Health inspection·June 30, 2022

F 0565 Level of Harm - Minimal harm or potential for actual harm 6. May 12, 2022 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, 2022 May 20 Concerns expressed regarding dietary services and unhappy with substitutes facility response - happy with response if there no excuses moving forward. Residents Affected - Some During a Confidential Group Interview on 6/28/22 at 11:00 p.m., residents (#12, 32,46,3,20,15 and33 ) stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food, which was terrible always late and frequently cold. During an interview on 06/28/2022 at 4:45 PM, Dietary Manager said that the previous dietary manager was let go (Present DM was not specific when she was let go) and they had been working with the Resident Council and the Food Committee, but had not had a chance to get together since she was terminated. She said they had been short-handed, and the food time is posted at 12:00 Noon and she said they must deliver the first tray by 12:00 Noon and the first tray was delivered by that time. Sometimes the hall trays do not get delivered until after 12:00 Noon and the dining room was delivered after all the hall trays are delivered. During an interview with Administrator on 06/30/2022 at 3:00 PM, she said food was the major topic and they tried to work with the residents. The kitchen was contracted out and they have made it known about the issues and were trying to resolve them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents of the facility ( Resident #'s 212, 56,and the North Eas [NAME] had the right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure : A. The floor was clean and free of soiled areas in Resident #212's room. B. The bedside table, infusion pole, and floor were cleaned and free of spills and debris in Resident #56's room C. Residents' equipment (Hoyer lift, wheel chairs, walkers and other pieces of heavy equipment) were stored in a way to ensure cleanliness, order, and resident/visitor safety. These failures could affect the residents, by placing them at risk for unsafe, unclean, and uncomfortable environment, low self-esteem, and a diminished quality of life. Findings included: An observation on 06/27/22 at 12:06 PM, and 6/29/22 at 3:37 PM revealed the floor of Resident # 212 was soiled with feces. The resident refused an interview. An observation of Resident # 56's room revealed a bedside table and an infusion pole sitting in the resident's room, had built up dust/grime and spilled tube feeding formula on the metal frames. There were multiple syringe caps littering the carpet of the room. The carpet in the room was soiled with stains. The resident was not interviewable due to cognitive impairment and aphasia. In interviews during the Resident council meeting on the 6/28/22 at 11:15 AM Resident #' s 12, 32, 28, 3, 20, 15, 2, and 33 complained about the housekeeping staff only pulling trash from the public bathrooms and living room areas of the facility, and never vacuuming or mopping the floors of the resident rooms. They concurred that the bathrooms sinks are never cleaned, and they had cleaned the sinks themselves. They stated they found this disgusting and stated it happened on a regular basis. An interview with the Housekeeping Supervisor on 06/29/22 4:30 PM, revealed the floors in the resident's rooms were to be mopped daily. She also stated she mopped Resident #212's floor on 6/28/22 and must have missed seeing the feces that was left on the floor. She stated she was responsible for monitoring to ensure the resident's rooms were cleaned and another housekeeper(who not available for an interview) should have mopped the room on 06/29/22. An interview on 06/29/22 at 3:46 with a facility nursing staff member that wished to remain anonymous, revealed the staff member felt Resident #56's room was always dirty. She stated the room was horrible and housekeeping did not keep the resident's room clean. She stated it was housekeeping's responsibility to clean the resident's bedside tables and Infusion poles. In an interview on 06/29/22 at 4:30 PM, the DON witnessed the condition of resident #'s 212 and #56's rooms. She stated the nurses were responsible for cleaning up anything that they spill, or for picking up any equipment or trash that they drop in a resident's room. She stated she was not aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 that resident #'s 212 and 56 rooms needed cleaning. Level of Harm - Minimal harm or potential for actual harm In an observation on 06/029/2022 at 03: 51 PM, of the North East hall revealed the area in front of the therapy room, at the end of the hall, had several walkers hanging from the walls on brackets. There were several walkers on each bracket. There were also several wheelchairs, a Hoyer lift, a weight chair, and various other pieces of unused resident equipment in the open hallway in direct view and access of residents and visitors. Residents Affected - Some In an interview on 01/10/2019 at 12:00 PM, the Administrator stated she was aware of the equipment stored at the end of the Northeast Hallway in front of the therapy room. She stated she could see that it did not contribute to a safe and home-like environment now that she had been made aware of it. She stated it has just been there so long; I didn't notice it being there. She stated she would move the equipment immediately. In a record review, the facility's policy, titled Quality of life - Home Like Environment dated revised October 2009 revealed in part: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. There characteristics include cleanliness and order, comfortable noise levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for direct resident care per shift on a daily basis. Residents Affected - Some The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, CNAs, and RNAs. The facility's failure could place residents at risk of not knowing the daily nurse staffing data. The findings included: Observation on 06/27/22 to 06/30/22 revealed the daily nursing staffing hours form was posted on the wall outside the Director of Nurses (DON) office on the main hallway entrance. Review of the Facility's staffing form titled Senor Care Centers dated 6/27/22 at 10:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled Senor Care Centers dated 6/28/22 at 11:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled Senor Care Centers dated 6/29/22 at 10:30 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Observation on 6/29/22 at 10: 40 AM revealed the daily nursing staff posted hours and resident census had not been modified to reflect the actual staff present on each shift nor a change in the resident census from 6/27/22 - 6/29/22. In an interview on 6/29/22 at 1:50 PM, the DON stated she completed the daily staffing sheets every morning for all three shifts, morning 6 AM - 2 PM, evening 2 PM - 10 PM, and night 10 PM - 6 AM. According to the scheduled staff, not the actual staff and posts it outside her door. She further stated she was not aware the staffing sheets were supposed to be completed at the beginning of each shift and reflect the actual number of staff on the floor. And could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. In an interview on 6/29/22 at 2:00 PM, the Administrator stated, the DON was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 0732 Level of Harm - Minimal harm or potential for actual harm posting the daily nursing staffing hours. And the posting of the actual staff present is a new one on me. The administrator further stated, not having the actual hours posted could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, showed: Residents Affected - Some Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift .will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3 .The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN [registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable and served at an appetizing temperature for 7 residents reviewed for palatable food. (Residents #2, #3, #12,#15, #28, #32 and #33 residents in a Residence Council Meeting) Residents Affected - Some This failure could place residents at risk of diminished nutrition and quality of life Findings included: During the resident council meeting on 06/28/2022 at 11:00 AM, residents attending (residents #2, #3, 12,15, 28, 32 and 33) stated that frequently, the food taste is terrible, cold, and always late. Resident #3 stated they have complained on several occasions and it would improve for a while then return to the food late cold and taste terrible. Review of Monthly Grievance Log for January, February, March. April, and May revealed complaints regarding food taste, cold and late. 1 January 30 resident complained regarding she was unhappy with breakfast - facility response showed Dietary Manager note of the complaint. 2. February 7 and 8 four residents complained about the quality of the food service - facility response They have new contract dietary service. 3. March 17 established food committee with 6 residents complaining to the dietary manager regarding taste, cold, and late service and not alternatives- facility response: Dietary Manager met with residents to discuss concerns and work with the food committee. 4. March 19 resident complained regarding food service - facility response will talk to the dietary manager 5. April 28 Resident Council expressed concerns with dietary department with staffing in department facility response - Dietary manager to attend next resident council meeting to work on resolving issues and work on staffing. 6. May 12 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, May 20 Concerns expressed regarding dietary services and unhappy with substitutes - facility response - happy with response if there no excuses moving forward. During a Confidential Group Interview on 6/28/22 at 11:00 p.m., the residents stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food which is terrible always late and frequently cold. Observation of a test tray evaluation on 06/28/2022 at 1:00 PM, revealed the test tray consisted of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 0804 1 cup of collard greens, 1 corn bread square, a bowl of beans and bacon, and a fruit cup Level of Harm - Minimal harm or potential for actual harm Three surveyors evaluated the test tray. The collard greens [NAME]-warm corn bread, [NAME]-warm, beans [NAME]-warm residents complain about food being cold taste during meal service. Residents Affected - Some Interview on 06/28/2022 at 1:00 PM, revealed the Admissions Manager (Administrator unavailable) stated corn bread [NAME]-warm collard greens [NAME]-warm beans warm. Flavor was good. During an interview on 06/28/2022 at 4:45 PM, the Dietary Manager said that the previous Dietary Manager was let go and they have been working with the Resident Council and the Food Committee, but have not had a chance to get together since she was terminated. She said we had been short-handed, and the food time is posted at 12:00 Noon and as I understand , we must deliver the first tray by 12:00 Noon and the first tray is delivered by that time. Sometimes the hall trays do not get delivered till after 12:00 Noon and the dining room is delivered after all the hall trays are delivered. She also said water should not be added to puree food. Observation of staff during diner food service on 06/28/2022 at 4:30 PM reveals 1 Cook 1 Dietary Aide 1 Dietary Manager Staff to provide meals for 63 residents who eat in the facility's only dining room. Observation of food delivered to the dining room 06/27/22 - 12:50 PM 06/28/22 - 1:00 PM 06/29/2022 request dietary policy and procedure and food times revealed Lunch meals time begin at 12:00 Noon. No dietary policy and procedure regarding delivery was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. Residents Affected - Some The facility failed to ensure a kitchen staff changed their gloves and washed their hands after putting hand within the trash can. This failure could place residents at increased risk of exposure to food-borne illnesses. Findings included: During meal service observation 06/28/2022 at 4:30 PM, Dietary Aide was observed moving a large garbage can out of his path by placing his fingers within the inside of a garbage can used near the stove. This staff failed to change gloves or wash hands prior to walking over to a reach in refrigerator moving three pitchers consisting of water, orange juice and cranberry juice. This staff removed a case of milk cartons and placed ten milk cartons in a pan with ice, and placing the pitchers and milk carton on a cart and took to the residents on the facility halls and dining room. During an interview with Dietary Aide on 06/29/2022 at 1:40 PM, he said he was confused about when to change gloves and wash hands and did not realize he needed to change gloves or wash hands after touching the inside of the garbage can. (Dietary Aide had not completed his Safe Serve Certification training at this time) During an interview with the Dietary Manager on 06/29/2022 at 1:45 PM, she said the Dietary Aide had only been working there for about a week and undergoing training on the Safe Serve Certification and they were required to complete it within 30 days. She said he was supposed to complete it on Monday 6/27/2022 and not sure he has completed it yet. The Dietary manager said he should have removed his gloves and washed his hands before providing food service to the residents. Review of the kitchen policy and procedures dated 2020 titled, Proper Hand Hygiene: Dining Services Employees. Handwashing with soap and water is required in a Dining Services Setting in the following situations: After handling dirty dishes or trash FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 9 of 9