Inspection·October 10, 2024

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cause cross contamination. She stated the negative impact could have been residents getting sick if they consumed unfit food. The dietician stated her expectations were for all kitchen staff to follow the regulations and education provided to them. During an interview on 10/10/24 at 11:38 AM, the DM stated, DA A only knew Spanish, and she could not translate the test. She stated the DM monitored what staff had their Food Handlers certificates and was herself that was responsible in having dietary staff complete and provide for their files. The DM stated the negative impact for residents could have been not knowing to check temperatures, or using wrong size of ladles, causing the resident to have too much food, or not enough which would lead to residents' incomplete nutritional value, causing weight loss. She stated she had not been aware of the time frame for staff to get certified which led to the failure. The DM stated her expectations were to pay more attention to all Food Handlers certificates and when each staff member was due to have it completed. Record review of DA A's personnel files, accessed on 10/10/2024 revealed no evidence of her Food Handlers Certificate with a hire date of 08/28/2024. Record review of DA A's Job Description Dietary Service Worker, signed by DA A and dated on 08/28/2024 revealed: The following is a non-exhaustive criterion that relates to the job of a Dietary Service Worker, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Dietary Service Worker and are related to the functions that are essential to the job of a Dietary Service Worker. KNOWLEDGE BASE: o Ability to ensure duties are completed in a timely, efficient manner-according to the schedule. o Ability to function as team member. o Ability to perform work tasks within the physical demand requirements as outlined below. o Genuine care for and interest in elderly and handicapped people. o Ability to comply with the Patient [NAME] of Rights and the Employee Responsibilities. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 2 of 9 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 10/10/2024 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 0802 Ability to comply with Company and departmental policies and procedures. Level of Harm - Minimal harm or potential for actual harm o Ability to properly wash, sanitize, and store all dishes, utensils, and cooking equipment. Residents Affected - Few o Assist in tray assembly and deliver carts to the appropriate nursing or dining areas. o Dispose of refuse according to departmental policy and procedures. o Assemble and deliver floor supplies according to the posted standards. o Put food and supplies away following the correct rotation (firs in, first out). o Ability to prepare all foods according to the menu and the standardized recipes in a safe, efficient, and sanitary manner. o Ability to ensure the proper preparation, portioning and serving of foods as indicated on the spreadsheets and the recipes. PHYSICAL DEMANDS: Sitting: 1 - 2 hours in an 8 hour work shift. Standing: 3-7 hours in an 8 hour work shift. Alternates continuous to walking. Walking: 3-7 hours in an 8 hour work shift. Alternates occasionally to standing. Lifting: 50 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 3 of 9 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 10/10/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Reliability, trustworthiness and consistency with regard to attendance is extremely important to thisjob. The ability to regularly and timely attend work, cooperative and politely work and deal with others, and to effectively multi-task and work in a stressful environment are also essential functions to this job. STATEMENT: This position reports directly to the Dietary Service Manager. Residents Affected - Few APPLICANT DECLARATION: I have read the qualifications and requirements of the position of DIETARY SERVICE WORKER. I understand and-certify that the foregoing is a non-exhaustive criteria that is consistent with the business needs of this facility and is a legitimate measure of the qualifications fora Dietary Service Worker; and relates to the functions that are essential to the job of a Dietary Service Worker. To the best of my knowledge; I believe that I can perform these duties. There was no policy provided concerning when the Food Handlers Certificate should have been obtained prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 4 of 9 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 10/10/2024 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure: 1. All opened items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. 2. The ice machine was cleaned properly. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: During observation on 10/08/2024 at 10:15 AM the facility kitchen revealed: Refrigerator #1 of 2 1 container of sliced pickles, outside the original container and covered with plastic wrap, unlabeled, or dated. 1 large container labeled Ranch dated 10/7/24 with no use by date. 1 large container labeled Gravy dated 10-6 with no use by date. 1 large container labeled Gravy dated 10-07-24 with no use by date. 1 large container labeled Minestrone Soup dated 10-06 with no use by date. 1 large container labeled Greens dated 10-07 with no use by date. 1 large container labeled Diced chicken dated 10-7 with no use by date. 1 large container labeled Pineapple Tidbits dated 10-08 with no use by date. 1 large container labeled Chili dated 10/07 with no use by date. Refrigerator #2 of 2 5 opened 46 oz. cartons of Ready Care Tea with no opened date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 5 of 9 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 10/10/2024 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 1 large container labeled Cherry Jello dated 9-25-24 with no use by date. Level of Harm - Minimal harm or potential for actual harm 1 opened gallon of milk with no opened date. 1 large container of Orange Jello dated 09-25-2024 with no use by date. Residents Affected - Many Kitchen dry storage (Pantry) 1 of 1 1 opened 5 lbs. container Creamy Peanut Butter with no opened date. 1 opened 10 lb. container of Baking Powder with no opened date. 1 opened 1 gallon container of soy sauce with no opened date. 1 opened bag of wheat bread with no opened date. 1 opened bag of hamburger buns with no opened date. Freezer 1 of 1 1 clear opened gallon bag of what appeared to be chicken strips, unlabeled, received date, opened date or use by date. 1 clear opened bag of what appeared to be meat balls with no received date, opened date or use by date. 10 frozen briskets, unlabeled or received date. 2 frozen pizzas, unlabeled and no received date. 3 clear bags of what appeared to be tator tots, unlabeled and no received date. 3 packets if frozen bacon, unlabeled and no received date. 2 packages of ham with no received date. During an interview on 10/08/2024 at 10:20 AM, DA A stated all items should have been labeled and dated with a received and use by date. During an interview on 10/08/2024 at 10:28 AM, the DM stated all opened food items should have opened dates. She stated all refrigerated items should have the date opened and use by date. The DM stated she monitored all areas of the kitchen. She stated the negative impact to residents could have been spoiled food which would have possibly made the residents sick. She stated staff had not paid attention to detail and that led to the failure. The DM stated her expectations was for staff to follow the rules and regulations as well as facility policies. During an interview on 10/10/2024 at 10:27 AM, the ADMN stated the policies and procedures were to follow the guidelines of having all food products labeled and dated. She stated the DM monitored her staff and followed up with in-services. The ADMN stated the negative impact for residents was that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 6 of 9 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 10/10/2024 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 - Many they could have potentially received old food which placed them at risk for gastrointestinal issues. She stated the delay in following up with the DM and supervisors led to the failure. The ADMN's expectations were to increase the audits and in-services on top of the ones they already had. During an interview on 10/10/2024 at 10:30 AM the Dietician stated all food items should have been dated, labeled with a use by date if in the refrigerator. During an interview on 10/08/2024 at 10:35 AM, DA B stated all refrigerated items should have had a use by date. She stated she knew the regulations and policies required staff to do so. Ice Machine During an observation on 10/08/2024 at 10:39 AM, the panel of the ice machine revealed dirty black substance on the inside panel of the ice machine. During an interview on 10/08/2024 at 10:40 AM, the DM stated the maintenance man (MM) cleaned the ice machine on a regular basis and did not know when the last time it had been cleaned. She stated the MM had a logbook of his maintenance and cleaning of the ice machine. The DM stated the MM also changed the filters on the ice machine when needed. The DM stated it was her and DA C who monitored. She stated the negative impact was that residents could have received dirty ice. The DM stated, not cleaning the ice machine and being lazy, as well as not taking the time to get the task completed led to the failure. She stated her expectations was that she expected it to be clean as she would not want ice for herself with the dirty panel inside of it. During an Interview on 10/08/2024 at 3:25 PM, the MM stated he did not have a logbook for cleaning the ice machine. He stated he only cleaned the filter and decalcified the lines. The MM stated he had never wiped down and/or cleaned inside of the ice machine, nor had he been told to do so. During an interview on 10/09/2024 at 10:08 AM, the ADMN stated it was the kitchen staff's duty to clean the ice machine. She stated there was a schedule for cleaning the equipment, with the ice machine being on Sundays. She stated she had done an audit two weeks ago and had not noticed the inside panel being dirty, but today, had noticed the inside panel being unclean with black stuff. She stated it was not the MM duty to clean the inside of the ice machine. The DM stated she felt the staff had not followed the cleaning schedule and that was what led to the failure. She stated she monitored the cleaning of equipment but had gotten busy with other things and assumed it had been done. The ADMN stated her expectations was to have all equipment cleaned in a timely manner. Record review of facility policy titled Storage Refrigerators dated 2012 revealed: All storage refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage. Procedure: 5. Food must be covered when stored, with a date label identifying what is in the container. Record review of facility policy titled Dry Storage and Supplies dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 7 of 9 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 10/10/2024 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 and insects. Level of Harm - Minimal harm or potential for actual harm Procedures: 4.Open packages of food are stored in closed containers with tight covers and dated as to when opened. Residents Affected - Many Review of FDA Food Code 2022: Full Document accessed on 10/16/2024 in annex 7 page 37, 38 revealed: Applicable Code Sections: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 10/16/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 8 of 9 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 10/10/2024 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 of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. Residents Affected - Many There was no policy provided concerning the cleaning of equipment provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 9 of 9