not bear weight, required one person assistance for bed mobility and two-person assist for transfers. Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of Resident #1's Physical Therapy Evaluation and Plan of Treatment dated 10/03/25 reflected Resident #1 demonstrated significant bilateral lower extremity weakness, greater on the right side, with impaired coordination, poor balance and severely reduced safety awareness. The therapist documented that Resident #1's dynamic standing balance was poor, her gross motor coordination impaired and her cognition severely limited, with the resident rarely able to understand or express needs. She had a known history of falling with injury, having sustained a right femoral neck fracture on August 2025 and continued to report fear of falling and unsteadiness when standing or walking. Resident #1's prior level of function had been supervision or touching assistance for mobility, which indicated a measurable decline and increased dependence at the time of the evaluation. Physical therapy goals focused on restoring safe bed mobility, transfer and ambulation with contact-guard to stand-by assistance to prevent additional falls. The therapist documented Resident #1 was a high fall risk who required close supervision and skilled intervention, emphasizing that without consistent staff oversight and assistance, the resident was at risk for further decline, immobility and repeat injury. Record review of a nursing progress noted dated 10/07/25 at 12:15 PM by ADON G reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be in the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall was documented as, 1 on 1 supervision. Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses station and landed on the left side of body. No LOC noted and mentation remained at baseline. VS assessed. Neuros assessed. Attempted to located wounds/injury. EMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 20 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. Review of the Resident #1's hospital records dated 10/09/25 reflected she admitted to the ER on [DATE] at 2:08 PM and had a 3cm deep laceration of the left occipital area (the smallest of the four brain lobes, located at the back of the head, and is primarily responsible for processing visual information)and a 10 cm surgical incision to the right hip that was dehisced with purulent discharge (means a surgical wound has opened up and is draining thick, pus-like fluid, which strongly indicates an infection) and packed with gauze, decreased range of motion, pain, tenderness noted in the left hip and she was not oriented and confused. The hospital documentation also reflected there was a PICC line to Resident #1's upper arm that appeared clotted and unable to be flushed. The hospital x-rays indicated Resident #1 had a left hip fracture and needed surgical repair. Resident #1 was then sent to her previous surgeon who did her right hip surgery at a higher level of care for orthopedics. An interview with the DOR on 10/15/25 at 11:26 AM revealed Resident #1was on physical and occupational therapy services and she did not have any balance or transfer ability, required constant redirection and could not follow instructions. The DOR stated the therapy department recommended the facility needed a 1:1 staff to sit with her and when that was recommended, typically the family would provide that individual, Because our facility is not equipped for that. If the family can't provide, I am not sure what we would do, probably recommend her go to a different facility. The DOR stated the facility did an intervention and use of call light, but the resident would not have been able know how to use it. The DOR stated she remembered after Resident #1 re-admitted from the hospital, I think she just crawled out of her wheelchair and fell and was sent due to pain. For therapy, the DOR said Resident #1 required one-step cues, had word salad and was not able to communicate or follow instructions. The DOR stated she evaluated her for the first time the second day of her admission, but Resident #1 had to be sent to the ER because she was vomiting black meaty substance. The DOR stated Resident #1 re-admitted on [DATE] and was a totally different person. For example, the first day the resident initially admitted , the DOR said she could not get her to open her eyes or lift her head off the bed. But when she came back from the hospital second time, the DOR said she was able to ask her how she was doing and the resident was more alert but still not able to hold a conversation. The DOR said Resident #1 used a wheelchair with maximum assistance and she thought the resident could take a few steps. The DOR stated, I don't think we got to a point where we tried to walk her. She would not sit still in her wheelchair and would climb over the footrests. The DOR stated Resident #1 came to the facility with an infected right hip wound from a recent surgery. She had a PICC line on her right bicep and pulled it out per clinical meeting report. The DOR said she did not know what the facility did about it, but she was sure they put it back in and wrapped it. She was not sure but felt the facility also had a 3rd party that could come and place one too. The DOR stated therapy saw Resident #1 for about a week and then she had a fall on 10/08/25 and that was when they found out she fractured her other hip. The DOR said they knew Resident #1 had a new hip fracture because the admissions coordinator was in contact with the hospital for updates. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did not fall on her shift. LVN D said when a resident fell, the nurse was supposed to look for injuries, notify the physician to see if the resident needed to be sent out based on vitals and injuries, then call the family and let them know. She said neurochecks got initiated right away and were done every 15 minutes for the first hour, then 30 minutes for an hour, then follow up for the next 72 hours. LVN D stated she did not assign a sitter to be with Resident #1 but did keep her by her out of caution in the hall or at the nurses' station. She said if therapy recommended a sitter for a resident for safety reasons, there were no actual sitters and she did not know what the protocol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 21 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was for that. LVN D said no one told her Resident #1 needed a 1:1 staff, It was her behaviors, she would try to get up out of her wheelchair. LVN D stated for residents identified as a high fall risk, the professional expectation was to keep them entertained, distract them and keep them beside the staff and within eyesight. LVN D stated, I have 14 residents on the hall. It is not always possible to keep a resident with me when I have 14 other residents. An interview with CNA H on 10/15/25 at 1:02 PM revealed she spent one week working with Resident #1 and needed help with basically everything such as changing, feeding, dressing. She said Resident #1 could kind of bear weight with two people on each side but could not do anything for herself and could not walk and she had never seen the resident try to. CNA H stated after one of her falls, Resident #1 needed to be 1:1. She said the fall occurred after lunch, and she heard a noise and when she went out into the hall, Resident #1 was in the hall on the ground surrounded by ADON G and the activity director. CNA H said Resident #1 was bleeding from her head and her hip was in pain because she was squirming around and could not get comfortable. She said the fall happened around 1:00 PM after lunch. CNA H stated earlier that day, She was good, she was supposed to be one-on-one, so we tried to keep her in sight, nurse kept her when passing meds and rolling her with her and I had her with me during documentation on my hall. CNA H said, however, during lunch it was difficult because the staff had to pass trays and feed residents. CNA H stated, I gave her to [ADON G] and [WCRN B] and [ADON G] was feeding her and the new man in therapy took her to therapy and as far as I know she was brought back and that is when she fell. CNA H stated, We knew she needed a one-on-one, it was obvious because we couldn't leave her alone without her ripping her lines, not only that, she would try to stand up and she was a fall risk. CNA H said there was no staff to do 1:1 for residents at the facility. She stated, Like me, I am on the hall down there by myself. I have 13 residents on my hall. I have a nurse and we don't have a med aide. In the past, we have had a resident like that with 1:1 every shift, so what they did at first they would ask us to come in for an extra shift to do it, one resident I think the family or facility got a person from a company to come and sit with the resident. CNA H said she thought it would have been safer for Resident #1 to have 1:1 supervision, For us, it would have helped us, she was big, like she needed a lot of help all the time, watch her or else things like this would happen like the falling. CNA H said her outcome for residents that were a high-fall risk was for the charge nurses to let the CNAs know more information about the residents, Like wounds or injuries because sometimes we don't know anything until we go into provide care. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed she repeatedly asked for the resident to be monitored more closely because she was weak and at risk for falls, but no supervision plan was implemented by the facility. An interview with LVN A on 10/15/25 at 3:55 PM revealed she worked with Resident #1 the day prior to her fall (10/07/25). She said she got up and walked out of bed. LVN A saw the resident at the door when she was passing meds. Then the next day when LVN A came for her next shift around 2:00 PM, she saw Resident #1 had to be babysat because she needed 1:1. LVN A said she believed Resident #1 needed a private sitter and it would have been the family's responsibility to provide one. LVN A stated, We don't have a memory care unit, especially on my hall because I am skilled nursing and I have 12 other people. So I parked my med cart by her and put her in a wheelchair in her doorway, and that is how I dealt with that. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated when she called, she stated, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we let her fall and break her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 22 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic, and no doses were missed. The ADON stated, That was my first concern since she did have an infection in her wound. The ADO then stated she notified the RP that an incident report to HHSC would be initiated for the fall with a major injury and the RP responded, ‘You have plenty of time to falsify the chart. The ADO said fall risk interventions for Resident #1 were to be in a low bed and have a fall mat, keep her in her wheelchair at the nurses' station so she could be supervised. The ADO said when a resident fell, it would be reviewed during the clinical stand-up meetings the next day when they pull a risk management report and the IDT would discuss interventions. She said if a resident was recommended for 1:1 supervision by the DOR, that should be communicated during the stand up meetings. She felt it was a teaching point she needed to do with the DOR because she came from assisted living and We don't provide 1:1 care, we provide assistance as we can accommodate. Anytime a resident is on 1:1, we will bring in extra staff, but then we have to look for a higher level of care because it is not sustainable. She said the facility could utilize department heads or CNAs who wanted extra money, but it was typically done for residents with behaviors or at the end of life and could be done on a case by case basis. The ADO did not know if Resident #1's RP was offered the option to hire a private sitter. She said the company could pay for a sitter because at one of the other facilities the company owned, she heard of them paying for up to four months for a 1:1 staff for a resident with behaviors. The ADO stated, We made sure the fall mat was in place and increased supervision.We spoke to the nursing staff about clear communication between shifts. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1 had two falls, the first one in her room where the intervention was increased supervision which escalated to 1:1, then the second fall occurred where she was sent to the hospital. She stated when 1:1 supervision was initiated; a staff member would be assigned to the resident at all times in arm's distance or less than six feet way. She did not know if the facility assignment sheets reflected the need for 1:1 coverage for Resident #1. She said change of shift communication was the monitoring system that ensured enhanced supervision remained in place one ordered. She also stated neurochecks documentation was completed following both falls through 10/08/25. The VPCO stated there had been no revision of facility policies or clarifications to policies as a result of the incidents with Resident #1. She felt the staff responded appropriately when Resident #1 had a fall. An interview with the DON on 10/16/25 at 1:00 PM revealed he was at the facility the day Resident #1 fell but did not witness anything. He said when he observed Resident #1, she was in pain and confused and the nurse who witnessed the fall reported she hit her head so she was sent to the ER for further evaluation. The DON stated Resident #1 had also fallen the day before but he did not know if it was witnessed or unwitnessed. He said when neurochecks were completed for a resident, they get the initial set every 15 minutes for the first hour, then every 30 minutes for two hours, then every hour for four hours and then continue to monitor every shift for 72 hours. He said the nurses did neurochecks to assess if the resident had any drastic changes in their blood pressure or any altered level of consciousness. The nurse then had to complete a progress note generated through PCC where they filled in the required information. The DON said neuros still had to be done during sleeping hours. An interview with ADON G on 10/16/25 at 1:20 PM revealed Resident #1's updated fall interventions were initiated when she completed the incident report, but she had made the mistake of clicking the wrong intervention. She stated Resident #1 should have had increased supervision, not 1:1. ADON G stated increased supervision meant more frequently monitored. She said if a resident needed 1:1 supervision, I've never done it, it is just reported with all the staff and they are made aware that the resident would require it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 23 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ADON G stated neurochecks were completed for Resident #1 post the first fall on 10/07/25. ADON G stated she witnessed Resident #1's fall on 10/08/25. She was at the med cat on the hall talking to a nurse and Resident #1 was at the nurses' station facing towards her in the hall. ADON G saw Resident #1 in the wheelchair start to stand up. As ADON G started to move towards her, Resident #1 turned around and fell. ADON G stated there was one nurse (LVN J) who had his back to her and he was documenting at the nurses' station and there were no other staff present. ADON G stated she assessed Resident #1 because she saw her hit her head on the counter of the nurses' station. When she and the other staff tried to turn Resident #1, she yelled out so they left her there, placed gauze in the vicinity of the wound and assessed her through neuros and vitals. She said Resident #1 never lost mentation, stayed at her baseline and was pleasant. 911 was called and she was sent out for evaluation. ADON G stated she did not think Resident #1 had been placed with LVN J specifically, I think he was just there, She said prior to the fall, she had assisted Resident #1 with her lunch and then therapy had taken her over and then I believe therapy left her at the nurses' station but I don't know. ADON G stated she did not know if Resident #1's fall could have been prevented. She stated, She could have fallen with 1:1, she was restless. Review of LVN J's witness statement of Resident #1's fall dated 10/09/25 reflected in full, I was sitting at the nurses station documenting and did not see the resident fall down. [Resident #1] fell behind me. An interview with the ADO on 10/17/25 at 9:26 AM revealed when she looked at Resident #1's incident report related to the first fall, she saw that ADON G made the intervention choice of 1:1 supervision on the report. The ADON stated she wanted to know if the CNAs knew Resident #1 was on 1:1 supervision so she called them and they did know she needed 1:1. The ADO stated the company's policy on what 1:1 supervision entailed was not specific on distance or location but she thought there was a policy for it. The ADO stated once ADON G made the new fall intervention of 1:1, her assumption was ADON G then told the staff Resident #1's new supervision requirements as well as during the stand up meeting where she thought the DOR was made aware of it. The ADO stated a physician's order was not required to initiate 1:1 supervision with a resident. The ADO stated Resident #1's care plan was updated with fall interventions but she did not know if the 1:1 supervision need was documented. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care, reassessment will occur after each fall. Interventions will be resident centered.The nurse will complete an event fall nurses note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. An Immediate Threat (IT) was identified on 10/17/25 related to Resident #1's lack of supervision and subsequent fall. The ADO was notified and provided with the IT template on 10/17/25 11:38 AM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 10/17/25 at 3:31 PM and reflected: Problem: F689 Accident and HazardsInterventions:1. Resident #1 no longer resides in the facility as of 10/8/25.2. No residents in the facility currently require 1:1 monitoring as of 10/17/25.3. All residents in the facility had fall risk assessments completed by the Regional Compliance Nurse, ADON, and Charge Nurses. Completed 10/17/25.4. All fall risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 24 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few care plans were reviewed by Compliance Nurse, ADON and Charge Nurses for appropriate interventions. Completion date 10/17/25.5. The compliance Nurse in-serviced the Administrator DON and ADON 1:1 on the following in-services. Completed 10/17/25.a. Abuse and Neglect Policy- including failure to provide fall risk interventions such as increased supervision could result in subsequent falls with injury to residents. The failure to provide supervision could be considered neglect.b. Fall Prevention Policy- to include appropriate interventions such as increased supervision to prevent falls.c. 1:1 Monitoring- when a resident is placed on 1:1 monitoring, an assigned staff member will be scheduled to monitor the resident to prevent accidents and hazards. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 1:1 monitoring orders will be put in EMAR and discontinued upon physician order.d. Documentation PolicyWhen a resident is placed on increased supervision, the charge will be documented in the chart via fall note or progress note every shift for a minimum of 72hrs. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 6. The medical director was notified of the immediate threat by the Administrator on 10/17/25.7. An ADHOC QAPI meeting will be conducted with the IDT to include the Medical Director to discuss the immediate threat citation and plan of removal. Completed 10/17/25.In-servicesAll staff were in-serviced by the Regional Compliance Nurse, DON, and ADON on the following in-services below. All staff not present will be in-serviced prior to the start of their shifts. All PRN will be in-serviced prior to their next scheduled shift. All new hires will be in-services during facility orientation. All agency staff will be in-serviced prior to their assignment if utilized. Completed 10/17/25a. Abuse and Neglect Policy- including failure to provide fall risk interventions such as increased supervision could result in subsequent falls with injury to residents. The failure to provide supervision could be considered neglect.b. Fall Prevention Policy- to include appropriate interventions such as increased supervision to prevent falls.c. 1:1 Monitoring- when a resident is placed on 1:1 monitoring, an assigned staff member will be scheduled to monitor the resident to prevent accidents and hazards. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 1:1 monitoring will not be removed unless ordered by a Physician.d. Documentation Policy- When a resident is placed on increased supervision, the charge will be documented in the chart via fall note or progress note every shift for minimum of 72hrs. Monitoring will be scheduled for all shifts and recorded on a monitoring form. Monitoring the Plan of Removal implementation occurred on 10/17/25 through 10/18/25. Facility monitoring activities included review of 24-hour reports, risk management logs, fall documentation and supervision assignment sheets to identify any additional incidents involving falls, inadequate supervision or lapses in 1:1 monitoring. No resident had fallen and there were currently no residents on enhanced supervision. A 100% sweep was conducted for all residents to re-assess their fall risk score and ensure it was accurate and care plan were reviewed for accuracy. Staff competency validations and in-service training records were reviewed for nursing staff related to fall protocols and supervision needs. 16 nursing and management staff were interviewed across all shifts (ADO, LVN A, WCRN B, RN F, ADON G, VPCO, MD K, LVN L, RN M, RN O, LVN R, LVN S, CNA T, CNA U, RN V, RNC) and demonstrated awareness of the facility's protocols related to increased supervision, fall prevention and documentation expectations. All staff monitored demonstrated understanding of when to initiated and document 1:1 supervision and how to escalate concerns to the licensed nurse of DON. A monitoring interview with ADON G was conducted on 10/18/25 at 12:26 PM regarding fall protocols and supervision for high-risk residents following the IT determination. ADON G stated the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift, and the charge nurse was responsible for those updates with the assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 25 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long, because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. She said nursing management verified that neurochecks and supervision interventions were implemented by reviewing them daily. ADON G stated after the IT was identified, the facility began daily review of critical systems-including abuse/neglect, wound vac, PICC line care, catheter management, change of condition and fall prevention and staff received in-servicing on each of those areas. She described new expectations for enhanced supervision and 1:1 monitoring. ADON G stated orders for 1:1 supervision were going to be issued by the physician, documented on paper forms and the charge nurse was to ensure follow through. The ADON said for a change in condition and neurochecks, nurses were expected to notify the physician immediately, initiate the fall protocol and record all neurological checks per policy. She said that supervision and neurochecks compliance was now being verified daily through management review. An interview on 10/18/25 at 12:43 PM with the ADO revealed care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. She said, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to interve Event ID: Facility ID: 675550 If continuation sheet Page 26 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement with a licensed pharmacy in a timely manner and that drugs are administered as ordered by the physician for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. The facility also failed to ensure these medications were obtained from the pharmacy and available for timely administration as ordered by the physician. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25)- Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025) Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25)-Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 27 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm ( a transparent medical dressing used to cover and protect wound sites); change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025). Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of Resident #1's order summary reflected the prescribing physician was MD C: -Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25); -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25) and Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25. Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused) and 9:00 AM (refused). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25). Record review of a Resident #1's pertinent nursing progress notes reflected: -09/24/25 at 6:00 PM by LVN A (admission nursing note) documented she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered.-09/24/25 at 8:46 PM LVN A documented Ertapenem was not administered due to awaiting delivery from pharmacy.- 09/25/25 at 12:14 AM LVN E documented Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-09/25/25 at 3:55 AM by LVN E documented the infusion company was contacted to schedule PICC replacement.-09/25/25 at 8:45 AM by LVN D documented, Nurse called [RP] or consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-09/25/25 at 9:15 AM by LVN D documented Resident #1's PICC line was in place and an x-ray confirmed placement.-09/25/25 at 10:06 AM by LVN D documented the Cefazolin was not administered due to Waiting on pharmacy.-09/25/25 by LVN A-Transfer Notification Progress Note by LVN A on reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place.-10/06/25 at 8:13 AM-e-MAR administration note by LVN D reflected the Lovenox injection was not administered due to Resident swatting at nurses hands and jumping.-10/06/25 at 8:40 PM LVN A documented, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-10/07/25 at 12:01 AM LVN E documented, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10 days. Order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 28 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. All needs anticipated and met by staff. Resting in bed with eyes closed. No s/s of distress/discomfort noted. Bed low, call light in reach, fall mat in place.-10/07/25 at 9:43 AM by LVN D documented Lovenox was not administered because, Resident pushed nurse's hands away and refused injection.-10/08/25 at 8:59 AM by LVN D reflected the resident refused the medication administration for Lovenox. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did pull out her PICC line and it was replaced by the infusion company during her stay. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the day of the second re-admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it was unable to flush the line because it was clotted in the PICC line due to being exposed to air. LVN A said Resident #1 had an arterial venous two port. She said she notified MD C and the RP but was not sure which infusion company to call due to recent contract changes and the recent facility company changeover. She said, They (unknown) were going to talk to administration and it was taken out of my hands. LVN A said she worked with Resident #1 the next evening and her PICC line was working. LVN A said she did not know what happened with the PICC line, I didn't get a good report on that, but it was functioning. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated there was no alternative when a when a resident pulled out a PICC line, and it wasn't until the second removal that MD C ordered an oral antibiotic to cover the resident until they tried to figure out what we were going to do. She further stated, We just didn't know what to do with her honestly. I don't think we were the right place for her, she needed memory care. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1's IV antibiotic was changed to oral because she was pulling at other things and the thought process by the charge nurse was to change the order to po to make it easier to administer. She stated, I believe the physician obliged and switched to Bactrim. The VPCO stated there was one dose that the charge nurse was unable to administer for IV antibiotics from the 10/06/25 into 10/07/25 due to the line being clotted, so an oral order was obtained and the new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 29 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotic was administered the morning of 10/07/25. She said the facility had an e-kit and that was where Resident #1 got her initial dose of Bactrim. An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay it she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he was not notified when Resident #1's PICC line was clogged but was told the next day the nurse had to get an order to change it to oral antibiotic. The DON stated there was a way to get a PICC line going again, there was a company the facility used that came out and unclogged them. The DON stated, I don't believe they came out and unclogged it. I don't know why. It was already discontinued and pulled out by the time I got to work so I didn't assess it. The DON stated his expectation was it a PICC line was clogged, the charge nurse should have called the infusion company to get a new one placed. He did not know if the infusion company worked 24/7, but thought if the line came out at night, they would come out the next morning. If it could not get replaced quickly, the DON said the nurse would notify the doctor. He did not know what the charge nurse did that night the PICC line was clogged. An interview with ADON G on 10/16/25 at 1:20 PM revealed she did not know Resident #1's PICC line was clotted or the IV meds had been stopped until she got to work the morning after and got shift report. ADON G said she was told the night nurse had received an order from MD C for an oral antibiotic. She did not know if that nurse had contacted the infusion company to come and replace the line before requesting the route change and she did not know if the charge nurse assessed the PICC line post-removal. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. An interview with the C-VP on 10/17/25 at 12:59 PM revealed Resident #1 was unable to receive one of her antibiotic medications three times via her PICC line and MD C was notified and the PICC line was removed. She did not know if MD C was told the IV antibiotic was unable to be administered per order. A follow up interview with LVN A on 10/17/25 at 2:05 PM revealed there was a pharmacy the facility used that did deliveries three times a day. She did not know the exact times, but thought one was at dinner time and one at midnight. LVN A said if a resident admitted in the later part of the afternoon, there may be some medications that would come in that night, but by the daytime next shift, they would all be coming in. She stated the latest she could order medications for a new admission from the pharmacy was around 5 or 6 pm for the midnight delivery. LVN A stated missing three doses of IV antibiotics, the facility should already be talking about a backup plan with the doctor. LVN A stated the problem with missing three doses of IV abx was you will not have a decrease in bacteria, there would be an increase and flora will start growing. LVN A stated she was open to oral antibiotics due to the problems with the PICC line and Resident #1 fiddling with the lines and unwrapping the bandaging. LVN A stated the facility tried long-sleeved shirts and [MD C] went with the flow of whatever we had to do. Regarding the Lovenox, LVN A stated she tried to contact the doctor and get a hold order which was done typically when residents refused it. She stated Lovenox was an anticoagulant and was prescribed because Resident #1 had a hip fracture and was prone to a DVT, which could travel to her lungs and give her a pulmonary embolism. She said anyone who had a surgery was prone to that, especially leg surgery. She stated she never administered Resident #1 Lovenox because it was a morning medication and she did not work that shift. If a resident refused a high risk medication, LVN A said the protocol was by the second refusal, she would notify the doctor. LVN A stated there was a problem the night she tried to fax MD C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 30 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some about Resident #1's PICC line being clotted and she did not start the oral Bactrim that night as a result. She stated the order would have been sent to the pharmacy and she felt like she probably gave it from the e-kit but could not remember. An interview with MD K on 10/17/25 at 1:00 PM revealed he was the medical director for the facility and he and MD C had the bulk of the residents as patients. He stated he did not know Resident #1 and had never seen her as she was not assigned as his patient. However, as the medical director, MD K stated if a resident had an IV antibiotic medication upon admission and the facility knew they would not be able to obtain and give the medication when it is to be given, they really did not have a choice but to send the resident back to the hospital. MD K stated, I've told them before to send them back and infuse as an outpatient in the emergency room at the hospital until we get the antibiotic delivered, then they can come back. He stated some residents were more critical than others, for example, if the resident admitted with sepsis, They certainly need to have it [IV abx] continued. MD K stated missing three doses of an antibiotic medication was too many and he thought that the facility's contracted pharmacy would have provisions to do stat deliveries. MD K stated Lovenox was an anticoagulant that was used to help prevent DVT for surgery and it should be readily available. He stated if a resident was refusing Lovenox, the simple solution would be to change the medication to Xarelto or Eliquis, both oral medications, But they need to call the doctor to consult us if the resident is refusing. MD K stated a lot depended on the patient and the shape they were in, if they were bedfast or had any peripheral edema. An interview with LVN L on 10/18/25 at 11:33 AM revealed when a new resident admitted with time-sensitive mediations, as the admission nurse he would write the order, enter it into the computer, call the pharmacy and verify if they received the order. Then if it was an antibiotic and the facility did not have it, he would check the e-kit to see if it was available and call the pharmacy to get the code. He stated if he needed a medication and it was not in the e-kit, he would call the pharmacy and let the doctor know the resident did not receive the dose and hope it came in the next day. LVN stated he did not administer Resident #1's Lovenox because it was a morning medication. He said Lovenox was quite important because it was a blood thinner, One degree lower than heparin. An interview with RN M on 10/18/25 at 11:49 AM revealed when a new resident admitted , the charge nurse who admitted the resident could always check the e-kit and see if the medication was available, if not, then call the pharmacy and see how soon they could get it to the facility. Then the physician should be contacted to see if he wanted an alternative medication or did he want to wait. RN M did not know what antibiotics were kept in the e-kit and said pharmacy usually came around 8-10 PM on her shift. RN M stated with the anticoagulant Lovenox, she did not work with Resident #1 but knew the medication was used to keep blood clots from forming and was usually used after surgeries. An interview with ADON G on 10/18/25 at 12:26 PM revealed when a resident was newly admitted , orders were to be entered timely and as ordered. For medications not in stock, ADON G said they worked with what they had in stock and usually did not get advanced notice of orders coming in with new admissions. She stated that the nursing management, which included herself and the DON, reviewed admissions, verified orders had been processed and the pharmacy had been contacted. ADON G stated there was no formalized tracking log showing timeliness for medication deliveries or stat medications. She said her expectation would be for the nurse to notify the physician immediately if a medication was unavailable or delayed, ADON G stated communication between nurses, pharmacy and provider was expected to be verbal and immediate for critical admissions and that if issues arose, They would be expected to call the pharmacy and discuss any issues. An interview on 10/18/25 at 12:43 PM with the ADO revealed that upon a resident's admission, nursing staff immediately entered new orders into e-MAR, which transmitted directly to the pharmacy. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 31 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be ‘hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given. Event ID: Facility ID: 675550 If continuation sheet Page 32 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25)- Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025) Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25)-Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm ( a transparent medical dressing used to cover and protect wound sites); change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 33 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025). Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of Resident #1's order summary reflected the prescribing physician was MD C: -Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25); -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25) and Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25. Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused) and 9:00 AM (refused). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25). Record review of a Resident #1's pertinent nursing progress notes reflected: -09/24/25 at 6:00 PM by LVN A (admission nursing note) documented she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered.-09/24/25 at 8:46 PM LVN A documented Ertapenem was not administered due to awaiting delivery from pharmacy.- 09/25/25 at 12:14 AM LVN E documented Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-09/25/25 at 3:55 AM by LVN E documented the infusion company was contacted to schedule PICC replacement.-09/25/25 at 8:45 AM by LVN D documented, Nurse called [RP] or consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-09/25/25 at 9:15 AM by LVN D documented Resident #1's PICC line was in place and an x-ray confirmed placement.-09/25/25 at 10:06 AM by LVN D documented the Cefazolin was not administered due to Waiting on pharmacy.-09/25/25 by LVN A-Transfer Notification Progress Note by LVN A on reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place.-10/06/25 at 8:13 AM-e-MAR administration note by LVN D reflected the Lovenox injection was not administered due to Resident swatting at nurses hands and jumping.-10/06/25 at 8:40 PM LVN A documented, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-10/07/25 at 12:01 AM LVN E documented, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10 days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. All needs anticipated and met by staff. Resting in bed with eyes closed. No s/s of distress/discomfort noted. Bed low, call light in reach, fall mat in place.-10/07/25 at 9:43 AM by LVN D documented Lovenox was not administered because, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 34 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident pushed nurse's hands away and refused injection.-10/08/25 at 8:59 AM by LVN D reflected the resident refused the medication administration for Lovenox. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did pull out her PICC line and it was replaced by the infusion company during her stay. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the day of the second re-admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it was unable to flush the line because it was clotted in the PICC line due to being exposed to air. LVN A said Resident #1 had an arterial venous two port. She said she notified MD C and the RP but was not sure which infusion company to call due to recent contract changes and the recent facility company changeover. She said, They (unknown) were going to talk to administration and it was taken out of my hands. LVN A said she worked with Resident #1 the next evening and her PICC line was working. LVN A said she did not know what happened with the PICC line, I didn't get a good report on that, but it was functioning. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated there was no alternative when a when a resident pulled out a PICC line, and it wasn't until the second removal that MD C ordered an oral antibiotic to cover the resident until they tried to figure out what we were going to do. She further stated, We just didn't know what to do with her honestly. I don't think we were the right place for her, she needed memory care. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1's IV antibiotic was changed to oral because she was pulling at other things and the thought process by the charge nurse was to change the order to po to make it easier to administer. She stated, I believe the physician obliged and switched to Bactrim. The VPCO stated there was one dose that the charge nurse was unable to administer for IV antibiotics from the 10/06/25 into 10/07/25 due to the line being clotted, so an oral order was obtained and the new antibiotic was administered the morning of 10/07/25. She said the facility had an e-kit and that was where Resident #1 got her initial dose of Bactrim. An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 35 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he was not notified when Resident #1's PICC line was clogged but was told the next day the nurse had to get an order to change it to oral antibiotic. The DON stated there was a way to get a PICC line going again, there was a company the facility used that came out and unclogged them. The DON stated, I don't believe they came out and unclogged it. I don't know why. It was already discontinued and pulled out by the time I got to work so I didn't assess it. The DON stated his expectation was it a PICC line was clogged, the charge nurse should have called the infusion company to get a new one placed. He did not know if the infusion company worked 24/7, but thought if the line came out at night, they would come out the next morning. If it could not get replaced quickly, the DON said the nurse would notify the doctor. He did not know what the charge nurse did that night the PICC line was clogged. An interview with ADON G on 10/16/25 at 1:20 PM revealed she did not know Resident #1's PICC line was clotted or the IV meds had been stopped until she got to work the morning after and got shift report. ADON G said she was told the night nurse had received an order from MD C for an oral antibiotic. She did not know if that nurse had contacted the infusion company to come and replace the line before requesting the route change and she did not know if the charge nurse assessed the PICC line post-removal. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. An interview with the C-VP on 10/17/25 at 12:59 PM revealed Resident #1 was unable to receive one of her antibiotic medications three times via her PICC line and MD C was notified and the PICC line was removed. She did not know if MD C was told the IV antibiotic was unable to be administered per order. A follow up interview with LVN A on 10/17/25 at 2:05 PM revealed there was a pharmacy the facility used that did deliveries three times a day. She did not know the exact times, but thought one was at dinner time and one at midnight. LVN A said if a resident admitted in the later part of the afternoon, there may be some medications that would come in that night, but by the daytime next shift, they would all be coming in. She stated the latest she could order medications for a new admission from the pharmacy was around 5 or 6 pm for the midnight delivery. LVN A stated missing three doses of IV antibiotics, the facility should already be talking about a backup plan with the doctor. LVN A stated the problem with missing three doses of IV abx was you will not have a decrease in bacteria, there would be an increase and flora will start growing. LVN A stated she was open to oral antibiotics due to the problems with the PICC line and Resident #1 fiddling with the lines and unwrapping the bandaging. LVN A stated the facility tried long-sleeved shirts and [MD C] went with the flow of whatever we had to do. Regarding the Lovenox, LVN A stated she tried to contact the doctor and get a hold order which was done typically when residents refused it. She stated Lovenox was an anticoagulant and was prescribed because Resident #1 had a hip fracture and was prone to a DVT, which could travel to her lungs and give her a pulmonary embolism. She said anyone who had a surgery was prone to that, especially leg surgery. She stated she never administered Resident #1 Lovenox because it was a morning medication and she did not work that shift. If a resident refused a high risk medication, LVN A said the protocol was by the second refusal, she would notify the doctor. LVN A stated there was a problem the night she tried to fax MD C about Resident #1's PICC line being clotted and she did not start the oral Bactrim that night as a result. She stated the order would have been sent to the pharmacy and she felt like she probably gave it from the e-kit but could not remember. An interview with MD K on 10/17/25 at 1:00 PM revealed he was the medical director for the facility and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 36 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he and MD C had the bulk of the residents as patients. He stated he did not know Resident #1 and had never seen her as she was not assigned as his patient. However, as the medical director, MD K stated if a resident had an IV antibiotic medication upon admission and the facility knew they would not be able to obtain and give the medication when it is to be given, they really did not have a choice but to send the resident back to the hospital. MD K stated, I've told them before to send them back and infuse as an outpatient in the emergency room at the hospital until we get the antibiotic delivered, then they can come back. He stated some residents were more critical than others, for example, if the resident admitted with sepsis, They certainly need to have it [IV abx] continued. MD K stated missing three doses of an antibiotic medication was too many and he thought that the facility's contracted pharmacy would have provisions to do stat deliveries. MD K stated Lovenox was an anticoagulant that was used to help prevent DVT for surgery and it should be readily available. He stated if a resident was refusing Lovenox, the simple solution would be to change the medication to Xarelto or Eliquis, both oral medications, But they need to call the doctor to consult us if the resident is refusing. MD K stated a lot depended on the patient and the shape they were in, if they were bedfast or had any peripheral edema. An interview with LVN L on 10/18/25 at 11:33 AM revealed when a new resident admitted with time-sensitive mediations, as the admission nurse he would write the order, enter it into the computer, call the pharmacy and verify if they received the order. Then if it was an antibiotic and the facility did not have it, he would check the e-kit to see if it was available and call the pharmacy to get the code. He stated if he needed a medication and it was not in the e-kit, he would call the pharmacy and let the doctor know the resident did not receive the dose and hope it came in the next day. LVN stated he did not administer Resident #1's Lovenox because it was a morning medication. He said Lovenox was quite important because it was a blood thinner, One degree lower than heparin. An interview with RN M on 10/18/25 at 11:49 AM revealed when a new resident admitted , the charge nurse who admitted the resident could always check the e-kit and see if the medication was available, if not, then call the pharmacy and see how soon they could get it to the facility. Then the physician should be contacted to see if he wanted an alternative medication or did he want to wait. RN M did not know what antibiotics were kept in the e-kit and said pharmacy usually came around 8-10 PM on her shift. RN M stated with the anticoagulant Lovenox, she did not work with Resident #1 but knew the medication was used to keep blood clots from forming and was usually used after surgeries. An interview with ADON G on 10/18/25 at 12:26 PM revealed when a resident was newly admitted , orders were to be entered timely and as ordered. For medications not in stock, ADON G said they worked with what they had in stock and usually did not get advanced notice of orders coming in with new admissions. She stated that the nursing management, which included herself and the DON, reviewed admissions, verified orders had been processed and the pharmacy had been contacted. ADON G stated there was no formalized tracking log showing timeliness for medication deliveries or stat medications. She said her expectation would be for the nurse to notify the physician immediately if a medication was unavailable or delayed, ADON G stated communication between nurses, pharmacy and provider was expected to be verbal and immediate for critical admissions and that if issues arose, They would be expected to call the pharmacy and discuss any issues. An interview on 10/18/25 at 12:43 PM with the ADO revealed that upon a resident's admission, nursing staff immediately entered new orders into e-MAR, which transmitted directly to the pharmacy. She stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675550 If continuation sheet Page 37 of 38 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 675550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pecan Tree Rehab and Healthcare Center 1900 E California St 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be ‘hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given. Event ID: Facility ID: 675550 If continuation sheet Page 38 of 38