Health inspection·September 20, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was dry in some spots. The substance appeared to be chocolate milk or coffee with cream. There were visible patches of dirt on the floor that were grayish/blackish in color . In an interview on 09/07/23 at 10:24 AM, the HK Manager stated on Thursday (08/31/23), he had only been working at the facility for one week. The HK Manager stated he realized the building was not in very good shape. The HK Manager stated he received several complaints from the residents that their rooms had not been cleaned for several days and to him, the rooms appeared as if they had not been cleaned for several days . The HK Manager stated he believed there were staffing issues prior to him starting, but now they were fully staffed. He stated HK was supposed to clean resident rooms daily, which consisted of emptying the trash, cleaning the bathroom, disinfect things that were touched daily such as bed side tables, sweep, and mop. The HK Manager stated they used a 5-Step Daily Housekeeping Procedure to ensure the rooms were cleaned appropriately. The HK Manager stated each room was supposed to be deep cleaned twice per month. He stated he was in the process of getting every room deep cleaned and then he would do routine cleaning and deep cleaning twice per month . An interview and observation on 09/07/23 at 10:52 AM of room [ROOM NUMBER] revealed food crumbs and crumbled paper debris around the resident's bed. Under the resident's bed was dust. The floor was sticky and had visible patches of grayish/blackish dirt stains. Resident #2 stated it had been about three days since HK cleaned her room. She stated HK did not clean daily. Resident #2 stated HK cleaned her room about 1-2 times per week. In a follow up interview and observation on 09/08/23 at 12:15 PM of room [ROOM NUMBER] revealed the room still had not been cleaned. The same observations from 09/07/23 at 10:07 AM were still present in room [ROOM NUMBER]. Resident #5 stated HK did not clean his room yesterday nor so far today. An interview and observation on 09/08/23 at 1:45 PM of room [ROOM NUMBER] revealed crumbled paper towels and small bits of trash sporadically over the floor. The floor was sticky. Resident #4 stated HK did not clean their room often. He stated the last time they cleaned was on Tuesday (09/05/23). Resident #4 stated HK did not generally come until his or Resident #3's FM complained . In an interview on 09/08/23 at 2:14 PM, the Administrator stated he started at the facility on 08/28/23 and realized HK was an issue. He stated resident's rooms were supposed to be cleaned daily but that was not happening. The Administrator stated there were issues with staffing when he first started at the facility. He stated there were 2 or 3 HK staff who could only work on certain days. The Administrator stated he hired a new HK Manager about one week ago and they were fully staffed. He stated the new HK Manager had prepared a schedule to provide consistency and to ensure the rooms were going to be cleaned daily . A record review of the facility's, undated, HK procedures titled 5-Step Daily Housekeeping Procedure, reflected Step 1: Empty trash and check supplies. Trash: Add liners to receptacles and sanitized as needed. Supplies: paper towels, toilet paper, and soap. Step 2: Clean (dust) all horizontal surfaces using 200 disinfectants. Horizontal Surfaces: picture frames, dressers, bed-side tables, TV, beds, handrails, sink, toilet, mirror & lights. Step 3: Spot clean walls and check privacy curtains. Step 4: Sweep/dust mop. Move furniture & sweep under beds. Step 5: Damp mop, mop under bed. A record review of the facility's policy titled Resident Rights, dated 05/2007, reflected Policy: It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 2 of 17 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 09/20/2023 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete A record review of the facility's policy titled Environmental Services- Housekeeping, dated 2022, reflected Policy: Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. Procedures: 1. All rooms of residents will be cleaned regularly. These duties include: a. Sweeping and mopping of the resident's room and restroom . e. Properly dispose of any trash in the room (declutter) . h. Frequently change mop water as to not transfer any infectious materials/substances from room to room . Event ID: Facility ID: 675579 If continuation sheet Page 3 of 17 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 09/20/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident #1, Resident #2, Resident #3) reviewed for ADL care. Residents Affected - Some The facility failed to ensure Resident #1, Resident #2 and Resident #3 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and decreased feelings of self-worth and dignity. Findings include: 1. Record review of Resident #1's electronic face sheet, dated 09/07/23, reflected the resident was admitted to the facility on [DATE] and was an [AGE] year-old female with a diagnoses which included age-related osteoporosis (causes bones to become weak and brittle) with current fracture, unspecified lack of coordination, unspecified dementia , and chronic pain. Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/23, indicated a BIMS score of 2, which indicated the resident's cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected Resident #1 was always incontinent of urine and bowel. Record review of Resident #1's Care Plan, dated 09/02/23, indicated a focus on area of bowel and bladder incontinence due to impaired mobility. The Care Plan interventions did not address peri care. 2. Record review of Resident #2's electronic face sheet, dated 09/08/23, reflected a female admitted to the facility on [DATE], who was [AGE] years old with diagnoses which included abnormalities of gait and mobility, unspecified lack of coordination, need for assistance with personal care, weakness, unsteadiness of feet, and muscle wasting and atrophy. Record review of Resident #2's Quarterly MDS Assessment, dated 04/02/23, indicated a BIMS score of 13, which indicated the resident's cognition was intact. She required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected she was occasionally incontinent of urine and always incontinent of bowel. Record review of Resident #2's care plan, dated 08/31/23, indicated a care area/problem of bladder and bowel incontinence due to history of UTI and impaired mobility with an intervention to Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. 3. Record review of Resident #3's electronic face sheet, dated 09/08/23, reflected a male resident who admitted to the facility on [DATE] and was [AGE] years old with diagnoses which included lack of coordination, difficulty in walking, pain in joint, right shoulder, and foot, history of falls, muscle weakness, and abnormalities of gait and mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 4 of 17 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 09/20/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's Comprehensive MDS Assessment, dated 06/23/23, indicated a BIMS score of 5, which indicated the resident's cognition was severely impaired. He required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected he was occasionally incontinent of urine and always incontinent of bowel. Record review of Resident #3's care plan, dated 07/07/23, indicated a care area/problem of occasional bladder and bowel incontinence. The Care Plan interventions did not address peri care. In a phone interview on 09/06/23 at 4:50 PM, Resident #1's family member (FM) stated Resident #1 had a camera in her room and on 09/02/23 at 1:50 PM the FM checked the camera and saw Resident #1 had not been changed since 2:15 AM. The FM stated she went to the facility about 2:30/3:00 PM and saw Resident #1 still had not been changed. The FM stated they spoke to LVN A about Resident #1 not being changed since 2:15 AM and asked who was Resident #1's CNA. The FM stated LVN A told her she was not sure who the CNA was for Resident #1. The FM stated she asked LVN A for help because she was going to change Resident #1 themselves. The FM stated eventually a CNA (did not remember their name) came to help change Resident #1. The FM stated it was about 3:30 PM before Resident #1 was changed, which meant she had not been changed for about 13 hours . In an interview on 09/07/23 at 10:53 AM, Resident #2 stated there were a few times per week she waited several hours to be changed. Resident #2 stated she would press her call light and it would take 2-3 hours before someone would answer and change her. She stated she reported this several times to the nurses who were covering her hall . Resident #2's FM was visiting and stated this happened because she would check the camera in her room. The FM stated on the weekend it was really bad. The FM stated she usually visited on weekends, and she had witnessed it took 3 to 4 hours before staff would respond to the call light to change Resident #2. In a phone interview on 09/07/23 at 2:17 PM, LVN A stated on 09/02/23 Resident #1's FM went to the facility and stated Resident #1 had not been changed for several hours and she was extremely wet. LVN A stated she told the FM she did not know who the CNA was for Resident #1, because it was around shift change and she did not know which CNA took over Resident #1's hall. LVN A stated she learned CNA B was assigned to Resident #1's hall from 6AM to 2PM. She stated CNA C was assigned to Resident #1's hall from 2PM to 10PM. LVN A stated CNA C went to change Resident #1. She stated CNA C stated Resident #1 was extremely saturated. LVN A stated she spoke to CNA B and asked her why she had not changed Resident #1. LVN A stated CNA B did not provide a direct answer and said, she had to do this and that. LVN A stated CNA C went to her very upset because while she was doing rounds, there were several residents who were extremely wet. LVN A stated she did rounds with CNA C to help her. LVN A stated she could not remember everyone who was extremely wet, but she definitely remembered Resident #3 because he had dried feces and a brown circle on his sheets. She stated this was an indication he had not been changed for several hours. LVN A stated she worked on the weekends and there were issues with CNAs because a lot of them were agency. She stated she received complaints from resident's that they would turn on call lights to be changed and no one would come for hours. LVN A stated she would have to go look for the CNAs who were usually in the breakroom or hiding in the front lobby because the receptionist left at 4PM. She stated she reported this issue to the Weekend Supervisor (WS ), the Staffing Coordinator (SC), and the DON. She stated the WS would say he would inform the SC to stop scheduling those CNAs, the SC would stop scheduling those CNAs, but the new agency staff would come in and do the same thing. LVN A stated the DON would tell her they were working towards getting the agency staff out of the building. In an interview on 09/08/23 at 11:30 AM, the SC stated she worked on 09/02/23 because she had two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 5 of 17 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 09/20/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some people call out and one person did not show up. She stated it was very chaotic. The SC stated she received complaints from the residents and nurses there were issues with residents not being changed in a timely manner. She stated residents were complaining they had not been changed for several hours and after pressing call lights they had to wait about 2 hours to be changed. The SC stated this was an issue in the facility during the 2PM to 10PM shift during the week and on the weekends. She stated the facility was staffing appropriately but it's a lot of agency from 2PM to 10PM and on the weekends and they were not on the floor. The SC stated she received calls from the weekend nurses who stated they could not find the CNAs and they were hiding, or on occasions they had left the building. She stated when this happened, she would not put them back on the schedule. In an interview on 09/08/23 at 1:08 PM, LVN D stated she worked Monday thru Friday from 6AM to 2PM. She stated on Wednesday (09/06/23) she received a complaint from Resident #2 when she answered her call light. LVN D stated Resident #2 stated she had not received incontinence care for a while and put on her call light. She stated Resident #2 stated her call light had been on for two hour. She stated she sent a CNA to change her, but she could not recall who. LVN D stated Resident #2's FM called and stated it had been about two hours when she checked the cameras. In an observation and attempted interview on 09/08/23 at 1:45 PM with Resident #3, he was observed to be in and out of a state of confusion. Resident #3 was asked if he received timely incontinence care, and his roommate, Resident #4 responded and stated no he did not. Resident #4 stated staff would not change Resident #3 for a while , so he would tell Resident #3 to press his call light, or he pressed his own call light for Resident #3. Resident #4 stated on the weekends it would take several hours before Resident #3 would be changed, even after pressing the call light. In an interview on 09/08/23 at 1:55 PM, the DON stated he had not received any complaints from residents or staff regarding timely incontinence care. He stated he had not received any complaints from weekend nurses of issues with CNAs not being on the floor or hiding. The DON stated his expectations were for staff to provide timely incontinence care. In a phone interview on 09/08/23 at 3:54 PM, CNA B stated she was assigned to Resident #1's on 09/02/23 from 6AM to 2PM. CNA B stated she could not remember if she changed Resident #1 during her shift on 09/02/23. She stated she could not remember if she checked in on her to see if she was wet during her entire shift on 09/02/23. CNA B stated she was supposed to do rounds to check residents to see if they needed to be changed but it was extremely busy her entire shift. CNA B stated she could not remember if LVN A asked her about not changing Resident #1. She stated she remembered her telling her she should have gotten her up for the day. In a phone interview on 09/13/23 at 11:28 AM, CNA C stated on 09/02/23 she worked a double shift from 6AM to 10PM. CNA C stated when the 2PM to 10PM started she was assigned to Resident #1 and Resident #2's hall. CNA C stated towards the beginning of her shift she heard Resident #1's FM telling LVN A she checked her camera and Resident #1 had not been changed all morning. CNA C stated LVN A told her to go change Resident #1. CNA C stated Resident #1 was wet and she believed it had been a while since she had been changed because some parts of the brief were dry. CNA C stated during her rounds she saw the residents were saturated and seemed as if they had not been changed for a while. CNA C stated when she got to Resident #3, it was really bad, so she called LVN A into the room. She stated she did not want to get blamed for him being in that condition. CNA C stated Resident #3's brief and bed sheet were saturated in urine, and he had dried up feces stuck to his bottom, so she knew he had not been changed during the 6AM to 2PM shift. CNA C stated she had to take Resident #3 to the shower . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 6 of 17 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 09/20/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy titled Incontinence Care, dated 03/2022, reflected Policy: It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the resident and providing care in a respectful manner. Procedure . 7. Check the resident for further incontinence regularly. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 7 of 17 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 09/20/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 5 residents (Resident #7) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #7 was accurately assessed, monitored, and treated for a change of condition when the resident was found to be in pain on 09/10/23 at approximately 10:30 PM. Resident #7 was not immediately sent to the hospital for emergency medical care. She was sent to the hospital on [DATE] after therapy staff notified the nurse of a leg deformity. At the hospital, Resident #7 was diagnosed with fractures of her left tibula and fibula (two bones in the lower leg, calf/shin area). This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe injury and pain, hospitalization, or even death. Findings include: A record review of Resident #7's face sheet, dated 09/13/23, reflected Resident #7 was an 81-year- old female, who originally admitted to the facility on [DATE] ad re-admitted on [DATE]. Resident #7had diagnoses which included: cognitive communication deficit, contracture unspecified ankle (a chronic loss of ankle joint motion due to structural changes in muscle), muscle weakness, reduced mobility, need for assistance with personal care, abnormal posture, pain in unspecified joint, muscle wasting and atrophy multiple sites, lack of coordination, unsteadiness on feet, falls, chronic kidney disease, unspecified fracture of shaft of left femur (thigh bone) with routine healing, and dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #7's Quarterly MDS Assessment, dated 08/30/23, indicated Resident #7's BIMS score was 0, which indicated the resident's condition was severely impaired. Resident #7 required extensive physical assistance of two or more staff for bed mobility, transfers, and toilet use. Resident #7's was not on a scheduled pain medication regimen and the other sections which referenced pain, were not competed and had dashes in the spaces. A record review of Resident #7's Care Plan, initiated date 05/24/22 and revision date 08/27/23, reflected she had acute/chronic pain. The interventions included Administer analgesic medication as per orders. Give ½ hour before treatments or care. Anticipate need for pain relief and respond immediately to any complaint of pain. Follow pain scale to medicate as ordered. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Pain assessment every shift. A record review of Resident #7's Progress Notes, written by LVN F on 09/11/23 at 12:37 PM reflected, Around 12:15 pm, this Nurse was doing dining room duties when staff therapy stated that resident needs to be checked to her lower extremity. This Nurse went into the residents' room and upon assessment, observed that resident's left lower leg below the knee was bent. Resident groaned in pain when leg was moved. Unable to rate pain due to baseline confusion. PRN pain meds tramadol 50 mg admin per MAR. [Physician] informed, came to assess resident and ordered that resident be sent to ER for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 8 of 17 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 09/20/2023 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 0684 further medical treat and eval. Resident is alert with baseline confusion. 911 called and resident picked up to ER via stretcher [hospital]. RP [family member] informed. Level of Harm - Actual harm Residents Affected - Few Record review of the facility's incident and accident log for September 2023 revealed Resident #7 had a physician diagnosed fracture on 09/11/23 at 12:23 PM. A record review of Resident #7's hospital records revealed she entered the hospital on [DATE] at 2:21 PM with chief complaint of leg injury and the following information provided by EMS Patient presents due to left tib (tibia) fib (fibula) deformity. Patient is from [Facility's name] nursing facility. EMS was called due to deformity of left tib fib. Patient is bed bound and nonverbal at baseline. She has a history of dementia. EMS reports that nursing staff at [Facility's Name] claim they found her in bed that way today. Last night her leg was normal. She is acting like her baseline mental status. The physical exam revealed . Musculoskeletal: Comments: Mid left tib fib has obvious deformity, distal portion of leg freely mobile and wobbly. Palpable pulse. Neurological: Moving all extremities except left leg. Makes eye contact. Shakes her head no to certain questions. The hospital records indicated x rays were conducted at 2:49 PM and Resident #7's final diagnosis included Closed displaced comminuted fracture of shaft of left fibula, initial encounter; Closed displaced comminuted fracture of shaft of left tibia, initial encounter. In a phone interview on 09/18/23 at 12:03 PM, OT K stated she worked with Resident #7 on 09/10/23. She stated it was her first time working with Resident #7. OT K stated Resident #7 had a therapy goal of feeding herself, so she went to work with her during lunch. OT K stated she arrived at Resident #7's room about 11AM. She stated Resident #7 was wet, so she changed her brief, got her dressed, and put her in her wheelchair. OT K stated she transferred Resident #7 by herself. She stated she took Resident #7 to the dining room and worked with queuing her while eating her lunch. OT K stated Resident #7 was in good spirts, talked some during her meal, and majority of her food. OT K stated after lunch she took her to the nurse's station, locked her wheelchair, and let the nurse know she was leaving. She stated that was about 12:30/1:00PM. OT K stated there was no indication the resident was in any pain. In a phone interview on 09/18/23 at 11:06 AM, CNA H stated she was assigned to Resident #7's hall on 09/10/23 from 2PM-10PM. CNA H stated when she started her shift at 2PM, Resident #7 was at the nurse's station and was there until dinner, which was about 5:30 PM. CNA H stated she checked her brief right before dinner, about 5PM, and she was dry. She stated she assisted her with eating dinner in the dining room and then brought her back to the nurse's station. CNA H stated she sat at the nurse's station until about bedtime. CNA H stated about 9/9:30PM, she checked Resident #7, and she was wet. CNA H stated she took Resident #7 to her room, transferred her from her wheelchair to the bed by herself , changed her brief, put her night gown on, and put her to bed. CNA H stated Resident #7 seemed fine and was not grimacing in pain when she transferred and changed Resident #7's brief. CNA H stated she worked a double, so when her 10PM- 6AM shift started she was assigned to a different hall. She stated about 10:30 PM she did her final rounds and when she went to check on Resident #7, she was holding her left hip area and her face was grimacing in pain. CNA H stated she told the 10:00 PM to 6:00 AM nurse, LVN I, Resident #7 looked as if she was in pain and was holding her hip. She stated she did not know if LVN I assessed Resident #7 because she went to start the next shift on another hall. In a phone interview on 09/18/23 at 2:24 PM, LVN I stated he was assigned to Resident #7's hall on 09/10/23 from 10PM to 6AM. LVN I stated at the beginning of his shift CNA H stated Resident #7 was holding her hip and her face looked as if she was in pain, so he did a head-to-toe assessment. LVN I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 9 of 17 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 09/20/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few stated the assessment consisted of him looking for swelling and redness and he used his hand to push down on Resident #7's hip and thigh area. He stated he did not see any swelling or redness and Resident #7 did not grimace in pain, yell or groan, nor attempted to move his hand when he pushed down on her hip and thigh area. LVN I stated based on this assessment, he felt the resident was not in pain and was fine . LVN I stated he did not observe Resident #7's leg distorted or unaligned. LVN I stated he did not push down on the resident's leg and only focused on the hip/thigh area because CNA H reported that was the area Resident #7 was holding. He stated he did not attempt to move Resident #7's leg or check for ROM . When LVN I was asked if he was supposed to check for ROM and attempt to move Resident #7's leg as a part of a head-to-toe assessment, he stated yes. LVN I stated he did not document that CNA H reported resident was in pain nor did he document the assessment he completed on Resident #7. He stated he was supposed to document the incident. LVN I stated he did not re-assess Resident #7 at any time during his shift because the first time he assessed her she did not show she was in any pain. LVN I stated he did not monitor Resident #1 for pain throughout his shift, but the CNAs did round and had not reported any signs of pain. In an interview on 09/18/23 at 10:58 AM, CNA G stated she was assigned to Resident #7's hall on 09/11/23 from 6AM-2PM. She stated she did rounds about 6:30 AM. CNA G stated Resident #7 was still asleep but she checked her brief, and it was dry. CNA G stated Resident #7 had breakfast and seemed normal. She stated Resident #7 never complained of any pain or appeared to be in pain. CNA G stated she checked Resident #7 about 11:00 AM and her brief was wet. She stated she noticed as soon as she moved Resident #7, she grimaced in pain. CNA G stated she told nurse, LVN F, Resident #7 seemed to be in pain. In an interview on 09/20/23 at 3:15 PM, OT J stated on 09/11/23 around lunch time, she went to Resident #7's room to do therapy. She stated the resident was laying on her right side, which was rare. OT J stated when she went to reposition her, and Resident #7 groaned loudly and her face was grimacing in pain. She stated once Resident #7 was laying flat on her back, she noticed her leg was bent and distorted. OT J stated she could clearly see it was fractured. She stated she went to get LVN F. In a phone interview on 09/18/23 at 11:38 AM, LVN F stated he was assigned to Resident #7's hall on 09/11/23 from 6AM to 2PM. LVN F stated around lunch time CNA G and Occupational Therapist (OT) J told him resident was in pain when they provided care. LVN F stated he went to complete a head-to-toe assessment on the Resident #7. He stated as soon as he pulled back the covers, he immediately noticed Resident #7's left leg was unaligned. LVN F stated he gently attempted to move the resident's leg and she groaned really loud in pain. He stated the facility doctor was at the facility, so he went to get her. LVN F stated the doctor assessed Resident #7 and gave an order to send her to the hospital. He stated she had a PRN order for Tramadol, so he gave her the pain medication and called 911. LVN F stated as long as Resident #7 did not move, she was ok. In a phone interview on 09/18/23 at 1:20 PM, the facility's Physician stated on 09/11/23 she was at the facility doing rounds and LVN F called her to Resident #7's room. She stated LVN F reported Resident #7 was in pain and her leg was unaligned. The Physician stated she went to assess Resident #7 and immediately saw her left leg was unaligned. She stated she did not attempt to move the leg because it was clearly fractured. She stated any nurse should have been able to immediately recognize the leg was unaligned. In an interview on 09/19/23 at 10:24 AM, the DON stated if a resident reported pain, it was his expectation that the nurse completed a head-to-toe assessment. The DON stated LVN I reported to him he completed a head-to-toe assessment on Resident #7, after CNA H reported seeing Resident #7 in pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 10 of 17 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 09/20/2023 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 0684 Level of Harm - Actual harm The DON stated LVN I reported Resident #7 did not seem to be in any pain during the assessment. He stated when completing a head-to-toe assessment checking ROM and attempting to move the extremities were a part of the assessment. The DON stated he was not aware LVN I did not complete these tasks during his assessment . Residents Affected - Few A record review of the facility's, undated, Head to Toe Assessment- Skills Checklist reflected Charting Instructions: Document the Head-to-Toe Assessment findings in PCC Progress Note under Nursing. If a resident presents a change in condition during the assessment, follow the Change in Condition Guidelines . Head to Toe Assessment Guidelines . Bilateral Checks: Bilateral checks for comparison need to be done for . Leg Strength- place your hands on the patient's thighs. Have the patient push legs against the resistance of your hands. Check for equality in strength A record review of the facility's policy titled, Significant Change in Condition, Response, revised January 2022, reflected Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) . new complaints of pain or worsening of pain . 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of exiting orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3 . Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs . 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report . 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly In interviews on 09/20/23 between 1:45 PM and 3:25 PM, staff interviews with LVN D, LVN F, LVN I, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q LVN R, RN S, LVN T, LVN U, ADON, and DON were conducted. All staff were able to articulate what they were taught, policies, protocols, and procedures related to pain assessments, head to toe assessments, change of condition, and injuries of unknown origin. In interviews on 09/20/23 with the ADON at 3:23 PM and the DON at 2:47 PM, they both stated they were responsible for verifying staff competency with staff weekly using the pain competency checklists, reviewing all residents with injury or pain each week in the clinical meeting to assure pain assessments were completed timely, and ensuring at each shift change nursing staff were trained on the assessment of residents for pain assessments and head-to-toe assessments prior to the start of their shift . A record review of the resident's electronic medical records revealed facility nurses had completed resident's pain assessments by 09/19/23 and there were no acute pain or major changes of condition identified. Record review of in-services titled Assessing for Pain and Head to Toe Assessment revealed LVN D, LVN F, LVN I, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q LVN R, RN S, LVN T, LVN U, ADON, and DON signed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 11 of 17 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 09/20/2023 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 0684 the facility's in-serviced logs, completed competency tests. Level of Harm - Actual harm A record review of the in-service log titled Subject: F684 Plan of Removal - Ad Hoc QAPI, dated 09/19/23, revealed signatures by the Medical Director, Clinical Resource Manager, DON, and the Administrator. Residents Affected - Few A record review of the in-serve log titled F684 Plan of Removal by the Clinical Market Lead, revealed the DON & Clinical Resource Manager received training on the assessment of residents for pain assessments and head-to-toe assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 12 of 17 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 09/20/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to administer Resident #1's tramadol HCI oral tablet on 09/02/23 at 1:00 PM and 09/03/23 at 1:00 PM for pain. This deficient practice could place residents at risk of not receiving the therapeutic effect of medications and a drug diversion. The findings include: Record review of Resident #1's electronic face sheet, dated 09/07/23, reflected a female who admitted to the facility on [DATE] and was [AGE] years old. Resident #1 had diagnoses which included age-related osteoporosis (causes bones to become weak and brittle) with current fracture and chronic pain. Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/23, indicated a BIMS score of 2, which indicated the resident's cognition was severely impaired Resident #1 was to receive a scheduled pain medication regimen. Record review of Resident #1's care plan, dated 09/02/23, reflected a focus that Resident #1 had acute/chronic pain due to age related osteoporosis. The Care Plan reflected the intervention included Administer [pain] medication as per orders. A record review of Resident #1's Order Summary, dated 09/07/23, reflected a physician order for Tramadol HCl Oral Tablet 50 MG (Tramadol HCI) Give 1 tablet orally three times a day for pain. Start date 03/14/23. A record review of Resident #1's MAR, dated September 2023, reflected the following: Tramadol HCl Oral Tablet 50 MG (Tramadol HCI) Give 1 tablet orally three times a day for pain. Start date 03/14/23 5:00 PM. The MAR reflected the hours for the medication were 9:00 AM, 1:00 PM, and 5:00 PM. There were no initials or check marks, which indicated the medication was not administered for the following times: 09/02/23 at 1:00 PM and 09/03/23 at 1:00 PM. In a phone interview on 09/06/23 at 4:50 PM, Resident #1's family member (FM) stated over the weekend (09/02/23 and 09/03/23) Resident #1 received all her doses of tramadol. The FM stated while at the facility on 09/02/23 they spoke to the Med Aide assigned to Resident #1's hall about 4PM. The FM stated they could not recall the Med Aide's name, but they pointed out Resident #1 did not receive her afternoon dose of Tramadol. The FM stated they reviewed the camera in Resident #1's room and saw she did not receive the medication. The FM stated the Med Aide said she was new and got behind. The FM stated Resident #1 did receive her 5PM dose. In a phone interview on 09/07/23 at 2:17 PM, LVN A stated on 09/02/23 Resident #1's FM went to the facility and stated Resident #1 had not received her tramadol medication. She stated Med Aide E was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 13 of 17 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 09/20/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm new and it was her first weekend working by herself. LVN A stated Resident #1's FM wanted to know who the Med Aide was on Resident #1's hall. LVN A stated she advised the FM that Med Aide E was assigned to Resident #1's hall and told the FM Med Aide E was new and behind. She stated one of the other Med Aides went to help her. LVN A stated she knew several medications were late, but she was not aware medications were missed . Residents Affected - Few In an interview on 09/07/23 at 3:25 PM, Med Aide E stated Saturday, 09/02/23, was her first day passing medications by herself and there were a lot of issues. Med Aide E stated she fell behind and another Med Aide had to help her. She stated Resident #1's FM told her she did not receive her tramadol. The Med Aide stated she told Resident #1's FM that it was her first day and she had fallen behind. She stated she was not aware Resident #1 did not receive the medication at all. Med Aide E stated she thought it was just late. She stated shortly after that conversation with Resident #1's FM, another Med Aide started helping her and there could have been a mix up between them. Med Aide E stated she may have thought the other Med Aide gave her the meds and she missed it. In an interview on 09/08/23 at 1:55 PM, the DON stated there had not been any issues reported to him regarding medications over the weekend (09/02/23 and 09/03/23). He stated there was a new Med Aide who started over the weekend, but nothing had been reported to him that resident's medications were late or not administered. The DON stated his expectation was for medications to be administered per physician orders. He stated the adverse actions would depend on the type of medication, but in general there were concerns residents would not receive the desired effect the medication was intended to provide. A record review of the facility's policy, titled Medication Administration, dated 05/2007, revealed It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: 2. Medications must be administered in accordance with the written orders of the attending physician . 8. Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled. 9. The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication. 10. The nurse administering the medications must initial the resident's MAR, on the appropriate line and date for that specific day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 14 of 17 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 09/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #7) reviewed for medical records . 1. The facility failed to ensure LVN F documented Resident #7 had a change in condition and was assessed when CNA H reported seeing Resident #7 grimacing in pain. 2. The facility failed to ensure Resident #7's electronic medical record accurately documented the residents level of assistance needed. These failures could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records. The findings include: A record review of Resident #7's face sheet, dated 09/13/23, reflected Resident #7 was an 81-year- old female, who originally admitted to the facility on [DATE] ad re-admitted on [DATE]. Resident #7 had diagnoses which included: cognitive communication deficit, contracture unspecified ankle (a chronic loss of ankle joint motion due to structural changes in muscle), muscle weakness, reduced mobility, need for assistance with personal care, abnormal posture, pain in unspecified joint, muscle wasting and atrophy multiple sites, lack of coordination, unsteadiness on feet, falls, chronic kidney disease, unspecified fracture of shaft of left femur (thigh bone) with routine healing, and dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #7's Quarterly MDS Assessment, dated 08/30/23, indicated Resident #7's BIMS score was 0, which indicated the resident's condition was severely impaired. Resident #7 required extensive physical assistance of two or more staff for bed mobility, transfers and toilet use. Resident #7's was not on a scheduled pain medication regimen and the other sections which referenced pain, were not competed and had dashes in the spaces. A record review of Resident #7's Care Plan, initiated date 05/24/22 and revision date 08/27/23, reflected she had acute/chronic pain. The interventions included Administer analgesic medication as per orders. Give ½ hour before treatments or care. Anticipate need for pain relief and respond immediately to any complaint of pain. Follow pain scale to medicate as ordered. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Pain assessment every shift. Further review of the Care Plan reflected Resident #7 had an ADL self-care performance deficit. The interventions included Transfer: Requires staff participation with transfers . Requires physical assistance with transferring. The Care Plan did not indicate if Resident #7 was a one-person or two-persons assist for transfers. In a phone interview on 09/18/23 at 11:06 AM, CNA H stated she was assigned to Resident #7's hall on 09/10/23 from 2PM-10PM. She stated about 10:30 PM she was doing her final rounds and when she went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 15 of 17 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 09/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to check on Resident #7, she was holding her left hip area and her face was grimacing in pain. CNA H stated she told the 10:00 PM to 6AM nurse, LVN I, Resident #7 looked as if she was in pain and was holding her hip. She stated she did not know if LVN I assessed Resident #7 because she went to start the next shift on another hall. In a phone interview on 09/18/23 at 2:24 PM, LVN I stated he was assigned to Resident #7's hall on 09/10/23 from 10PM to 6AM. LVN I stated at the beginning of his shift CNA H stated Resident #7 was holding her hip and her face looked as if she was in pain, so he did a head-to-toe assessment. LVN I stated the assessment consisted of him looking for swelling and redness and he used his hand to push down on Resident #7's hip and thigh area. He stated he did not see any swelling or redness and Resident #7 did not grimace in pain, yell or groan, nor attempted to move his hand when he pushed down on her hip and thigh area. LVN I stated based on this assessment, he felt the resident was not in pain and was fine. LVN I stated he did not document that CNA H reported resident was in pain nor did he document the assessment he completed on Resident #7. LVN I stated he was supposed to document this incident. In an interview on 09/18/23 at 1:15 PM, the DON stated staff were in-serviced to review the Special Instructions of PCC to know how to transfer the residents and not review the MDS. He stated Resident #7's Special Instructions indicated she was a one-person assist with a gait belt. The DON stated the MDS was completed based on the highest level of care the resident needed within the 7-day look back period, so it would be possible the MDS said one thing and the Special Instructions stated something different. It was brought to the DON's attention the Special Instructions sections was updated on 07/12/23 and MDS was completed on 08/30/23, and was asked if CNAs had been using two-personas assist for transfers within the look back period, should the Special Instructions section be updated to reflect the Resident's needs, and the DON stated No. He stated during that look back period residents may have been weak during that time period and just need extra help . In an interview on 09/19/23 at 9:20 AM, LVN U stated she was the MDS nurse for the facility. She stated when she filled out the Section G0110. Activities of Daily (ADL) Assistance for transfers it was based on what the CNAs documented within the 7- 14 day look back period. LVN U stated Resident #7's MDS, dated [DATE], the CNAs mostly labeled Resident #7 as a total dependence with 2-person transfers, so the MDS reflected Resident #7 was a two-person assist. She stated during the look back period, the resident was weak, unable to walk, and had coccyx wound, so a 2-person assist for transfers was needed for care. LVN U stated if the therapy assessment was uploaded in PCC, she would review it, but in most cases, it was not completed, so they would go by what the CNAs documented. A record review of the facility's, undated, Head to Toe Assessment- Skills Checklist, reflected Charting Instructions: Document the Head-to-Toe Assessment findings in PCC Progress Note under Nursing. If a resident presents a change in condition during the assessment, follow the Change in Condition Guidelines. A record review of the facility's policy titled, Significant Change in Condition, Response, revised January 2022, reflected Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) . new complaints of pain or worsening of pain . 2. The nurse will perform and document an assessment of the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 16 of 17 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 09/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A record review of the facility's policy titled, Resident Assessments and Associated Processes, dated January 2022, reflected It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. Procedures: Comprehensive Assessment: included the completion of the MDS (Minimum Data Set) . Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment . An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences using the RAI (Resident Assessment Instrument) and will include at least the following: . Customary routine . Mood and behavior patterns . Physical functioning and structural problems . Documentation of resident participation in the assessment process . 2. The assessment process will include direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on all shifts . 3. Comprehensive assessments will be conducted . when there is a significant change in the resident's status . a. Significant Change: is a major decline or improvement in a resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions; the decline is not considered self-limiting (note: self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.) . 4. Each resident will be assessed every three months between comprehensive assessment using a standardized quarterly review process . 6. MDS data is signed/stored electronically in the clinical health record and is readily and easily accessible to all professionals who need to review the information in order to provide care to the resident Event ID: Facility ID: 675579 If continuation sheet Page 17 of 17