Health inspection·June 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm running for months. She stated that the curtains in the room have never been cleaned/laundered since she has been in the room. She stated that spiders come out from the attic access located in her room and crawl around her room at night. While she denied any insect bites at the facility, she stated she was once bitten by a brown recluse in the past prior to admitting to the facility and is terrified of spiders. She stated she and her husband have informed the administrator of their concerns but nothing has been done about it yet. Residents Affected - Few Upon inspection of resident's room: 1. Resident's room had attic access located on the ceiling that was insufficiently secured with a rusted, metal hook and eye fastener with approximately a 1-inch gap between the ceiling and the easement, exposing the attic. 2. Every corner of the room had spider webbing located on the upper wall area; with dead and live flying insects and dead and live spiders present. 3. Resident's air conditioner was dirty, with significant accumulation of brown, black, and grey sediment located within and around the air vents. Additionally, the air conditioner's removable filters had a significant accumulation of brown and grey sediment present. Significant amounts of unidentifiable brown, black, and grey sediment was present under and around the air conditioner. 4. Resident's bathroom walls had significant yellow discoloration along the walls and around the toilet. Toilet was observed running with water rippling in the toilet and making a high-pitched sound coming the base. 5. Both curtains in the room were observed to have multiple brown, red, pink, and yellow stains, and discoloration. In interview and observation on 06/28/23 at 01:13 PM with Resident #82 revealed her sitting up in her bed eating lunch. She stated the housekeeper, HSK B, had already performed her service for the day. She stated that she just quickly came in and then left. She stated she was not satisfied with her service and that her room still feels unclean. She stated that the issues from yesterday are still present today and it was very frustrating for her, as she does not have the ability to clean her room herself. Upon inspection of resident's room: 1. Resident's room had attic access located on the ceiling that was insufficiently secured with a rusted, metal hook and eye fastener with approximately a 2-inch gap between the ceiling and the easement, exposing the attic. 2. Every corner of the room had spider webbing located on the upper wall area; with dead and live flying insects and dead and live spiders present. 3. Resident's air conditioner was dirty, with significant accumulation of brown, black, and grey sediment located within and around the air vents. Additionally, the air conditioner's removable filters had a significant accumulation of brown and grey sediment present. Significant amounts of unidentifiable brown, black, and grey sediment was present under and around the air conditioner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 2 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 0584 Level of Harm - Minimal harm or potential for actual harm 4. Resident's bathroom walls had significant yellow discoloration along the walls and around the toilet. Toilet was observed running with water rippling in the toilet and making a high-pitched sound coming the base. 5. Both curtains in the room were observed to have multiple brown, red, pink, and yellow stains, and discoloration. Residents Affected - Few In interview with HSK B on 06/28/23 at 1:46 PM, she stated she was responsible for cleaning [Resident #82's room number] 06/27/23 and 06/28/23. She stated she felt like the staffing in her department was okay and she had enough time to do everything she needed to do. She stated she had completed her daily clean for the day in [Resident #82's room number] . She stated she sometimes had a checklist she used but did not use the checklist this week. She stated some residents do not like her to move their furniture in their room but the resident in [Resident #82's room number] did not have that preference. She stated she had noticed the attic easement in the resident's room but was not concerned about the condition of the opening. She stated has never been trained to clean resident walls but stated that it would be reasonable to expect that to be part of her daily duties. She stated she noticed spiders in the room a week ago and let HSK Supervisor know. She stated she would not want to live in a room with live insects. She stated she was told by HSK Supervisor last week to clean around the air conditioner better, but she stated when she tried to clean the air conditioner where was hard black residue that was hard to get off. She stated she would not want to live in a room where the air conditioner was dirty. She stated that she thinks the maintenance department should be responsible for deep cleaning the air conditioner. Additionally, she stated as far as she knows, the curtains in [Resident #82's room number] have not been laundered, but she had not noticed they were dirty. She stated when she reports things to her management or to maintenance, things normally get addressed quickly, but she just have missed the condition of [Resident #82's room number] because she did not report the concerns to her management. In interview with HSK Supervisor on 06/28/23 at 2:16 PM, she stated [Resident #82's room number] did not meet her expectations. She stated she has not been able to implement effective measures for improvement because of lack of staffing. She stated she does not know the last time room [Resident #82's room number] was deep cleaned. She stated the attic easement in [Resident #82's room number] has been like that for as long as she has worked at the facility and did not see it as a concern. When asked for a potential source of spider activity in the room, she then stated that it could be the opening from the attic easement and stated she would then report it to maintenance. She stated the air conditioner was deep cleaned two weeks ago but stated when she observed the current accumulation present on the air conditioner in [Resident #82's room number] , she stated she will consider moving the frequency to weekly. She declined to comment on the potential outcome to the resident at the time of interview, but stated it was her responsibility to ensure housekeeping staff are providing sufficient services for a clean, homelike environment. In interview with Maintenance on 06/30/23 at 11:06 AM he stated the attic easement/ladder door in [Resident #82's room number] was sagging open because of the type of lock installed on it. He stated once it was brought to his attention yesterday, he installed a flat securement/lock so the door is now flush with the ceiling. He stated he did not know about the issue until it was brought to his attention. He stated it was housekeeping responsibility to ensure resident rooms were clean. He stated that he was responsible for cleaning, servicing, and the maintenance of the individual room air conditioners. He stated they check the filters once a month but does not know the last time [Resident #82's room number] 's air conditioner was cleaned or serviced. He stated he did not keep records on such things. He stated if a resident's air conditioner was not clean, he expected staff to report it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 3 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to him through the work order system so he could address it. He stated the curtains in resident rooms were housekeeping's responsibility to clean/launder. He stated if can cause allergies or discomfort for the resident if their environment was not clean and homelike. In interview with Administrator on 06/30/23 at 1:16 PM he stated he was not aware of any environmental concerns in [Resident #82's room number] , either reported by the staff, residents, or family members. He felt like the attic easement was not a problem nor a source for spiders. He did state that it was unacceptable for an accumulation of spider webs with live spiders to be present in any of his resident rooms. He stated his expectations were for resident rooms to be clean, safe, and homelike. He expected staff to report concerns to maintenance or housekeeping to be addressed in a timely manner. Record review of the facility work order log dated 05/01/23-06/30/23 revealed no documentation of work orders or pest control sightings for [Resident #82's room number] . Review of facility policy, Infection Control . Pest Control, rev. 04/08/21, Procedures: 1. The facility will have a Pest Control vendor . 4. Monitoring of the environment will be done by the facility's staff. 5. Pest control problems will be reported promptly. Review of facility policy, Pest Control, undated, provided by the facility on 04/20/2023 revealed Policy Statement . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation . 1. This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 4 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 observation, interview, and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 1 (Resident #133) reviewed for accidents hazards/supervision. The facility failed to implement interventions to prevent elopement and failed to adequately supervise Resident #133 to prevent him from leaving the facility on 06/05/2023 without staff knowledge. Resident #133 was located 0.4 miles away from the facility. This failure could place residents requiring supervision at risk for serious injury and death. In Immediate Jeopardy (IJ) was identified to have existed from 06/05/2023 to 06/05/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance: moved Resident #133's room close to the nurse's station and placed a wanderguard bracelet on Resident #133. The facility Administrator was provided the IJ template on 06/30/2023 at 12:24 PM. Findings included: Record review of Resident #133's face sheet, dated 06/30/2023, revealed he was a [AGE] year-old male admitted to the facility on [DATE] from a skilled nursing facility with a primary diagnosis that included surgical aftercare following surgery on the digestive system and other diagnoses that included muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, alcoholic cirrhosis of liver without ascites, heart failure, hypotension, acute kidney failure, and benign prostatic hyperplasia. Record review of Resident #133's MDS, dated [DATE], revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #133 had wandering behavior 1-3 days upon assessment and required extensive one person assist for bed mobility, toileting, and personal hygiene and required the use of a walker and wheelchair for mobility. Record review of Resident #133's care plan, dated 06/03/2023, revealed Resident #133 had an indwelling catheter, was an elopement risk with history of attempts to leave the facility unattended x1 on 06/05/2023, and at risk for falls. Record review of Resident #133's Nurse note on admission dated 06/02/23 at 8:35 PM by LVN T revealed he was alert and oriented x 2 at times . but very confused . had a healing surgical wound to his abdominal area with a Jackson Pratt drain present . foley-cath . with urine dark [NAME] with traces of blood and bruising to both hands, arms, and lower abdominal area. Record review of Resident #133's Nurse Note dated 06/05/23 at 8:30 AM by LPN L revealed the resident in bed holding [Jackson Pratt] JP drain after self removal. Record review of Resident #133's Nurse Note dated 06/05/23 at 11:45 AM by DON revealed IDT team note: resident with a BIMS of 10 . Resident states 'I left to go get some food from one of my favorite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 5 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 restaurants.' Physician and LVN D and was at bedside and completed head to toe assessments. No injuries noted at this time. Resident had a few episodes of minimal low-level confusion. New order for wander guard placed. Wander guard placed at this time. Resident is cooperative and not attempting to wander or elope at this time . Resident being moved to a room close to nurse station for increased observation. Record review of Resident #133's Nurse Note dated 06/05/23 at 12:48 PM by LPN L revealed Notified of resident being out of the building this AM. Code green activated. Resident returned to building via staff via wheelchair. Head to toe assessment performed no new injury noted no decrease in ROM noted. Wander guard attached to right ankle. Resident stated, 'I don't like the food and went to go get something to eat.' Record review of Resident #133's Nurse Note dated 06/06/23 at 1:30 AM by RN O revealed Patient found lying on the floor next to his bed, appeared confused, unable to describe what he was trying to do. Patient might have slid off the bed with bed in the lowest position, no complaint of pain, no injuries this time, vital signs stable, neuro checks started . Record review of Resident #133's Nurse Note entries dated 06/06/2023 at 7:23 AM and 06/07/2023 at 7:07 AM by RN G revealed Continues to exit seek . no late injury noted . Record review of Resident #133's elopement/wandering evaluation, dated 06/02/2023, revealed a score of 28 out of 55, indicating a high [elopement] risk. Record review of Resident #133's elopement/wandering evaluation completed after elopement, dated 06/05/2023, revealed a score of 17 out of 55 indicating a high risk. Record review of Resident #133's June 2023 TAR reflected, monitor placement and functioning of wander guard every shift, if wander guard is nonfunctioning replace immediately -Order Date- 06/05/2023. Record Review of 24-hour report dated 06/02/2023 reflected, Admissions - Resident #133, [room number] full code, Dx hernia repair, Abd - JP drain empty every shift, Foley Catheter 16Fr/10mL, Alert and Oriented x2 forgetful, assist x1, P.O. med. Record Review of 24-hour report, dated 06/04/2023, reflected Resident #133 .repeat BMP, low/decreased Sodium. Record Review of 24-hour report, dated 06/05/2023, reflected Resident #133 JP out, moved, eloped, wanderguard, room number]. Record Review of the Provider Investigation Report (PIR) revealed based on camera surveillance, around 09:50 AM on 6/05/23, patient wheeled himself out of his room, down the hall toward the short-term care nurses' station. At 9:53 AM, Resident #133 goes out of camera view as he entered a foyer/sitting area for the short-term care entrance to the facility. At that point he is no lover visible by camera surveillance. Around 10:45 AM Resident #133's roommate (from his home residence) called the facility to inform us that Resident #133 was at a neighboring restaurant. At that point in time the facility was alerted to a Code Green elopement . Around 10:50 the Administrator and DON found Resident #133 at the restaurant and asked if he was okay. He explained he lives nearby and likes this restaurant and would stop by to get something to eat. Investigation notes revealed Resident #133 responded that he did not want to go back to the facility and was going to have his roommate come pick him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 6 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 up, but the roommate was in a meeting and could not come right now but was hopeful he could get a ride later. At this point Resident #133's second resident representative and her husband showed up at the restaurant to help persuade the resident to return to the facility. Further review of the PIR revealed resident returned to the facility in the facility van. The Facility Investigation Summary reflected, investigation found that Resident #133's medical records did not indicate any previous elopement attempts or wandering behaviors at [hospital/facility names]. The investigation found that Resident #133 had a change in condition with improved mobility, increased confusion and exit seeking desires . Observation of facility grounds when exiting the main door and rehab door revealed the outside area and parking lot was unsecured and led to residential streets and a major highway. [restaurant name] was located 0.4 miles away from the facility. Observation and interview of Resident #133 on 06/28/2023 at 04:16 PM, revealed the resident was well groomed and dressed, lying in bed, wearing nonskid socks and a gray ankle bracelet. When asked about the elopement, Resident #1 stated that he does not normally act like that, they [staff] were very concerned and did those tests and found he had a UTI. Resident #133 said the staff would not let him go outside now because they think he would run away. Resident #133 stated he actually thought he was somewhere else, and he was trying to leave because he was hungry and knew of a place close by. Resident #133 said the day he left, 4 people came to the restaurant to get him, 2 guys that worked at the facility and 2 of his friends. Resident #133 said he was not injured that day. Resident #133 said the ankle bracelet was to keep track of him. Interview with LVN F on 06/28/2023 at 04:26 PM, revealed he remembered the incident, but it happened on the first shift when he was not there, and since then they have monitored Resident #133 every 2 hours, and his wander guard would set off the alarm if he left the building. LVN F stated the resident has been very compliant and has not tried to get out since. LVN F said Resident #133 did not try to leave before that incident. LVN F stated if a resident was an elopement risk they have alarms and staff check on them. When asked what you do when a resident elopes, LVN F stated once identified the resident has left, check all the rooms and facility, if we don't find them, we make an announcement so everyone tries to find the person, go outside and look around. When we find them, bring them in, inform family, let the DON know and an incident report. LVN F said we want to make sure the person is ok and no harm, let the doctor know and if the doctor wants labs, psych evaluation or whatever is necessary. LVN F said they use wander guards if the resident was a risk, get a doctor order and explain to the resident that it was a little gadget to allow staff to know where they were at all times and if they try to leave the alarm would go off. LVN F said some residents understand it was for their safety but some get confused. Interview with Resident #133's Emergency Contact/Representative on 06/29/2023 at 10:23 AM, revealed Resident #133 lived independently prior to being at the facility, had been in the hospital since 04/11/2023, and she was aware of the elopement incident. She stated Resident #133 had wheeled himself out of the facility, and at the time was on his meds, had a UTI and was trying to escape. He was trying to get home or a place where he would go quite frequently, something familiar. She said Resident #133 thought he left his truck there [at the restaurant] and could not find it so called one of his friends to pick him up. She said that friend knew better so he called another friend (Resident #133's second listed representative) and that representative called the facility. The Emergency Contact stated Resident #133 had no past wandering or elopement behaviors, but he had liver disease and when on the UTI meds he started imagining things and remembering things from before and just got confused. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 7 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 Interview with LVN D on 06/29/2023 at 10:50 AM, revealed he was not able to answer what elopement interventions/monitoring were in place for Resident #133 upon admission, but the wanderguard was put on after the fact. When asked what you do if an elopement risk was high, LVN D stated that was evaluated when they came in and the wanderguard was not put on at first but at attempt or when they have made an attempt to leave. LVN D said he was not on the floor and was in the morning meeting when Resident #133 left and was later told he went out about 15 feet from here (he pointed at the rehab entrance and not main building entrance) and exited the door from the lobby. LVN D stated there was a code to enter before leaving but were also fire doors so if pushed long enough the door would open. LVN D stated he saw Resident #133 lying in bed about 9:30 am on 06/05/2023 on his last round before going to the morning meeting. LVN D stated when a resident elopes and gets out, a code green was called, they search the building and then if they cannot find the resident, they work the surrounding area. LVN D stated the had a code green drill last month. LVN D stated he does not usually do elopement assessments because admissions come in on the evening shifts but during the day if he notices wandering or exit seeking behaviors, he would let the ADON or DON know and it was communicated on shift change. Interview with Resident #133 on 06/29/2023 at 11:10 AM, revealed when he admitted he was in another room and the morning he left there was a receptionist sitting in the lobby and told her he was going to get something from the truck and opened the door or went out with some other people, and did not remember if the door alarm went off. Resident #133 stated this happened about 10:15 AM, and he did not know the names of the streets he took but took the side and residential roads because he did not want to take the highway. He said he was tired when he got there, was not scared, and was going to come back. He said he thought he could come and go but they changed hisroom when he came back. Interview with CNA E on 06/29/2023 at 11:34 AM revealed he worked that day (06/05/2023) and was doing something for another resident when Resident #133 was gone and all the people tried to find him. CNA E stated the alarm was currently working on the door and after the resident came back, he was moved to his (CNA E's) assigned hall because the resident was trying to go outside. CNA E stated if a resident eloped he would report to the nurse, search all the rooms, closets and outside the building. Interview with CNA C on 06/29/2023 at 12:16 PM revealed she worked with Resident #133 on 06/05/2023. She stated she did rounds from down the hall, got him dressed and in his wheelchair around 9:45 or 9:50 AM and asked him if he was going up front. The resident said yes, he was going to roll up their himself and she went to another room to assist another resident and that was when they got the alert. CNA C stated the last time she saw him he was going to do therapy and did not see him leave the facility and did not see any exit seeking or wandering behaviors that day and put a wanderguard after the incident. CNA A stated they make sure to keep an eye on him, have a routine, walk back and forth down the hall and check on them to make sure everybody was fine. She stated she did get training on elopements before the incident and if a resident tried to leave how to alert everybody, how to approach the resident and try to get them back in. CNA A stated Resident #133 did have a catheter and she put it on his chair with a privacy bag that morning and therapy was always in that area because they sit there and work with residents, but no one was assigned to sit at the entrance. She stated they did complete a code green drill before the incident and where they told us how to get the resident in, what areas to look and that everybody has to look. Interview with DON on 06/29/2023 at 01:12 PM revealed the DON, ADONs, and Clinical Resources do quarterly elopement drills and then review. He stated they had an elopement incident on 06/05/2023 and the drill was a week earlier on 05/25/2023 so they reviewed and had an in-service. He stated we go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 8 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 over the process and take a resident in an office or conference room therefore providing a live demonstration. He stated if a resident was an elopement risk they do a new assessment, and if they are confused the first intervention was the wanderguard but if not confused, do other interventions, because we cannot use a wanderguard on an alert and oriented resident as it would be considered a restraint. Other interventions included talking with them, frequent checks, assess, move the resident closer to the nurses' station and alert staff of needing to watch the person, talk with the family, and care plan. The DON stated the administrator did the investigation, and they do have cameras in the building, but do not cover every exit and the door he went out does not have a camera. He stated there is a code to open the door, and the alarm was currently functioning. He stated there was a front entrance way that therapist's work by but it was not their job to monitor who comes in and out and there was no receptionist at that entrance. The DON said the elopement drills included other departments, they call code green on the intercom, and everyone stops what they are doing to look for the resident. The DON stated Resident #133 admitted on the 2 to 10 shift and the nurse did an inaccurate assessment for elopement that included mental illness, but the resident did not have mental illness. The DON stated he redid the assessment after the elopement and it scored in the 20s but it was a horrible assessment because you can be an 11 and be high risk, there was not middle. There could be a lot of people that score high who are not appropriate. The DON stated Resident #133 had slight confusion at the time of elopement. When asked what interventions were done at the time prior to elopement, the DON said frequent monitoring, assess the patient check frequently and make sure they are OK but the monitoring was not charted. The DON said Resident #133 had a catheter at time of elopement and transported in a wheelchair. He said the resident lived in the neighborhood and went to his favorite restaurant and post elopement interventions included head to toe assessment with no injuries, physician and family notification, got an order for the wanderguard and moved to room [ROOM NUMBER] by the nurses' station, education, monitoring and a care plan meeting. The DON stated Resident #133 did have a fall on 06/06/2023 about 15 hours after elopement in the middle of the night. He said fall precautions were in place that included low bed, call light in reach, checking on him and not low on staff that night. After the fall, an Xray showed an injury that was found to be chronic and the family confirmed that he had a problem with the hip, if he had an acute injury the CT scan would have showed that. The DON said since elopement, Resident #133 did not have any other elopements or falls. The DON stated his expectation was for nurses to alert him when residents were exit seeking. Attempted interview with LVN T on 06/29/2023 at 02:15 PM by telephone was unsuccessful. Interview with Weekend Supervisor on 06/30/2023 at 10:08 AM revealed he worked the weekend on 06/03/2023 and 06/04/2023 and did not observe any wandering behaviors from Resident #133. He said he did check on Resident #133 that weekend, and all staff check on our residents, make sure the doors are not beeping, especially new residents on that hall they monitor closely but he did not get any reports from the nurses that Resident #133 was close to the door. He stated when he came back the next weekend the resident was moved. He said according to the assessment, if the resident was a high elopement risk and they were confused they use a wanderguard and made sure it was in place every shift, but if not confused they closely monitor behaviors like exit seeking, keep eyes on them and monitor. He said if the person has a wanderguard they are monitored every 2 hours and if no wanderguard then every hour. Interview with Administrator, DON and Clinical Resources on 06/30/2023 at 12:24 PM, they said up until the point Resident #133 eloped, he had not tried to. Record reveiw of Emergency Prepardeness DRILL - Missing Person/Elopement dated 05/25/2023, revealed LVN D, CNA C, and CNA E participated in the drill. Review of the drill further reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 9 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 following: Level of Harm - Immediate jeopardy to resident health or safety .2. Locations searched within the facility and any pertinent details for each: Entire facility 3. Time when search of facility grounds was initiated and any pertinent details: Resident was located inside the facility x2 . Residents Affected - Few 6. Location of Resident when found: 1) Education room [ROOM NUMBER]) Private dining room * Describe staff response to drill: Both shifts responded and systematically searched the building unitl the residents were located . Record review of Elopement In-Service, dated 06/05/2023, revealed LVN F and LVN T signed the attendance sheet. The inservice futher reflected: 1. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions. 2. If a resident is missing it is a facility-wide emergency. Code [NAME] will be announced. The missing resident procedures will be initiated: A. Determine if the resident is out on an authorized leave or pass. B. If the resident was not authorized to leave, institute a search of the premises. C. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify: Administrator Director of Nursing Services Residents legal representative or emergency contact Attending physician Law Enforcement Officials D. Provide search teams with resident identification information and begin extensive search of the surrounding territory. 3. When the resident returns to the facility: A. An assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. B. Notify search teams that the resident has been located C. The attending Physician and Resident Representative will be notified of the resident's return (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 10 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 and the resident status. Level of Harm - Immediate jeopardy to resident health or safety D. Document relevant information in the resident's medical record. 4. An Elopement/Wandering Evaluation will be completed post elopement incident with follow up documentation for a minimum of 72 hours following the incident. Residents Affected - Few Record review of policy titled Wander System Monitoring Program revised 09/2007, reflected It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents a wondering risk . any resident previously identified as a wandering risk will be reassessed quarterly, and with changes in behavior, all residents identified to be at risk for wondering, will have a wonder monitoring bracelet . Procedures: 1. An initial wondering assessment will be completed on all new residence on admission. See Elopement Risk Assessment. 2. Any resident displaying significant change of status or change of behavior pattern will be reevaluated for potential wondering . Record review of policy titled Elopement/Unsafe Wandering, revised 06/2018, reflected It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . Procedures: 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wondering evaluation completed to determine risks for elopement and unsafe, wondering on admission, and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors identified on an elopement/wondering evaluation are considered at risk and will have an individual individualized care plan developed that includes miserable objectives, and time frames for the care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wondering behavior . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 11 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 5 medication carts (medication cart #1 and medication cart #2) observed for medication storage reviewed for medication labeling. The facility did not ensure that 2 medication carts were secured and unable to be accessed by unauthorized personnel and residents on the 100 hall. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion. Findings include: 1. During an observation on 06/27/23 at 3:15 PM a medication cart #1 was parked outside of room [ROOM NUMBER]A at unlocked. Medication aide 12 ft away with another cart was observed. Observed LVN-K walking out of room [ROOM NUMBER] to return to the medication cart. Observed several blister packs of prescribed medication, glucose testers in top draw. There were no residents observed near the medication cart, however staff were passing medication cart down the hall. During an interview on 06/27/23 at 3:18 PM with MA said he was keeping an eye on the medication cart for LVN-K because he was called away for help by a hospice aide to help. MA said he was watching the medication cart. He said he did not lock the cart, however all carts should be locked to prevent medication access that could lead to resident harm. During an interview on 06/27/23 at 3:20 PM with LVN K said he left the medication cart to help a hospice patient and forgot to lock it. LVN K said the medication cart should have never been left unlocked as it could allow residents to access medication and take the incorrect meds or for medications to be stolen. During an observation on 06/28/23 at 11:45 AM during routine resident rounds on the 100 hall, medication cart #2 was parked outside room [ROOM NUMBER] unlocked for approximately 2 to 3 minutes. LVN-J was observed 10 to 12 ft away pushing a Hoyer lift and walking back to the medication cart. Observed several blister packs of prescribed medication, inside 2nd draw. There were no residents observed near the medication cart, however 4 men including life safety and a can were observed near the cart working. In an interview with LVN-J on 06/28/23 at 11:48 AM revealed he left the cart to move a Hoyer lift. He asked who opened the medication drawers of the cart. He said he did not take his eyes off the cart. He said the maintenance personnel was working in a resident room with other repairman and moved Hoyer lift in the hall blocking entrance to the hall. He said the protocol was for the medication cart to be locked when unattended to prevent unauthorized staff, visitors, and residents from accessing the medication. He said leaving a medication cart unlocked could lead to a resident accessing and overdosing or being harmed. During an interview on 06/29/23 at 2:10 PM the DON, he said medication carts should never be left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 12 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unattended or unlocked. The DON said the importance of locking medication cart was because they contained drugs and narcotics and residents or unauthorized individuals take medications causing harm or steal and residents miss their medications. During an interview on 06/30/23 at 12:29 PM with the ADM revealed he expects medication carts to be locked when unattended by authorized personnel. The ADM said the importance of locking the medication carts were to protect resident, residents, visitors, and staff out of the medications. Record review of facility policy titled Storge of Medication undated policy indicated, .compartments containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 13 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 in the facility's only kitchen. Residents Affected - Some 1. Facility dishwasher aide M failed to cover beard and hair while working in the kitchen. 2. Facility cook H failed to cover beard, hair, and face mask upon entering the kitchen. These failures could affect residents who received their meals from the facility's only kitchen by placing them at risk for food-borne illness and food contamination. The findings include: During an observation of the kitchen on 06/28/23 at 11:30 AM the dishwasher was observed ambulating through the kitchen from the dishwasher to the tray line with pots and pans to store on the storage rack. He was not wearing a beard restraint nor hair restraint while working in the kitchen cleaning and storing dishes in the kitchen. During an observation on 06/28/23 at 11:50 AM the cook entered the kitchen and walked to the food prep and food serving line with his hair net in his hand, leaving hair on his head and beard exposed and uncovered. In an interview on 06/28/23 at 2:00 PM with dishwasher M, he stated all staff were expected to wear hair net. He said he was not aware that net was needed under his ball cap, and he has been working here in the kitchen for 2 years. He said he attended training today by DM and it was unsanitary to not cover beard and hair as it could cause food borne illnesses and cause cross contamination to dishes and food. In an interview on 06/28/23 at 2:30 PM with cook H. He stated that the hair net was in his hand. He said he said it was important to cover all hair in the kitchen to prevent cross contamination and hair in the food. He was educated to wear hair coverings by DM today. He said his education was on beard covering and kitchen sanitation, including doffing hair net, mask, and beard restraint upon entrance to the kitchen. In an interview on 06/29/23 at 09:00 AM with the DM, revealed she expects all staff upon entering the kitchen to practice good sanitation by putting on a hair net for all hair coverings when entering the kitchen then wash hands to prevent bacteria and food borne illnesses to the residents. She said she has educated the staff previously however she does not know why the staff did not follow procedures. She said she has educated the staff on food and kitchen sanitation. In an interview with the ADM on 6/30/23 at 1:55 PM revealed he expects the dietary staff to follow kitchen sanitation guidelines for maintain a clean dietary environment free from particles of hair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 14 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 by covering both beards and hair while working gin the kitchen. Level of Harm - Minimal harm or potential for actual harm Review of facility policy revealed all staff should wear provided face and hair covering while working in the kitchen. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 15 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, 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 two (Resident #190 and Resident #191) of five residents observed for infection control. Residents Affected - Few The facility failed to ensure MA A sanitized the blood pressure device and cuff between resident #190 and Resident #191. This failure placed residents at risk of cross-contamination and infections. Review of Resident #190's Face Sheet, dated 06/28/23, revealed he was a [AGE] year-old male admitted for rehabilitation on 06/22/23 from the hospital, Relevant diagnoses included muscle weakness, gait and mobility abnormalities, lack of coordination, reduced mobility, hypertension, and epilepsy. Review of Resident #191's Face Sheet, dated 06/28/23, revealed she was a [AGE] year-old female admitted for rehabilitation on 06/22/23 from the hospital. Relevant diagnoses included pneumonia, cerebral infarction, difficulty swallowing following neuro-vascular disease, type 2 diabetes, depression, and chronic pain disease. In observation of MA A on 06/27/23 at 9:18 AM, he obtained Resident #190's blood pressure from his left forearm. MA A failed to sanitize the blood pressure device and cuff prior to use with Resident #190. In observation of MA A on 06/27/23 at 9:52 AM, he obtained Resident #191's blood pressure from her right upper arm. MA A failed to sanitize the blood pressure device and cuff before, between, or after use with Resident #190 and Resident #191. In interview with MA A on 06/27/23 at 10:15 AM, he stated he was in a rush and forgot to sanitize the blood pressure device and cuff before, between, and/or after resident use. He stated he has been in-serviced on the importance, as it was important for infection control purposes to prevent cross-contamination. In interview with ADON on 06/30/23 at 10:08 AM, she stated her expectations were for all staff to sanitize equipment between resident use. She stated it was important for infection control purposes to prevent cross-contamination. In interview with DON on 06/30/23 at 10:52 AM, he stated MA A made a mistake, and his expectations were for staff to sanitize multi-use equipment between resident use. He stated it was important for infection control purposes to prevent infection. He stated at the facility, he was the infection control preventionist and that it was ultimately his responsibility to ensure staff adhere to infection control practices and procedures. In interview with Administrator on 06/30/23 at 1:16 PM he stated his expectations were for staff to sanitize multi-use equipment between resident use for infection control purposes. He stated it was the DON's responsibility to ensure staff adhere to infection control practices and procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 16 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy, Equipment . Cleaning, rev. 05/07 stated Policy: It is the policy of this facility to implement the following procedures to ensure equipment is cleaned and cared for appropriately. Procedures: 1. Reusable resident items are cleaned and disinfected between residents . 4. Intermediate and low-level disinfectants will be utilized for non-critical items including . blood pressure cuffs/machines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 17 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 of 5 residents (Resident #82) observed for environment. Residents Affected - Few The facility failed to ensure Resident #82's room remained free of pests. This failure could place residents at risk of not receiving a safe, clean, comfortable and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: Review of Resident #82 Face Sheet, dated 06/28/23, revealed she was an [AGE] year-old female admitted on [DATE] from the hospital, Relevant diagnoses included chronic kidney disease, type 2 diabetes, pneumonia, anxiety disorder, coronary artery disease. Review of Resident #82's Quarterly MDS, dated [DATE] stated she was moderately cognitively impaired with a BIMS score of 08. Resident #82 required extensive assistance of two staff with bed mobility, toileting, and personal hygiene. Record review of Resident #82's Comprehensive Care Plan dated 07/19/23 revealed she was at risk for an ADL self-care performance deficit related to limited mobility and is dependent upon staff for various ADL activities. Record review of facility roster, Untitled, dated 06/28/23 revealed Resident #82 resided in [room number] . Review of the most recent pest control visit 06/23/23 for 8:33 AM - 9:02 AM, titled Service Inspection Report, revealed General Comments/Instructions . Treated exterior for spiders and general pests. Review of facility Independent Services Agreement, dated 12/01/19 revealed a current contract. In interview and observation on 06/27/23 at 12:17 PM with Resident #82 revealed her resting in her bed. She stated she has been a resident at the facility for almost a year and her room has never been deep cleaned. She stated that spiders come out from the attic access located in her room and crawl around her room at night. While she denied any insect bites at the facility, she stated she was once bitten by a brown recluse in the past and is terrified of spiders. She stated she and her husband have informed the administrator of their concerns but nothing has been done about it yet. Upon inspection of resident's room: 1. Resident's room had attic access located on the ceiling that was insufficiently secured with a rusted, metal hook and eye fastener with approximately a 1-inch gap between the ceiling and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 18 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 0925 easement, exposing the attic. Level of Harm - Minimal harm or potential for actual harm 2. Every corner of the room had spider webbing located on the upper wall area; with dead and live flying insects and dead and live spiders present. Residents Affected - Few In interview and observation on 06/28/23 at 01:13 PM with Resident #82 revealed her sitting up in her bed eating lunch. She stated the housekeeper, HSK B, had already performed her service for the day. She stated that she just quickly came in and then left. She stated she was not satisfied with her service and that her room still feels unclean. She stated that the issues from yesterday are still present today and it was very frustrating for her, as she does not have the ability to clean her room herself. Upon inspection of resident's room: 1. Resident's room had attic access located on the ceiling that was insufficiently secured with a rusted, metal hook and eye fastener with approximately a 2-inch gap between the ceiling and the easement, exposing the attic. 2. Every corner of the room had spider webbing located on the upper wall area; with dead and live flying insects and dead and live spiders present. In interview with HSK B on 06/28/23 at 1:46 PM, she stated she was responsible for cleaning [Resident #82's room number] 06/27/23 and 06/28/23. She stated she felt like the staffing in her department was okay and she had enough time to do everything she needed to do. She stated she had completed her daily clean for the day in [Resident #82's room number] . She stated she sometimes had a checklist she used but did not use the checklist this week. She stated some residents do not like her to move their furniture in their room but the resident in [Resident #82's room number] did not have that preference. She stated she had noticed the attic easement in the resident's room but was not concerned about the condition of the opening. She stated has never been trained to clean resident walls but stated that it would be reasonable to expect that to be part of her daily duties. She stated she noticed spiders in the room a week ago and let HSK Supervisor know. She stated she would not want to live in a room with live insects. She stated she was told by HSK Supervisor last week to clean around the air conditioner better, but she stated when she tried to clean the air conditioner where was hard black residue that was hard to get off. She stated she would not want to live in a room where the air conditioner was dirty. She stated that she thinks the maintenance department should be responsible for deep cleaning the air conditioner. Additionally, she stated as far as she knows, the curtains in [Resident #82's room number] have not been laundered, but she had not noticed they were dirty. She stated when she reports things to her management or to maintenance, things normally get addressed quickly, but she just have missed the condition of [Resident #82's room number] because she did not report the concerns to her management. In interview with HSK Supervisor on 06/28/23 at 2:16 PM, she stated [Resident #82's room number] did not meet her expectations. She stated she has not been able to implement effective measures for improvement because of lack of staffing. She stated she does not know the last time [Resident #82's room number] was deep cleaned. She stated the attic easement in [Resident #82's room number] has been like that for as long as she has worked at the facility and did not see it as a concern. When asked for a potential source of spider activity in the room, she then stated that it could be the opening from the attic easement and stated she would then report it to maintenance. She declined to comment on the potential outcome to the resident at the time of interview, but stated it was her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 19 of 20 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsibility to ensure housekeeping staff are providing sufficient services for a clean, homelike environment. In interview with Maintenance on 06/30/23 at 11:06 AM he stated the attic easement/ladder door in [Resident #82's room number] was sagging open because of the type of lock installed on it. He stated once it was brought to his attention yesterday, he installed a flat securement/lock so the door is now flush with the ceiling. He stated he did not know about the issue until it was brought to his attention. He stated it was housekeeping responsibility to ensure resident rooms were clean. In interview with Administrator on 06/30/23 at 1:16 PM he stated he was not aware of any environmental concerns in [Resident #82's room number] , either reported by the staff, residents, or family members. He felt like the attic easement was not a problem nor a source for spiders. He did state that it was unacceptable for an accumulation of spider webs with live spiders to be present in any of his resident rooms. He stated his expectations were for resident rooms to be clean, safe, and homelike. He expected staff to report concerns to maintenance or housekeeping to be addressed in a timely manner. Record review of the facility work order log dated 05/01/23-06/30/23 revealed no documentation of work orders or pest control sightings for [Resident #82's room number] . Review of facility policy, Infection Control . Pest Control, rev. 04/08/21, Procedures: 1. The facility will have a Pest Control vendor . 4. Monitoring of the environment will be done by the facility's staff. 5. Pest control problems will be reported promptly. Review of facility policy, Pest Control, undated, provided by the facility on 04/20/2023 revealed Policy Statement . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation . 1. This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 20 of 20