Health inspection·August 31, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some approximately ¼ inch long. She stated she would like them trimmed and filled, but she was unable to do it herself due to her arthritis in her hands. In an interview on 8/31/23 at 10:40 AM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. When questioned by the surveyor why she did not code the contractures to Resident #7's fingers as a limitation in ROM in her upper extremities, she stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The MDS nurse she talked to her company MDS consultant, and she stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #7's functional status was not impaired. 2. Resident #35 Review of Resident #35's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's admission MDS Assessment, dated 3/30/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Review of Resident #35's Significant Change in Status MDS Assessment, dated 4/27/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. The assessment documented the resident was receiving hospice care services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 2 of 24 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 08/31/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #35's Quarterly MDS Assessment, dated 7/27/23, he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Observation on 8/28/23 at 11:16 AM revealed Resident #5 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. In an interview on 8/31/23 at 5:40 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The LVN stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #35 could eat finger foods. 3. Resident #45 Review of Resident #45's admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system and documented contractures: flexion contractures bilateral lower extremities and left upper extremity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 3 of 24 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 08/31/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #45's Initial admission MDS Assessment, dated 12/18/22, revealed the resident required extensive assistance with 1 person assisting for transfers and bed mobility, required supervision with 1 person assisting while walking in-room, there were no functional limitations in range of motion in upper extremities or lower extremities, and mobility devices used were a walker and a wheelchair. Review of Resident #45's admission MDS Assessment, dated 1/10/23, revealed the resident required extensive assistance with 1 person assisting for transfers and extensive assistance with 2 persons assisting for bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 3/28/23, and Significant Change in Status MDS Assessment, dated 5/01/23, revealed there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 8/01/23, revealed the resident required extensive assistance with 2 persons assisting for transfers and bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. The LVN stated Section G0400 of the RAI Manual defined lower extremities as the hip, knee, ankle, and foot. The LVN stated if the limitation in Resident 45's knees did not limit her functional ability, she could not code a limitation in range of motion. She stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 4. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 4 of 24 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 08/31/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #63's admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's admission MDS Assessment, dated 9/16/22, revealed a BIMS score of 14 out of 15 (cognitively intact), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessment, dated 12/17/22, revealed a BIMS score of 11 out of 15 (moderate cognitive impairment) and he was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Significant Change in Status MDS Assessment, dated 2/07/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessments, dated 5/10/23 and 8/01/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left-hand fingers. During an interview and observation on 8/29/23 at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left-hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 5 of 24 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 08/31/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints. b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 6 of 24 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 08/31/2023 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 0641 c. Muscle wasting and atrophy; Level of Harm - Minimal harm or potential for actual harm d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or Residents Affected - Some f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 7 of 24 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 08/31/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident care plans were updated timely after completion of comprehensive assessments for 1 of 6 (Resident #38) reviewed for care plan timing and revision, in that: Resident #38's comprehensive care plan was not updated within seven days after completion of his comprehensive MDS Assessment on 6/28/2023. The facility's failure placed residents at risk of not having their needs met due to lack of direction related to care area triggers. The findings included: Record review of Resident #38 revealed a [AGE] year-old male with the following diagnosis: chronic kidney disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Vascular Dementia, Anxiety Disorders, Hypertension (high blood pressure) and constipation. Record review of Resident #38's MDS Nursing Home Comprehensive (NC) Item Set started June 14, 2023 and completed June 28, 2023 (date RN Assessment Coordinator signed assessment as complete) revealed CAA triggers for the following: 02. Cognitive Loss/Dementia 06/14/2023 04. Communication 06/14/2023 05. ADL Functional/Rehabilitation Potential 06/14/2023 06. Urinary Incontinence and Indwelling Catheter 06/14/2023 11. Falls 06/14/2023 12. Nutritional Status 06/14/2023 16 Pressure Ulcer 06/14/2023 17 Psychotropic Drug Use 06/14/2023 Record review of Resident #38's care plan revealed the following: - Cognitive Loss/Dementia, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Communication, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - ADL/Functional/Rehabilitation Potential, care plan was not updated to show it had been reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 8 of 24 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 08/31/2023 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 0657 based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. Level of Harm - Minimal harm or potential for actual harm - Urinary Incontinence and Indwelling Catheter, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. Residents Affected - Few - Falls, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Nutritional Status, no care plan for this issue found. - Pressure Ulcer, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Psychotropic Drug Use, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/17/2019. In an interview on 08/29/2023 at 2:30 PM, the DON said that care plans should be updated no later than seven days after a comprehensive MDS assessment has been completed. The DON did not know why this one was not done and offered no resident outcomes. The facility supplied three policies related to care plans and comprehensive assessments, none of which indicated the number of days after a comprehensive assessment that a care plan should be completed or updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 9 of 24 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 08/31/2023 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 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 residents received adequate care to maintain the highest practical physical and psychosocial well-being for 5 of 26 residents (Residents #7, #21, #33, #63, and #68) reviewed for ADL care, in that: Residents Affected - Some 1. The facility failed to ensure Resident #7's right hand fingernails were trimmed and filed. 2. The facility failed to ensure Resident #21's fingernails on both hands were cleaned and her toenails on both feet were filed or trimmed. 3. The facility failed to ensure Resident #33 had his fingernails on both hands trimmed and filed. 4. The facility failed to ensure Resident #63's left hand fingernails were trimmed and filed. 5. The facility failed to ensure Resident #68 had her toenails on both feet cut and filed. This failure placed residents at risk for experiencing a decreased quality of life and an increased risk for infection and injury. The findings included: 1. Resident #7 Review of Resident #7's admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: hypertension (high blood pressure); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); dysphagia (difficulty swallowing), congestive heart failure (failure of the heart to adequately pump blood to the body) and mitral valve insufficiency( failure of the mitral valve to close which causes a back flow of blood to into heart). Review of Resident #7's Annual MDS Assessment, dated 8/10/23, revealed she was independent with personal hygiene. During an observation and interview on 8/29/23 at 10:26 AM, Resident #7 was sitting up in her bed. She was noted to have contractures to the 3rd and 4th fingers of her right hand and her fingernails were ¼ inch long. The resident stated she would like to have her fingernails cut, but she could not do it herself. She stated she had asked someone to do it, but she could not recall who she asked. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. She stated the nurses were responsible to keep the Diabetics Nails cut. She stated nail care did not necessarily mean the nails were cut, just that they were clean. She stated toenails were not cut by the aides or the nurses. She stated the podiatrist cut residents toenails. Interview with CNA G revealed that CNAs should do nail care when they bathed the residents unless (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 10 of 24 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 08/31/2023 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 0677 they were diabetic, and then they were cut by the LVN. Level of Harm - Minimal harm or potential for actual harm 2. Resident #21 Residents Affected - Some Review of Resident #21's admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: Diabetes; congestive heart failure (failure of the heart to adequately pump blood to the body); pruritus (an uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues) and schizoaffective disorder (a mental disorder with cycles of improvement that may include the symptoms of delusions, hallucinations, depressed episodes, and periods of manic energy). Review of Resident #21's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she required extensive assistance of one person physically assisting for personal hygiene. In an interview and observation on 8/28/23 beginning at 11:30 AM Resident #21 was in her room. She had a visible scabbed rash that she stated covered her entire body. She stated she had seen a dermatologist and had another appointment on 8//29/23. Her toenails were unkempt and approximately 1/4 inch in length. She stated she would like them to cut. She stated she did not remember when they were last cut. Her fingernails were dirty. She stated she scratched constantly until the rash bleeds, and nobody ever offered to wash her hands before she eats. She stated she feels like the aides get irritated because she gets her nails and sheets dirty, but she can help herself. A deep brown substance was noted underneath her fingernails. Spots of old dried blood was noted on resident #7's sheets. In an interview with the ADON on 8/28/23 at 1:00 pm she stated Resident #7 scratched her skin constantly. She stated that she had been seen by a dermatologist and had another appointment was scheduled the following day. She stated Resident #21 should have nail care every shift because she constantly scratches the rash until it bleeds. She stated the nurses were responsible for cutting the nails of a diabetic resident, but an aide could clean the nails. She stated it was the LVN's responsibility to monitor to see that the resident's nails were clean. In an observation on 8/30/23 at 10:00 AM an unidentified CNA who stated she was in training was observed in Resident #21's room with a bath basin containing water cleaning and filing resident #21's nails. In an interview with the DON on 8/30/23 at 1:30 PM she stated it would be impossible to do nailcare on Resident #21 every time she got her nails dirty because she constantly scratched and made herself bleed. She stated she would purchase gloves to see if this kept the resident from making herself bleed. 3. Resident #33 Review of Resident #33's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] his diagnoses included muscle weakness, intellectual disability; full incontinence of feces; difficulty in walking; unspecified urinary incontinence. Review of Resident #33's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance of one person physically assisting for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 11 of 24 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 08/31/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 8/28/23 at 10:38 AM revealed Resident #33 was up in his wheelchair and was returning from therapy. He was transferred to his bed with extensive assistance by a therapist. The resident's nails were chipped, with sharp edges. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She observed Resident #33's nails and agreed they needed to be trimmed and filed. She stated he could injure himself with his jagged chipped nails She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. 4. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (right sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance with two persons physically assisting for personal hygiene. During an observation and interview on 8/28/23 at 10:25 AM, Resident #63 was resting on his back in bed on an air mattress with a pillow under his knees. The resident stated he did not get out of bed except for showers. During and observation and interview on 8/29/23 at 3:26 PM, Resident #63 was not able to raise his left arm and his left-hand fingers were contracted. Resident #63 stated his left-hand fingers hurt. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she had noticed Resident #63's left hand fingers were contracted, swollen, and very tender. She stated the resident had severe arthritis and he yelled out when she barely touched his finger. The Hospice RN stated Resident #63's fingernails were long, and her aides could cut and file his nails. She stated ultimately the facility was responsible for the care of the resident. During an interview and observation on 8/30/23 at 3:23 PM, Resident #63's family members were seated in chairs in the resident's room. The family stated they had come to meet with the Hospice nurse. The family stated Resident #63 had a stroke and he could not use his left side. The family stated the resident's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. Resident #63 attempted to open his left-hand fingers and he could not open or move (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 12 of 24 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 08/31/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm the small finger (digit 5) and the ring finger (digit 4). His left-hand fingernails appeared to extend an approximate ¼ inch over the tip of his fingers, and his fingers were contracted toward the palm of his left hand. 5. Resident #68 Residents Affected - Some Review of Resident #68's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] her diagnoses included: muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues). morbid obesity (weight 80 to 100 lbs. over ideal body weight); high blood pressure; age related cognitive decline; generalized weakness. Review of Resident #68's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she was independent with personal hygiene with supervision only. She had a BIMS score of 13 (cognitively intact). In an interview and observation on 08/28/23 at 10:09 AM resident #68's left foot was uncovered on her bed. Her toenails on her left foot were ¼ inch in length. She stated she would like to have them cut or filed and had asked to see the podiatrist. She stated she was able to cut them herself before she came to facility, but now she needed someone else to do it because she could not do it herself. She stated she had asked a nurse for someone to cut them, but nobody had. She did not remember who she asked, but it was when she was in a room on the other side of the building. She stated the social worker stated she would put on a list to see the podiatrist. In an interview with the social worker on 8/31/23 at 2:00 PM the social worker revealed she had placed Resident #68 on the list for the podiatrist. She stated she did not normally place any resident on the list to be seen by the podiatrist until she was sure that the resident was going to be a long-term resident. She stated when it was determined a resident was going to be long- term and remain in the facility she talked with the resident to see if they needed referrals to see a podiatrist, optometrist, dentist, etc. She stated she normally does then when she does this when she completes her section of the MDS assessment. Review of the document titled: Care of Fingernails/Toenails provided by the Administrator on 8/31/23 revealed the following [in part]: Purpose The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. General guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 13 of 24 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 08/31/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **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 entered the facility without limited range of motion did not experience a reduction in range of motion; residents with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion; and residents received appropriate services, equipment, and assistance to maintain or improve mobility for 3 of 15 residents (Residents #34, #45, and #63) who were reviewed for care and assistive devices to maintain mobility and avoid further contractures. 1. Resident #35 had contracted fingers in both hands and did not use assistive devices to prevent further contractures. 2. Resident #45 had contractures in both legs and did not use positioning devices to avoid pressure applied between her knees and protect her feet and ankles while seated in a wheelchair. 3. Resident #63 had contractures in the small finger and ring finger of his left hand and did not use an assistive device to prevent further contractures. The facility's failure placed residents at risk for developing avoidable and worsening contractures, decreased functional mobility and range of motion in extremities, and decreased feelings of well-being and quality of life. The findings included: 1. Resident #35 Review of Resident #35's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 14 of 24 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 08/31/2023 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 0688 extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Level of Harm - Minimal harm or potential for actual harm Observation on 8/28/23 at 11:16 AM revealed Resident #35 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. Residents Affected - Some In an interview on 8/31/23 at 3:01 PM, the LVN Treatment Nurse stated she did weekly skin assessments on Wednesdays. She stated she saw Resident #35 for maceration (redness and excoriation) on his buttocks. She stated the resident's fingers had been a little swollen this week. She stated he could open his fingers, but it depended what mood he was in. During an observation and interview on 8/31/23 beginning 3:16 PM, accompanied by the LVN Treatment Nurse, revealed Resident #35 was resting on his back in bed with the room light off. The resident's hands were closed in fists. The LVN donned gloves and asked Resident #35 if he could open his left hand fingers. The resident moved his left thumb and index finger and was unable to open his other left hand fingers. Resident #35 was able to open right hand thumb and was unable to open his remaining right hand fingers. Resident #35 stated his hands and fingers hurt a little. The LVN noted a red area on the inner crease of the right thumb. 2. Resident #45 Review of Resident #45's admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 15 of 24 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 08/31/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system - contractures: flexion contractures bilateral lower extremities and left upper extremity. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. During an interview and observation on 8/29/23 beginning at 1:44 PM, Resident #45 stated she could move her right leg and stated she could not move her left leg. She stated she could move left arm but could not lift it. Resident #45 stated she thought she may have had a stroke during the past. Resident #45 was seated in a wheelchair with her feet in an awkward position on the foot pedals. The resident's knees appeared contracted and touching, and her feet were at an angle toward the outer sides of the foot pedals, with the outer sides of her feet and ankles against the extension bars connected to the foot pedals. No protective padding or positioning pillows were observed between her knees or between her outer feet and wheelchair foot pedal extension bars. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 3. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 16 of 24 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 08/31/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left hand fingers. During an interview and observation on 8/29/23 beginning at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she was at the facility to evaluate Resident #63 for services per his family's request for a change in hospice agencies. The RN stated she had noticed the resident's left hand fingers were contracted, swollen, and very tender. She stated Resident #63 had severe arthritis and he yelled out when she barely touched his finger. The RN stated he would benefit from soft hand rolls. She stated ultimately the facility was responsible for the care of the resident. In an interview on 8/30/23 at 3:23 PM, Resident #63's family members stated they had come to meet with the nurse from Hospice. The family stated Resident #63 had a stroke and he could not use his left side. The family stated Resident #63 had received therapy and they did not recall the resident having a hand splint or hand roll for his left hand. The family stated Resident #63's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. They family stated they brought small balls for the resident to have in his hands and they did not know what happened to them. Resident #63 attempted to open his left hand fingers and he could not open or move the small finger and ring finger. In an interview on 8/31/23 at 3:09 PM, the LVN Treatment Nurse stated she did not know anything about Resident #63's hands. She stated she knew his hands shook and he had tremors. During an observation and interview on 8/31/23 beginning at 3:31 PM, accompanied by the LVN Treatment Nurse, revealed Resident #63 was resting in bed. His family members were seated in chairs in the room and were visiting with him. Resident #63 was unable to open his left hand small finger and ring finger. The resident's family stated the resident's left hand had been getting progressively worse since he had his stroke. The family did not recall seeing Resident #63 use a hand roll. The LVN stated a contraction device for Resident #63's hand could be ordered by the therapy department. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 17 of 24 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 08/31/2023 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 0688 Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Some 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints; b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; c. Muscle wasting and atrophy; d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 18 of 24 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 08/31/2023 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 0688 f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . Level of Harm - Minimal harm or potential for actual harm 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: Residents Affected - Some a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 19 of 24 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 08/31/2023 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 food service safety in 1 of 1 kitchen, in that: Residents Affected - Many 1. The lids to the bulk storage containers were soiled with food particles. 2. Opened gravy mix and breaded chicken patties were not stored in sealed bags. 3. The vent-a-hood was soiled with grease and the interior surface of the deep fryer unit was soiled with fried food crumbs. 4. Sanitized cooking utensils and pans were stored on hooks suspended in the air from a frame located near the ceiling air duct vents and the sanitized surfaces were not protected from contaminants in the air. 5. Knives were stored on a magnetic strip rack and in a metal box holder mounted on a wall with the sanitized knife blades exposed to the air and potential contaminants. 6. The service delivery door to the outside of the building was not kept securely closed. The facility's failure placed residents at risk for foodborne illness and a decline in health status. The findings included: Observation on 8/28/23 at 8:35 AM, during the initial tour of the facility kitchen, revealed the following: 1 - the dry food storage area had plastic bulk storage bins containing granulated sugar and flour; the lids to the bins were lightly soiled with sugar crystals, food crumbs, and flour dust; 2 - the dry food storage area had wire rack shelf units; a shelf held an open paper package of gravy mix that had been rolled closed and wrapped with plastic cellophane wrap that was not labeled and dated; the CDM removed the wrapped package from the shelf; 3 - the freezer unit contained an open cardboard box with breaded chicken patties that were in a bag that was open to the air and not securely closed; the CDM removed the box from the freezer and handed it to the Dietary Supervisor and told her to throw it away; 4 - the vent-a-hood located above the oven unit and grill was soiled with grease; 5 - the deep fryer unit was covered with a rectangular metal sheet pan; the interior surface of the deep fryer had dried fried food crumbs and was filled with dark colored cooking oil; 6 - cooking utensils and pans were hanging from hooks on a metal frame above the food preparation counter, with the sanitized food surfaces of the utensils and pans exposed to potential contaminants in the air; ceiling air duct vents were located near the metal frame; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 20 of 24 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 08/31/2023 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 7 - a magnetic knife rack was mounted to a wall with knife blades stuck to it; Level of Harm - Minimal harm or potential for actual harm 8 - a knife holder box, with knives stored blade end down inside the box, was mounted on the wall next to the magnetic knife rack. Residents Affected - Many During an observation and interview on 8/30/23 beginning at 1:27 PM, the service delivery door to the outside of the building was observed located near the Dietary Supervisor's office. The door was self-closing and self-locking and also had a deadbolt lock. The deadbolt lock had been turned, preventing the door from closing completely and leaving a small gap of space between the door and the door frame, which could allow the entrance of pests. The CDM stated she thought the staff had taken the trash out to the dumpster and had turned the deadbolt to prevent the door from locking so they could get back into the kitchen without using a key. In an interview on 8/31/23 at 3:59 PM, the CDM stated she would provide a policy for storing sanitized pans and food preparation utensils. Review of the facility's policy and procedure for Manual Warewashing, dated as revised September 2017, provided by the CDM, revealed it did not include the storage of sanitized pans and food preparation utensils. A policy and procedure for the storage of sanitized pans and utensils used for food preparation was not provided before the completion of the survey and exit from the facility on 8/31/23. The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 21 of 24 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 08/31/2023 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 (3) At least 15 cm (6 inches) above the floor. Level of Harm - Minimal harm or potential for actual harm (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: Residents Affected - Many (1) In a self-draining position that allows air drying; and (2) Covered or inverted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 22 of 24 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 08/31/2023 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 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 on 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 to help prevent the development and transmission of communicable diseases and infections for one of two residents (Resident #1) reviewed for infection control practices, in that: Residents Affected - Few CNA A failed to perform proper hand before resident contact and after glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. The findings included: Review of Resident #10's face sheet dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] whose diagnoses included: high blood pressure, kidney disease, and malnutrition. Review of Resident #1's Significant Change MDS assessment dated [DATE] revealed Resident #10 required total dependence of ADL's and she was incontinent of both bowel and bladder. Observation of incontinence care performed by CNA A and CNA B for Resident #10 on 8/29/23 at 10:30 revealed CNA A did not perform hand hygiene after entering Resident 10 s room and prior to donning gloves to begin incontinent care. CNA A removed Resident #1's brief that was soiled with urine and feces. CNA A wiped the resident from front to back. CNA A did not perform hand hygiene after changing gloves and before positioning Resident #10 on her left side and cleaning her buttocks. He changed gloves and performed hand hygiene before placing a new brief on Resident # 10. He removed his gloves and performed hand hygiene before leaving the room. In an interview on 08/29/23 at 10:45 a.m. with CNA A, he revealed he should have washed his hands before starting care and performed hand hygiene between each glove change during care. CNA A stated he had infection control training. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. He stated he was nervous and there were several knocks on the resident's door during incontinent care which cause him to become distracted. 29/23 During an interview with the DON on 8/29/23 at 1:00 PM., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand hygiene when entering the residents' room before beginning care, between glove changes and when completing care and leaving the room. and change of gloves as needed. She stated the LVN's were responsible for monitoring the aides on a shift-to-shift basis. And the ADON's performed proficiency exams on the aides when they began employment and annually. She stated she intended to start inservicing her staff immediately. Review of the facility's infection control policy titled Hand washing/Hand Hygiene, dated August 2015, reflected the following [in part]: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 23 of 24 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 08/31/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub or alternatively soap and water Before and after coming on duty, Before and after direct contact with residents and after removing gloves Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675633 If continuation sheet Page 24 of 24