Inspection·September 13, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they just threw a boot on it. She stated the staff never removed the boot and had never checked the skin underneath it. There were no concerns with circulation or skin integrity to Resident #55s lower extremity. Review of Resident #55's electronic physicians' orders revealed: non weight bearing to right lower extremity with a start date of 07/17/2023. Review of the electronic physicians' orders revealed no evidence of an order for the boot to her right ankle and no orders to check for circulation of skin integrity underneath the boot. Further review of the electronic physicians' orders revealed no evidence of an order for x-rays of the ankle or referral to orthopedic doctor. Review of Resident #55's electronic nurses notes revealed no evidence of documentation related to resident's right ankle injury until 07/17/2023. Review of the electronic progress note dated 07/17/2023 at 09:27 am, revealed: Physician contacted facility to report that patient had a possible fracture to ankle. New orders received 1.) NWB to RLE, 2.) Consult with orthopedics. Review of electronic nurses noted dated 07/26/2023 at 2:10 pm, revealed: When returned from orthopedic doctor Resident #55 was in walking boot on right foot no orders were returned with Resident #55. Resident #55 stated she is to further exam of her right foot. Review of the X-ray report for Resident #55 dated 07/14/2023 at 3:30 pm, revealed: Procedure: X-ray ankle. Conclusion: Suspected lateral malleolar fracture although the evaluation is limited due to the patients positioning. Review of Resident #55's electronic record revealed no evidence of an incident report regarding Resident #55's ankle injury. During an interview on 09/13/23 at 05:35 PM, the DON stated Resident #55 went to a neurologist appointment on 07/13/2023 around 12:00 PM, CNA F was transferring Resident #55 from mechanical lift to the electric wheelchair when Resident #55 stated her foot hurt. She stated an x-ray was performed on 07/14/2023. The DON stated on 07/17/2023 the physician called the facility and said Resident #55 had a fractured ankle. The DON stated orders were received to make Resident #55 non weight bearing and to consult orthopedics. The DON stated Resident #55 saw the orthopedic doctor on 07/26/2023 and returned to the facility with and ankle boot on but no orders. The DON stated there should have been more follow up when informed ankle was hurt. The DON stated the documentation should have been better. She stated the nurses' notes should have told a complete story of the incident and everything that was done. She stated the incident where her ankle was hurt should have been documented but did not require an incident report because there was not an actual incident that took place. She stated when Resident #55 came back from the doctor with a boot and no orders the nurse should have contacted the doctor to get orders. She stated there should have been an order for the boot and for checking pulses and monitoring skin integrity for the boot. The DON stated the boot should have been care planned. She stated this was just a lack in documentation and it was her place to ensure the nurses were documenting accurately. The DON stated these failures could have resulted in lack of treatment, increased pain, and possible skin issues. During an interview on 9/13/2023 at 6:05 PM, Resident #55 stated she had an appointment with the neurologist but could not recall the date. She stated there were 2 staff members that assisted her in the mechanical lift to her electronic chair. She stated she was not positioned correctly in her chair due to her hips working. She stated CNA F was there when Resident #55 stated she could reposition herself. She stated when she placed pressure on her right foot, she experienced excruciating pain. She stated she went to the appointment then back to the facility. She stated she went overnight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 2 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 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 - Minimal harm or potential for actual harm Residents Affected - Few without being seen or sent to the emergency room the next day. She stated she informed the nurses she was hurting and had injured her ankle, and nothing was done until the evening of the next day because she insisted. During an interview attempt on 09/13/2023 at 6:00 PM, CNA F did not answer her phone. A voicemail was left with no return phone call. During an interview on 09/13/2023 at 6:30 PM, the Administrator stated she did not consider Resident #55's ankle injury a suspicious injury. They stated they did not feel the need to investigate because Resident #55 stated what happened. The Administrator stated there was no abuse or neglect. She stated Resident #55 hurt her ankle when adjusting herself in her chair. The Administrator stated she felt that Resident #55's ankle injury was handled appropriately. Review of the facility policy titled, Immobilization Devices, Splints/Slings/Collars/Straps dated 2003, Revealed in part: immobilization devices are splints, sling, cervical collars, and clavicle straps that are applied to restrict movement support and preserve the integrity of an injured area . Major considerations involved in administering these applications are proper alignment and optical peripheral neurovascular function in the body part immobilized. Goals: 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure: .8. All immobilization devices except clavicle straps, should be removed periodically. All devices will be monitored on every two hour schedule. Monitoring will be documented in the clinical record or flow sheet. 9. Neurovascular assessment should be performed during. And after the application of the immobilization device. 10. Skin integrity should be assessed periodically when the device is removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 3 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 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 0801 Level of Harm - Potential for minimal harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses. Findings included: Review of the DM's employee file revealed a hire date of 06/16/2022 as the DM. There was no documented evidence of a Dietary Manager Certificate found in the file. During an interview on 09/13/2023 at 10:15 AM, the DM stated she had taken the certification several months ago but did not have the certificate. The DM stated she didn't know why she did not have a copy of the certificate. The DM stated it was in her email and she could not open her email. During an interview on 09/13/2023 at 2:30 PM, the ADMN stated the DM had completed the course for her certification but did not know why the facility did not have a copy. The ADMN stated the facility should have had a copy of the DM's certification, and the certificate would be the only evidence to proof she had completed the certification course. The ADMN stated the DM went home to print her certificate and would bring the certification as soon as she got it. The ADMN stated the importance of having a certified DM was to ensure residents received food that stored and cooked correctly and met their nutritional needs. During an interview on 09/13/2023 at 4:45 PM, the ADMN stated she had not been able to get a copy of the certification and was not able to reach the DM. During an interview on 09/13/2023 at 7: 30 PM, the AMDN stated she was not able to provide further evidence of the DM's certification Review of facility job description titled, Dietary Service Manager signed 06/16/2022 by the DM revealed; Current certification by state as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 4 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 09/11/2023 between 10:30 AM and 11:30 AM of the kitchen revealed: Freezer 1. Two packages of salami that were not labeled with a receive date or food item description. 2. One package of salami that was not labeled with a receive date or food item description; and meat was covered with ice crystals. 3. One package of hamburger patties that were in a plastic bag with a seal that was not sealed and open to air. 4. One hamburger patty laying on shelf in the freezer not covered or stored in storage container. During an interview on 09/11/2023 at 10:45 AM, the DM stated food items should have been labeled with a received date, an open date and item description if food was out of the original package. The DM stated what led to failure was staff get in a hurry and do not take the time to write on food items or seal them correctly. The DM stated the hamburger patty should not have been laying on shelf uncovered. The DM stated she was responsible to monitor staff. The DM stated food not being stored or labeled correctly could have led to residents getting sick or food lose quality. Observation on 09/13/23 between 10:00 AM and 10:30 AM of the kitchen revealed [NAME] A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing broccoli. [NAME] A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing beans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 5 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 09/13/2023 at 10:35 AM, [NAME] A stated she should have washed her hands every time she changed her gloves. [NAME] A did not provide a response as to why she did not wash her hands after changing gloves. During an interview on 09/13/2023 at 10:45 AM, the DM stated staff should have washed their hands with soap and water every time they change their gloves. The DM stated not performing hand hygiene could have caused cross contamination and residents could have gotten sick. The DM stated staff getting in hurry and forgetting led to failure of not washing hands. During an interview on 09/13/2023 at 4:45 PM, the ADMN she stated hand hygiene should occur before you put on gloves and after you remove gloves. The ADMN stated food items should have been labeled with an open date, a receive date and description of food item (if not in original packaging). The ADMN stated not performing proper hand hygiene and/or storing and labeling food correctly could have led to residents getting sick. The ADMN stated staff in hurry and new staff may have led to failures in the kitchen. Record review of facility policy titled, Storage Refrigerators, without a date revealed Food must be covered when stored, with a date label identifying what is in the container. Record Review of facility policy titled, Fundamental of Infection Control Precautions, dated 10/21/22 revealed: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene . After removing gloves . wearing gloves does not replace the need for hand washing because gloves may have small inapparent defect or be torn during use FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 6 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 (Resident #53 and 78) of 8 residents reviewed for medical records. Facility failed to document follow-up observations and monitoring for Resident #53 after she had falls. Facility failed to document follow-up observations and monitoring for Resident #78 after he had falls, behaviors, and antibiotic therapy. These failures placed residents at risk for continuity of care and early detection of complications related to medications and injuries. Findings included: Resident # 53 Record review of Resident #53's Facesheet dated 09/13/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included Vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Senile degeneration of brain, Schizoaffective disorder bipolar type, osteoporosis without current pathological fracture. Record review of Resident #53's Quarterly MDS dated [DATE] revealed No BIMS score with problems with short- and long-term memory issues. She had at least 1 fall in the previous 3 months. She needed extensive 2-person assistance for transfers and supervision with 1-person for walking. Record review of Resident #53's Care plan last updated 09/11/23 revealed: is a high risk for falls r/t Confusion. Fall without injury 01/12/23, Fall without injury 01/26/23, fall without injury 02/22/23, fall without injury 04/07/23, fall with injury 07/09/23 (laceration), fall without injury 09/11/23. The resident will be free of minor injury through the review date. #53 will have a reduction in falls through the review date. Anticipate and meet Resident #53's needs. Be sure Resident #53's call light is within reach and encourage her to use it for assistance as needed. Educate Resident #53/family/caregivers about safety reminders and what to do if a fall occurs. Encourage Resident #53 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that Resident #53 is wearing appropriate footwear, shoes or non-skid socks when ambulating or mobilizing in w/c. Follow facility fall protocol. Resident #53 needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. low bed with fall mat in place while in bed, hipsters on at all times. PT to evaluate and treat as ordered or PRN. 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 #53/family/caregivers/IDT as to causes. Record review of Resident #53's Progress from 04/12/23 to 09/15/23 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 7 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 04/12/23 through 05/13/23 Level of Harm - Minimal harm or potential for actual harm Effective Date: 05/07/2023 14:30 Type: Nursing Note Residents Affected - Some Note ext: resident found laying on her back on floor in room resident assessed moves all ext well no s/s or c/o pain no injuries noted. resident wearing hipsters and no slide socks notified RP, PCP, ADONS DON ADMIN No additional notes after fall on 5/7/23 over the next 3 days. 06/13/23 through 07/13/23 Effective Date: 07/09/2023 20:00 Type: Nursing Note Note Text : RESIDENT SENT TO ER POST FALL DUE TO HEAD LACERATION 2 STAPLES APPLIED REMOVE STAPLES IN 10 DAYS. Effective Date: 07/09/2023 18:45 Type: Nursing Note Note Text : CNA REOPORTED TO THIS RN THAT RESIDENT HAD FALLEN RESIDENT FOUND LAYING ON HER LEFT SIDE ON MAT WITH HEAD NEXT TO NIGHTSTAND RESIDENT ASSESSED MOVES ALL EXT W/O S/S OR C/O PAIN NOTED 2CM LACERATION TO LEFT SIDE OF HEAD. CLEANED WITH NSS AND GAUZE RESIDENT SENT TO THE ER FOR EVALUATION AND SUTURESNOTIFIED DON ADMIN RP AND PCP No additional notes after fall on 7/9/23, or follow-up monitoring for staples. 07/14/23 to 08/14/23. No progress notes at all. 08/15/23 through0 9/15/23 No note regarding fall on 09/11/23. During an observation and interview on 09/11/23 at 11:47AM with Resident #53, surveyor observed Resident #53 in her room, in the middle of the floor behind her wheelchair with her door closed, and the lights off. There was a floor mat leaning against Resident #53's roommate's bed. Resident#53 was making a noise, like a cutting ahahahahah noise. Surveyor pushed resident call light and went to the hallway and seen housekeeping and asked that they get a nurse, as resident was in the floor. Surveyor asked Resident #53 if she was in pain and she said yes. She was asked where she was hurting and did not answer and again began making the ahahahah sound. Resident #53 was observed scooting around on the floor frequently while awaiting assistance from staff and had been in the process of trying to get up out of the floor per self when RN B entered her room. Resident #53 then finished getting up after RN B provided her hand to resident. Resident #53 was observed with a bulkiness to her hips and RN B said Resident #53 had hipsters on to protect her hips during a fall, a low bed, and also a fall mat. She said Resident #53 had a history of frequent falls. Resident #53 appeared wet from incontinent episode through her sweatpants. An aide had entered Resident #53's room then went out to get another set of hipsters and nurse stayed with resident. RN B asked Resident #53 if she was hurting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 8 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #53 said yes but then would not say, point or indicate where the pain was. Resident#53 began to pace around room and began moving things from 1 part of the room to another part of the room and then began opening and shutting dresser drawers. RN B said Resident #53 was able to ambulate well per self and rarely would sit in her wheelchair. Nurse aide returned to room as the nurse was opening the door to look out for aide, Resident #53 just began walking out of room, so aide decided they would take resident to the shower room. Aide said that hospice had just been in and did Resident #53's shower not too long ago. Resident#53 did well ambulating in her room without need of assistance of the staff as well as walking through the hallway and she did not ambulate with the appearance of difficulty or pain. RN B said, Resident #53 had not had a true fall in quite some time. She said Resident #53 did scoot off her bed or the chair in her room or sometimes even her wheelchair, and she would just sit down in the floor and scoot around on her bottom sometimes. Resident # 78 Record review of Resident #78's Facesheet dated 09/13/23 revealed An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Other idiopathic peripheral autonomic neuropathy. Record review of Resident #78's admission MDS dated [DATE] revealed no BIMS score with difficulty with short- and long-term memory. He needed ADL assistance of extensive 2-person assistance for transfers and supervision of 1-person for ambulating. He did utilize a wheelchair. Resident #78 had at least 1 fall since admission. Record review of Resident #78's Careplan last updated 9/13/23 revealed: The resident is high risk for falls r/t Confusion, Gait/balance problems. 08/16/23 fall with injury, 08/17/23 fall with injury, 08/19/23 fall with injury, fall with injury 09/02/23 fall with injury (hematoma, skin tear) 09/13/23. The resident will be free of falls through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear (Specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non- skid socks) when ambulating or mobilizing in w/c. Follow facility fall protocol. Hipsters to be worn at all times to prevent injury from falls. Resident #78 to wear soft helmet while OOB and ambulating to prevent further injury from falls. Pt evaluate and treat as ordered or PRN. The resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). The resident needs activities that minimize the potential for falls while providing diversion and distraction. Record review of Resident #78's Progress notes dated 08/14/23 through 09/14/23 revealed: Effective Date: 08/17/2023 14:20 Type: Nursing Note Note Text: notified PCP of change in condition, PCP ordered resident to be sent to ER for EVAL. (RP) notified. Effective Date: 08/17/2023 03:11 Type: Nursing Note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 9 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 LATE ENTRY Level of Harm - Minimal harm or potential for actual harm Note Text: CNA notified this nurse that resident was on the floor. He was on his back with head by the closed bathroom door and his legs were straight out in front of him. Vital signs obtained, head to toe assessment done Residents Affected - Some with no new injuries noted. Assisted resident back to his bed. No s/s of pain or discomfort. Bed in lowest position and call light in reach. Notified (RP), PCP, and admin. Effective Date: 08/18/2023 22:11 Type: Nursing Note Note Text: this nurse heard a noise and observed resident lying on the floor in the hallway. this nurse assessed resident for injury a hematoma was forming on the left side of forehead (same area from a previous fall) and the dressing on resident's left elbow had been scraped open. resident moves all extremities without pain or discomfort admin., DON, on call DR and (RP) were all notified neuros. Initiated. Effective Date: 08/19/2023 10:00 Type: Nursing Note Note Text: RN IN ER CALLED AND INFORMED THAT TEST RESULTS CAME BACK ON HIS URINE AND HE HAS ECOLI IN HIS URINE NEW ORDER RECIEVED FROM ER DR FOR MACROBID BID X 10 DAYS RESIDENTS RP CALLED AND NOTIFIED Effective Date: 09/02/2023 05:45 Type: Activity Note Text: this RN heard a crash found resident lying on his back on the floorresident assessed resident moves all ext w/o s/s or c/o pain noted raised knot with a 1 cm laceration on top first aid admin neuros started. notified RP PCP DON AND ADMINISTRATOR Effective Date: 09/07/2023 10:11 Type: Nursing Note Note Text: Resident having increase in behaviors hitting at staff and using foul language. Staff attempting to redirect resident, resident continues to hit and kick at staff, cursing while doing it. Effective Date: 09/09/2023 12:34 Type: Nursing Note Note Text: Resident standing in room holding on to his wheelchair running it into the bathroom door over and over cursing and yelling at staff. Resident redirected, attempted to get in bed staff helped resident to bed, fall mat next to bed. WCTM Effective Date: 09/13/2023 06:30 Type: Nursing Note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 10 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note Text: Resident using foul language hitting punching at staff trying to bite staff. Staff attempts to redirect resident not easily redirectable. DR. notified of behavior prn lorazepam 0.5mg Q6 hrs. prn. (Draft) No follow up notes from any shifts regarding resident behaviors, falls, or antibiotic use. During an observation on 09/11/23 at 12:09PM of Resident #78, he had a soft open helmet on. He was observed several times getting out of wc and ambulating towards a closet in the dining/activity area. Resident #78 did not respond to any questions and only looked at surveyor during questions. During an interview on 09/13/23 at 02:53 PM with ADM, she said the expectation was to document daily per shift x 3 days (72 hours) when there has been a fall or a change of condition. She said if a resident had an antibiotic, the nurses should have charted on each shift the entire time the resident was taking the antibiotic and then for3 days after. ADM reviewed Resident #78's progress notes from admission 8/15/23 to 9/13/23 and verified that the staff did not chart per their policy for documentation. During an interview on 09/13/23 at 3:39PM with DON she said she expected that the nurses documented in a progress note for a fall at the time of the incident and then each shift for the next 3 days afterwards. She said if a resident was taking an antibiotic, the nurses should have been documenting a progress note each shift the entire time the resident took an antibiotic and then for an additional 3 days each shift after the resident completed the antibiotic. During an interview on 09/13/23 at 5:36PM with LVN E, she said any time a resident had a fall, the nurses were to complete an incident report and if the fall had been unwitnessed or the resident hit their head, the nurse was supposed to start neurological checks. She said the nurses were supposed to do a nurses note with details about the fall and then put the fall on the 24-hour report to alert all other nurses to the fall. LVN E said that would be followed up by all 3 shifts of nurses writing a progress note for the next 3 days after the fall. She said any resident that had a new medication would have all 3 shifts of nurses to write a nurses note for 3 days after the new medication was started and if a resident had an antibiotic, then the nurses were supposed to write a nurses note each shift the entire time a resident was on an antibiotic and then for 3 days after the resident stopped the antibiotic. LVN E said if a nurse did not chart as she had explained, it could have been because they had just been too busy, or they simply forgot to chart something. She said if the residents did not have that type of charting completed during events of falls or antibiotics, then their medical records were not accurate, and it could place the residents at risk because they would not have documentation to assist in early detection of problems. LVN E said that each unit had a cheat sheet inside the 24 hour report binder that assisted the nurses with what to chart and how often to chart for different events. During an interview on 09/13/23 at 5:53PM with DON, she said herself and the ADON monitored all unit's 24-hour report sheets, and they would monitor the nurses charting to ensure that the nurses were charting as they were supposed to. She said they had trained all their nurses when they first started on the type of charting and how often they were supposed to chart, as well as different in-services throughout her time as the DON. She said even though she was responsible for monitoring the nurses charting, she had obviously not monitored everyone because of the issues that had been brought to her attention. Record review of facility policy labeled Documentation last revised 2/13/07 revealed: Documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 11 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge) . Complete documentation in narrative nursing notes in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Daily summaries per shift will be required on residents requiring acute care. Record review of facility policy labeled User Friendly Guide on when to complete assessments undated revealed: Behavior Assessment Q 8 hours for 3 days post resident to resident incident . Fall Nurses Note when a resident falls and every 8 hours for 3 days post fall . UTI Assessment every 8 hours while on treatment and then for 3 days post treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 12 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (CNA-C, and MA-D) staff observed for infection control. Residents Affected - Some 1. The facility failed to ensure MA-D did not sanitize the blood pressure cuff before or after use between residents. 2. The facility failed to ensure CNA-C performed proper peri-care (incontinent care) or proper hand hygiene for Resident #18. These failures could place residents of the facility at risk of infections due to unclean BP cuffs and incontinent care. Findings included: Observation on 09/13/2023 between 7:37 AM and 8:00 AM, MA-D did not sanitize the blood pressure cuff before or after use between 3 of 3 residents (Resident #56, 47, and 71) during morning resident medication pass. An interview on 09/13/23 at 8:20 AM, MA-D stated the blood pressure cuff should have been cleaned and sanitized before and after each resident. She stated she had not cleaned the Blood Pressure Cuff because the was nervous. She stated the negative impact to residents could have been possible cross contamination between residents. An interview on 09/13/2023 at 2:34 PM, the DON stated the staff should have followed the facility policy. She stated the ICP should have monitored staff members for proper infection control practices. She stated the negative impact could have been passing infections from one resident to another. The DON stated the MA was PRN was called in short notice. She stated it was that that led to the failure. Her expectations were for the residents to be correctly taken care of with staff following the facility policies. Record Review of In Service Training Attendance roster for Disinfecting Small Equipment dated 08/24/2023 revealed: Cleaning of small equipment related to disinfecting. All small equipment to include but not limited to: .4. Blood Pressure Cuffs Must be cleaned between Clients. Process for disinfecting is to wipe the device completely outer and inside surfaces with available disinfecting wipe. Please use wipes and apply designated kill times to ensure that adequate time is taken between use. Record Review revealed MA-D had not been in attendance Disinfecting of Small Equipment dated 08/24/2024. There were no further policies provided concerning disinfecting of small equipment before exit of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 13 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 facility. Level of Harm - Minimal harm or potential for actual harm Record Review of the resident #18's Face Sheet dated 09/11/2023, revealed he was an 88 yr. old male. His original admit to the facility was 07/18/2020. Resident #18 had a diagnosis of Cerebral Infarction (stroke). The MDS assessment Section C, Cognitive Patterns dated 08/22/2023, revealed a BIMS score of an 11 (moderately impaired) and Section G, Functional status of personal hygiene was extensive assistance. Residents Affected - Some Record review of Resident #18's Care Plan dated 07/03/2023 revealed Resident #18 had an ADL self-care performance deficit related to activity intolerance. The goal for Resident #18 would be to improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Observation on 09/13/2023 at 1:26 PM, CNA-C performed incontinent care for Resident #18, folding the same wipe two and three times each before discarding. CNA-C also did not pull Resident #18'a foreskin back to clean underneath cleaning in a downward swipe. An interview on 09/13/2023 at 1:59 PM, CNA-C stated she should have pulled the foreskin back to help prevent bacteria buildup as well as infection. She stated Resident #18 was known for yelling while being cleaned and did not want him to do that in front of surveyor observation. CNA-C stated she had been taught the one-wipe, one swipe but she was in a hurry to finish not taking the time to get a new one. An interview on 09/13/23 at 2:34 PM, the DON stated the foreskin should have been pulled back and cleaned correctly. The DON stated she had always taught the one wipe one swipe rule. The DON stated it was herself as well as the ADON who monitored the staff checkoffs, doing that on a weekly basis but had no documentation for those. The DON stated the negative impact to residents was a potential for a UTI. The DON stated what led to the failure was not following something they go over frequently which was one wipe one swipe. She stated she would not have felt comfortable with the three-fold for a bowel movement. Her expectations for staff were to follow facility policy and procedures. An interview 09/13/23 04:50 PM the DON stated CNA-C had no previous in-services documented concerning un-circumcised male incontinent care. Record review titled Certified Nurse Aide Competency Verification for CNA-C was dated 02/04/2022. Record review of the policy titled Perineal Care Male dated 08/08/2023 revealed: Purpose: To clean the male perineum without contaminating the urethral area with germs from the rectal area. Procedural Guidelines . F .DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE TISSUE OR WIPES . I .Gently wash perineal area, wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area to avoid contaminating urethral area with germs from the rectum. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE WASHCLOTH OR PRE-MOISENED CLEANSING WIPE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 14 of 15 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Retract foreskin of uncircumcised male Level of Harm - Minimal harm or potential for actual harm Wash the urethral area in a circular motion Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 15 of 15