Inspection·July 14, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. LVN L stated new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 2 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 skin problems or discoloration should have been reported to physician as soon as it was noticed. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. Residents Affected - Few During an interview on 07/12/23 at 1:44 PM, the DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 3 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 Level of Harm - Immediate jeopardy to resident health or safety 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. Residents Affected - Few During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: 1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm 2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm 3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 4 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 7-12-23 1:45pm Level of Harm - Immediate jeopardy to resident health or safety 4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. Residents Affected - Few 5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM 6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm 7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. 8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services. 9. Incident Report ADON LVN 7-12-23 at 6:42pm Self-Report Completed 7-12-23 by the Administrator 3:21PM 10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm Include actions that were performed toa address to citation: 7-13-23 11:00am 1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm 2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm 3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm 4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties. 5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant 6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 5 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 Level of Harm - Immediate jeopardy to resident health or safety 7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. 8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. Residents Affected - Few 9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm. 10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. 11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. 12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. 13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. 14. Team members will receive required training prior to their shifted. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director. Involvement of QAPI An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy. On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 6 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 Record review of the following documents, dated 07/12/23, were as follows: Level of Harm - Immediate jeopardy to resident health or safety 1. The SBAR was completed. Residents Affected - Few 3. The incident report was completed, and the physician, family, DON, and Administrator were notified. 2. A physician progress note was completed and addressed Resident #4's bruising. 4. New orders were obtained for labs. 5. The trauma assessment was completed. 6. The pain assessment was completed. 7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician. 8. The therapy screen was completed. 9. The provider investigation report was completed. 10. The skin assessments were reviewed for all residents in the facility. 11. Skin sweeps were reviewed and completed for all residents in the facility. 12. Safe surveys for residents and staff were reviewed with no problems identified. 13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 7 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 8 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #9 and #129) reviewed for Medicare/Medicaid coverage. Residents Affected - Few The facility failed to ensure Resident #9 and #129 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #9's face sheet, dated 07/12/2023, indicated Resident #9 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and heart failure ((chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #9's annual MDS assessment, dated 04/26/2023, indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 was moderately cognitively impaired with a BIMS score of 12. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #9 was receiving Medicare Part A services starting on 04/19/2023 and the last covered day of Part A services was 05/08/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #9 of the option to continue services at the risk of out-of-pocket. 2. Record review of Resident #129's face sheet, dated 07/12/2023, indicated Resident #129 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included CKD (gradual loss of kidney function over time), dysphagia (difficulty swallowing), and atrial fibrillation (irregular, often rapid heart rate). Record review of Resident #129's admission MDS assessment, dated 12/06/2022, indicated Resident #129 understood others and usually made herself understood. The assessment indicated Resident #129 was severely cognitively impaired with a BIMS score of 4. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #129 was receiving Medicare Part A services starting on 12/02/2022 and the last covered day of Part A services was 01/02/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #129 of the option to continue services at the risk of out-of-pocket. During an interview on 07/14/2023 at 12:00 p.m., the Administrator stated the previous social worker was responsible for ensuring Resident #9 and #129 were issued a SNF ABN. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 9 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated there was not an effective plan in place to ensure the forms were completed. The Administrator stated it was important for the resident to receive the form just in case they wanted to appeal, and they would know they had days remaining on their benefit. The Administrator stated there was no negative outcome for not receiving a SNF ABN form prior to covered days being exhausted. Record review of the facility's' policy titled, NOMNC & ABN's dated 4/20/2023 indicated, .the social service department was responsible for completing and issuing these forms to the resident and/or family to be signed Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 10 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 provide a safe, clean, and comfortable environment for 5 of 19 residents (Resident #16, Resident #19, Resident #21, Resident #40, and Resident #75) reviewed for environment. The facility failed to repair deep scrapes that exposed the sheetrock on the wall behind the head of the bed and on the wall next to the bed for Resident #16, Resident #19, Resident #21, and Resident #40. The facility failed to ensure Resident #75's bed linens were changed. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 07/14/2023 indicated Resident #16 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, without behavioral (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), unspecified, and cerebral infarction, unspecified (damage to tissues in the brain due to a loss of oxygen to the area). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #16 had a short and long-term memory problem. The MDS assessment indicated Resident #16's ability to make decisions regarding tasks of daily life was severely impaired (never/rarely made decisions). During an observation and attempted interview on 07/10/2023 at 10:09 AM, Resident #16 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. During an observation on 07/11/2023 at 09:01 AM, Resident #16 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. 2. Record review of a face sheet dated 07/11/2023 indicated Resident #19 was an [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease, unspecified (progressive disease that destroys memory and other important mental functions), anxiety disorders unspecified (mental illness defined by feelings of uneasiness, worry and fear), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #19 was usually understood and understood others. The MDS assessment indicated Resident #19's BIMS was 0, which indicated severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 11 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 During an observation and attempted interview on 07/10/2023 at 10:03 AM, Resident #19 was non-interviewable, and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. During an observation on 07/11/2023 at 08:56 AM, Resident #19 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. 3. Record review of a face sheet dated 07/11/2023, indicated Resident #21 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential (primary) hypertension (high blood pressure), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #21 was rarely/never understood and rarely/never understood others. The MDS assessment indicated Resident #21 had a short and long-term memory problem. The MDS assessment indicated Resident #21's ability to make decisions regarding tasks of daily life was severely impaired (never/rarely made decisions). During an observation and attempted interview on 07/10/2023 at 09:52 AM, Resident #21 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. During an observation on 07/11/2023 at 08:54 AM, Resident #21 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. 4. Record review of a face sheet dated 07/11/2023, indicated Resident #40 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cerebral infarction, unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #40 was sometimes understood and understood others. The MDS assessment indicated Resident #40's BIMS was 0, which indicated severe cognitive impairment. During an observation and attempted interview on 07/10/2023 at 9:50 AM, Resident #40 was non-interviewable and there were scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. During an observation on 07/11/2023 at 08:52 AM, Resident #40 had scrapes that exposed the sheet rock on the wall behind the head of the bed and on the wall beside the bed. 5. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 12 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 required supervision for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of the care plan with date initiated of 07/05/2023, indicated Resident #75 had an ADL self-care deficit and required set up staff participation to use the toilet, for transfers, bathing, dressing, and eating, and 1 staff participation to reposition and turn for bed mobility. During an observation on 07/10/2023 at 10:15 AM, Resident #75 had several dark yellowish stains at the foot of the bed on his sheet and a reddish stain on his sheet towards the center of the bed. Resident #75 said he was not sure if his sheets had been changed. During an observation and interview on 07/11/2023 at 5:11 PM, Resident #75 had had several dark yellowish stains at the foot of the bed on his sheet and a reddish stain on his sheet towards the center of the bed. Resident #75 said he was not aware the staff was supposed to be changing his sheets because he was just there for therapy and would be leaving soon. Resident #75 said it would be nice for the sheets to be changed and to have clean sheets. Resident #75 said the reddish stain was probably blood. During an observation and interview on 07/12/2023 at 10:59 AM, LVN A observed the damaged walls in Resident #16, Resident #19, Resident #21, and Resident #40's rooms. LVN A said she had verbally reported the damaged walls to the Maintenance Supervisor for him to repair them. LVN A said it was important for damages to the residents' rooms to be fixed because the facility was the residents' home, and it should look neat. LVN A observed Resident #75's sheet with the multiple dark yellowish stains and reddish stain and said the sheets should have been changed by the CNAs. LVN A said the residents bed linens should be changed daily by at least every shift and as needed. LVN A said the CNAs were responsible for changing the residents' bed linens. LVN A said it was important for the residents' bed linens to be changed for them to have a clean environment and she did not want them to have dirty sheets. During an observation and interview on 07/12/2023 11:08 AM, the Maintenance Supervisor observed the damaged walls in Resident #16, Resident #19, Resident #21, and Resident #40's rooms. The Maintenance Supervisor said he was aware of the damaged walls to Resident #19, Resident #21, and Resident #40's rooms, but he was not aware of the damaged walls to Resident #16's room. The Maintenance Supervisor said the staff notified him verbally of rooms needing repair, and they could also record it on the maintenance log. The Maintenance Supervisor said he was working on getting the rooms repaired. The Maintenance Supervisor said it was important for the residents' rooms to be free of damages for the residents' dignity and everyone wants a good-looking room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 13 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 During an interview on 07/13/2023 at 8:24 AM, the ADON said the residents' bed linens were supposed to be changed on their shower days. The ADON said the CNAs and the nurses were responsible for changing the residents' bed linens. The ADON said there was currently not a system in place for monitoring to ensure the CNAs changed the residents' bed linens. The ADON said it was important for Resident #75's bed linens to be closed because he had wounds and port and they could get infected. The ADON said it was important for the residents' linens to be changed for good hygiene and because it made the residents feel better when they got in a clean bed. The ADON said the facility did ambassador rounds that management was assigned to certain rooms and were supposed to be looking at the rooms to ensure they were clean, and damages repaired. The ADON said she did not know who was assigned to Resident #16, Resident #19, Resident #21, and Resident #40's rooms. The ADON said the Maintenance Supervisor was responsible for making sure the residents' rooms were repaired. The ADON said it was important for the residents' rooms to be repaired and not have damaged walls so the residents could have a homelike environment, for them to feel better about their home and for visitors to see the residents' home in good repairs. During an interview on 07/13/2023 at 09:04 AM the DON said all the staff should be making sure the residents' rooms did not have damages. The DON said if the staff noticed damages to a resident's room, they should report it to the Maintenance Supervisor. The DON said it was important for the residents' rooms to be free of damages for them to have a homelike environment. The DON said the residents having damaged walls could make them feel uncomfortable. The DON said the residents bed linens should be changed on their shower days and as needed. The DON said anybody could change the residents bed linens, but generally the CNAs on the hall were the ones responsible for changing the bed linens. The DON said it was important for the residents to have clean bed linens to make them feel comfortable. During an interview on 07/13/2023 at 1:42 PM, CNA C said the CNAs should be changing the residents' sheets on shower days or if they were soiled. CNA C said she was not responsible for changing Resident #75's sheets on his bed. CNA C said CNA D was responsible for changing Resident #75's sheets on his beds. During an interview on 07/13/2023 at 2:04 PM, CNA D said the sheets on the residents' beds should be changed on their shower days or if they were dirty. CNA D said she was not assigned to care for Resident #75. CNA D said according to the schedule for the day CNA C was responsible for providing care to Resident #75, and she should have changed Resident #75's bed linens. CNA D said it was important for the residents to have clean linens on their beds because of infection, and she did not want anybody to lay down in dirty sheets. During an interview on 7/13/2023 at 2:20 PM, the Administrator said the staff doing daily rounds should report to the Maintenance Supervisor damages to the residents' rooms. The Administrator said the Maintenance Supervisor was responsible for ensuring the residents' rooms were in good repairs. The Administrator said he expected for the Maintenance Supervisor to repair damages to the residents' rooms. The Administrator said the Maintenance Supervisor tried to get to the rooms as he could to fix them. The Administrator said it was important for the residents' rooms to be fixed to make it as much of a homelike environment for them. The Administrator said he wanted to the residents to have a safe and pleasant home. The Administrator said the CNAs were supposed to change the residents bed linens if they were soiled, and the nursing staff was responsible for making sure they did this. The Administrator said he expected the CNAs to change the residents' bed linens. The Administrator said it was important for the residents' bed linens to be changed for their hygiene and for infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 14 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's document titled, Maintenance Log, dated from 11/16/22 to 07/11/23, indicated an entry dated 6/12 (no year indicated), Room No. 209 paint walls and floor reported and initialed by the Dietary Manager. room [ROOM NUMBER] was Resident #21 and Resident #40s room. Record review of the Maintenance Log did not indicate entries related to Resident #16's and Resident #19's rooms. Record review of the facility's policy titled, Resident Rooms and Environment, last revised 08/2020, indicated, Purpose To provide residents with a safe, clean, comfortable and homelike environment. Policy The Facility provides residents with a safe, clean, comfortable, and homelike environment . Event ID: Facility ID: 675664 If continuation sheet Page 15 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement written policies that prohibit and prevent abuse, neglect, and exploitation for 1 of 19 (Resident #4) residents reviewed for abuse and neglect. Residents Affected - Few The facility did not implement their abuse and neglect policy and procedure when the staff did not report Resident #4's bruises of unknown source to the abuse coordinator. This failure could place the residents at increased risk for abuse and neglect. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 16 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0607 Level of Harm - Minimal harm or potential for actual harm During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. Residents Affected - Few During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working there but had come and gone in the same area. LVN L was unable to say if the discoloration were the same ones or were in the same area. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician and the abuse coordinator. During an interview on 07/12/23 at 1:44 PM, the DON stated she expected all skin integrity issues to be documented, which included bruising or areas of discoloration. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week and was unsure how the bruising occurred. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated increased bruising should have been reported to the abuse coordinator if the origin was unknown. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which has aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding and increased bruising and bleeding because she was taking a blood thinning medication. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 17 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated bruising of unknown origin should have been reported to the physician and the abuse coordinator. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. During an interview on 07/14/23 at 12:04 PM, the Administrator stated he expected staff to report injuries of unknown origin to him, as the abuse coordinator. The Administrator stated he was ensuring staff were following abuse and neglect policies by frequent in-servicing and questioning staff and residents during walking rounds. The Administrator stated it was important to follow abuse and neglect policies to ensure residents remained free of abuse and neglect. Record review of the Abuse Prevention and Prohibition Program, revised on 10/23/22, revealed VII. Special Considerations for Investigation of Injuries of Unknown Origin (Unexplained Injuries) A. Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure that resident safety is not compromised, and action is taken whenever possible, to avoid future occurrences. B. If a resident is observed with unexplained injuries, the Charge Nurse on duty will complete AP - 31 - Form A - Incident & Accident Report Form, or a substantively similar form, and record such information into the resident's medical record. C. Documentation must include information relevant to risk factors and conditions that causes or predisposes someone to similar signs and symptoms (e.g., receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement). i. Any descriptions in the medical record must be objective and sufficiently detailed (e.g., size and location of bruises), and should not speculate about causes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 18 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 19 residents (Resident #4) reviewed for abuse and neglect. The facility did not ensure facility staff reported bruising of unknown origin for Resident #4 to the abuse coordinator (Administrator). This failure could place the residents at increased risk for abuse and neglect. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 19 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working there but had come and gone in the same area. LVN L was unable to say if the discoloration were the same ones or were in the same area. LVN L stated injuries of unknown source should have been reported to the physician, family, and abuse coordinator as soon as it was noticed. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician and the abuse coordinator. During an interview on 07/12/23 at 1:44 PM, the DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week and was unsure how the bruising occurred. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated bruising of an unknown source should have been reported to the abuse coordinator as soon as it was noticed. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which has aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding and increased bruising and bleeding because she was taking a blood thinning medication. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 20 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated bruising of unknown origin should have been reported to the physician and the abuse coordinator. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. During an interview on 07/14/23 at 12:04 PM, the Administrator stated he expected staff to report injuries of unknown origin to him, as the abuse coordinator. The Administrator stated he was ensuring staff were following abuse and neglect policies by frequent in-servicing and questioning staff and residents during walking rounds. The Administrator stated it was important to follow abuse and neglect policies to ensure residents remained free of abuse and neglect. Record review of the Abuse Prevention and Prohibition Program, revised on 10/23/22, revealed VII. Special Considerations for Investigation of Injuries of Unknown Origin (Unexplained Injuries) A. Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure that resident safety is not compromised, and action is taken whenever possible, to avoid future occurrences. B. If a resident is observed with unexplained injuries, the Charge Nurse on duty will complete AP - 31 - Form A - Incident & Accident Report Form, or a substantively similar form, and record such information into the resident's medical record. C. Documentation must include information relevant to risk factors and conditions that causes or predisposes someone to similar signs and symptoms (e.g., receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement). i. Any descriptions in the medical record must be objective and sufficiently detailed (e.g., size and location of bruises), and should not speculate about causes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 21 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #75) reviewed for baseline care plans. The facility failed to ensure Resident #75 had a baseline care plan completed within 48 hours of admission This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Record review of the Baseline Plan of Care-V2 indicated an admission date of 06/30/2022 and it was signed completed on 06/26/2023 by LVN A. Record review of another Baseline Plan of Care-V2 indicated an admission date of 06/30/2022 and it was signed completed on 07/03/2023 by LVN A. During an interview on 07/12/2023 at 11:02 AM, LVN A said the baseline care plan should be completed within 24 hours after admission. LVN A said the baseline care plan signed completed 06/26/2023 corresponded to Resident #75's initial admission date of 06/22/2023. LVN A said it was completed late. LVN A said the baseline care plan signed completed on 07/03/2023 corresponded to the admission date of 06/30/2023, and it was note completed on time. LVN A said she did not know why she had completed Resident #75's baseline care plans late. LVN A said it was important to complete the baseline care plan within 24 hours after admission, so the CNAs knew what the residents required for their care and the level of assistance they needed. During an interview on 07/13/2023 at 8:32 AM, the ADON said the baseline care plan was supposed to be completed by the nurse on admission, if the admitting nurse was not able to complete it, the next shift nurse was responsible for completing it. The ADON said the DON and herself tried to make sure the nurses were completing the baseline care plans timely. The ADON said the baseline care plans should be completed by the next day after admission. The ADON said Resident #75's baseline care plan for his admission on [DATE] was completed on 06/26/2023, which indicated it was 3 days late. The ADON said Resident #75's baseline care plan for his admission on [DATE] was completed on 07/03/2023, which indicated it was completed 3 days late. The ADON said she did not know why Resident #75's baseline care plans were completed late. The ADON said it was important to complete the baseline care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 22 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0655 on time because it let the staff know what the residents needed and how to take care of the residents Level of Harm - Minimal harm or potential for actual harm During an interview on 07/13/2023 at 9:09 AM, the DON said the baseline care plan should be completed 72 hours after admission. The DON said the charge nurses were responsible for completing the baseline care plans. The DON said she monitored the completion of the baseline care plans. The DON said it was important for the baseline care plan to be completed timely, so that the staff knew how to accurately take care of the residents. Regarding Resident #75's baseline care plans the DON said the nurses had 72 hours to complete them. Residents Affected - Few During an interview on 07/13/2023 at 2:22 PM, the Administrator said the Social Worker, DON, and MDS Coordinator worked together to ensure the baseline care plan was completed timely. The Administrator said the baseline care plan should be completed within 48 hours of admission. The Administrator said he expected the residents' baseline care plans to be completed within 48 hours of admission. The Administrator said it was important for the baseline care plans to be completed timely, so the staff would know how to take care of the residents. Record review of the facility's policy titled, Care Planning, last revised October 24, 2022, indicated, . The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 23 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 13 residents reviewed for care plans. (Resident #4) The facility did not implement Resident #4's care plan related to anticoagulant therapy. This failure could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . The interventions further included: Antidote is Vitamin K. Have on hand for emergencies.; Labs as ordered. Report abnormal lab results to the MD. Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 24 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented, however the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration comes and goes frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication.LVN L stated the facility staff was aware of Resident #4's skin status because it has been discussed several times, especially regarding transfers. LVN L stated the discoloration had been present since she started working there but had come and gone in the same area. LVN L stated if Resident #4's care plan stated to monitor, document, and report bruising, it should have been monitored, documented, and reported. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated residents who took a blood thinning medication should have been moitored for bruising per the care plan. During an interview on 07/12/23 at 1:44 PM, the DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, following the care plan, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 25 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on per the care plan. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. During an interview on 07/14/23 at 12:04 PM, the Administrator stated bruising was normal for a resident who was taking a blood thinning medication. The Administrator stated he expected clinical staff to monitor for signs of bleeding, which included bruising, and report any changes to the physician. The Administrator stated the nursing management was responsible for monitoring clinical staff. The Administrator stated it was important to ensure residents taking a blood thinning medication were monitored and adequately assessed to ensure residents received the care they required as outlined on their care plan. Record review of the Inservice Schedule, undated, revealed no in-service training was scheduled regarding anticoagulant monitoring and following the plan of care. Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 26 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0656 Record review of the Care Planning policy, revised 10/24/22, did not address implementation of the care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 27 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 19 residents (Resident #75) reviewed for care plan timing and revision. The facility failed to ensure Resident #75 was invited to participate in the development and review of his care plan. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 required supervision for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #75's care plan with a date initiated of 06/26/2023, did not address inviting Resident #75 to participate in the development and reviewing of his care plan. During an interview on 07/10/2023 at 10:50 AM, Resident #75 said he had not had a care plan meeting with the IDT. Resident #75 said the facility staff had not discussed his care plan with him or provided him his care plan. During an interview on 07/12/2023 at 2:17 PM, the Social Worker said she was responsible for setting up the care plan meetings. The Social Worker said when the care plan meeting took place, the information was entered into the electronic health record under the assessment tabs as an assessment form. The Social Worker said care plan meetings were done with the 48-hour care plan for new admissions, quarterly, and as needed. The Social Worker said she was not sure if a care plan meeting had been done with Resident #75 that she would have to ask the DON. Record review of Resident #75's electronic health record on 07/12/2023 did not reveal a care plan meeting had been completed. During an interview on 07/13/2023 at 8:24 AM, the ADON said the Social Worker was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 28 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 setting up the care plan meetings. The ADON said care plan meetings took place upon admission and quarterly, but she was unsure how long after admission the care plan meeting was done. The ADON said after having a care plan meeting it was entered as a care plan conference form in the assessments in the electronic health record. The ADON checked Resident #75's electronic health record and did not find a care plan conference assessment for Resident #75. The ADON said that she recalled there had not been a care plan meeting with Resident #75. The ADON said it was important to have care plan meetings with the resident and/or resident representative so the facility could adjust their plan of care to the residents' needs. During an interview on 07/13/2023 at 9:11 AM, the DON said care plan meetings were scheduled by the Social Worker. The DON said for the care plan meetings the IDT team gathered along with the resident and family to discuss the plan of care and discharge planning, if applicable. The DON said the care plan meeting was documented in the electronic health record as a care plan assessment. The DON said she did not recall if they had a care plan meeting for Resident #75. The DON said it was important to have care plan meetings with the residents, so the staff knew how to accurately care for the residents and the residents' preferences. During an interview on 07/13/2023 at 2:24 PM, the Administrator said the Social Worker was responsible for setting up the care plan meetings. The Administrator said he expected the residents to have care plan meetings. The Administrator said the initial care plan meeting was done within 48 hours of admission for newly admitted residents. The Administrator said it was important for the care plan meetings to be done with the residents so the staff knew if the residents may have special needs and to make sure all the residents' needs were met. During an interview on 07/14/2023 at 10:02 AM, the Social Worker said it was important for the care plan meetings to be done because the facility needed to establish the plan of care and the goals for the residents. The Social Worker said she did not know why the care plan meeting with Resident #75 was not done. Record review of the facility's policy titled, Care Planning, last revised October 24, 2022, indicated, . Resident Rights- Care Planning A. The resident has a right to be informed, in advance, of changes to the plan of care. B. The resident has the right to receive the services and/or items included in the plan of care. C. The resident has the right to see the care plan, including the right to sign after significant changes are made to the plan of care. IV. IDT Meetings A. The Facility will invite the resident, if capable, and their family to care planning meetings . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 29 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 13 (Resident #4) residents reviewed for quality of care. Residents Affected - Few 1. The facility failed to intervene when Resident #4, who was taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), had increased bruising, which indicated a change of condition. 2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessments. An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk for adverse reactions while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 30 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Level of Harm - Immediate jeopardy to resident health or safety Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Residents Affected - Few Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. Record review of the Weekly Wound Progress, dated 07/12/23, revealed scabbing to toes that measured pinpoint; multiple areas or discoloration to left leg below that knee that measured scattered; discoloration to bottom of right foot 5th toe that measured 2.5 cm x 1.5 cm; linear scratch to left front of shoulder that measured 3.5 cm x 0.1 cm; dicoloration to right upper arm that measured 6 cm x 5.5 cm; discoloration to left anterior leg above the knee that measured 16 cm x 18.5 cm; disocloration to right anterior leg above the knee with scabbing that measured 11.5 cm x 9 cm; discoloration to right front shoulder that measured 4 cm x 3 cm; discoloration to back of left hand that measured 2 cm x 3 cm. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L said she was unable to call the discoloration a bruise because bruising was usually blue, green, or reddish-purple and the discoloration on Resident #4 was reddish burgundy. LVN L stated when she completed the weekly skin assessments, she was only documenting skin impairments on the form. LVN L stated skin impairments were areas on the skin that required a treatment. LVN L stated she did not document areas on the skin that did not require a treatment, such as bruising. LVN L stated she was asked by the DON to reopen her skin assessment and document a complete head to toe assessment because the state agency wanted them to. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 31 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated if Resident #4 had a history of discoloration and skin problems that should have been addressed on the care plan. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. During an interview on 07/12/23 at 1:44 PM, the DON stated the treatment nurse was responsible for ensuring weekly skin assessments were completed. The DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated she did not ask the treatment nurse to reopen her skin assessment. The DON stated it was a miscommunication because she thought it was requested by the state agency. The DON stated a one-on-one in-service on accurately completing and documented skin assessments was given to the treatment nurse on 07/12/23 and prior to that she was provided training by the ADON on how to perform skin assessments when she was hired at the facility. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON stated Resident #4 should have had a care plan in place to address recurrent bruising. The DON was unsure why Resident #4 did not have a care plan in place to address recurrent bruising. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for increased bruising, especially if a resident was taking a blood thinning medication. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 32 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. Residents Affected - Few Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 33 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising. The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: 1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm 2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm 3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm 4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. 5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM 6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm 7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. 8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services. 9. Incident Report ADON LVN 7-12-23 at 6:42pm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 34 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Self-Report Completed 7-12-23 by the Administrator 3:21PM Level of Harm - Immediate jeopardy to resident health or safety 10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm Residents Affected - Few Include actions that were performed toa address to citation: 7-13-23 11:00am 1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm 2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm 3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm 4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties. 5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant 6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. 7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. 8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. 9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm. 10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. 11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 35 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. 13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. 14. Team members will receive required training prior to their shifted. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director. Involvement of QAPI An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy. On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the following documents, dated 07/12/23, were as follows: 1. The SBAR was completed. 2. A physician progress note was completed and addressed Resident #4's bruising. 3. The incident report was completed, and the physician, family, DON, and Administrator were notified. 4. New orders were obtained for labs. 5. The trauma assessment was completed. 6. The pain assessment was completed. 7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician. 8. The therapy screen was completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 36 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 9. The provider investigation report was completed. Level of Harm - Immediate jeopardy to resident health or safety 10. The skin assessments were reviewed for all residents in the facility. Residents Affected - Few 12. Safe surveys for residents and staff were reviewed with no problems identified. 11. Skin sweeps were reviewed and completed for all residents in the facility. 13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 37 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #54 and Resident #75) reviewed for respiratory care. Residents Affected - Few 1. The facility did not ensure Resident #54 had a physician's order for oxygen that she wore continuously. 2. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #75. These failures could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: 1. Record review of the face sheet, dated 07/11/2023, revealed Resident #54 was an [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood), shortness of breath, and COPD - chronic obstructive respiratory disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the MDS assessment, dated 06/27/2023, revealed Resident #54 had clear speech and was usually understood by staff. The MDS revealed Resident #54 was usually able to understand others. The MDS revealed Resident #54 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #54 had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat. The MDS revealed Resident #54 received oxygen while a resident at the facility during the 14-day look-back period. Record review of the comprehensive care plan, revised on 04/11/2023, revealed Resident #54 had a diagnosis of COPD. The interventions included Give oxygen therapy as ordered by the physician. Record review of the order summary report, dated 07/12/2023, revealed Resident #54 had no physician order for oxygen. During an observation and interview on 07/10/2023 at 9:09 AM, Resident #54 was sitting up in her bed with the head of the bed elevated. She was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. Resident #54 stated she had worn oxygen continuously, since she admitted to the facility, because she had problems breathing. Resident #54 stated the facility staff change her oxygen tubing weekly and checked her oxygen saturations daily. During an observation on 07/10/2023 at 2:18 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. During an observation on 07/11/2023 at 9:33 AM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 38 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 07/11/2023 at 4:25 PM, Resident #54 was wearing a nasal cannula with the oxygen concentrator on and set at 4 liters per minute. During an interview on 07/13/2023 at 2:03 PM, LVN E stated Resident #54 wore oxygen continuously. LVN E stated the charge nurses were responsible for putting orders for oxygen in the electronic charting system. LVN E stated Resident #54 should have a physician's order for oxygen. LVN E stated the order probably did not get put back on when she came back from the hospital. LVN E stated the nurses try to check each other when residents readmit from the hospital. LVN E stated it was important to ensure Resident #54 had a physician's order for oxygen because you need a doctor's order for it. During an interview on 07/13/2023 at 3:43 PM, the DON stated nurses were responsible for ensuring physician orders for oxygen were in the computer. The DON stated that was monitored by reconciling with the physician and performing 24-72-hour chart audits and admissions and readmission. The DON stated Resident #54 should have a physician's order for oxygen. The DON stated she expected nursing staff to ensure a physician's order for oxygen was placed in the electronic monitoring system. The DON stated it was important to ensure an order for oxygen was placed in the computer for the safety and well-being of residents and to follow the plan of care. During an interview on 07/14/2023 at 12:04 PM, the Administrator stated he expected the nursing staff to ensure an order for oxygen was placed in the computer. The Administrator stated the DON and ADON were responsible for monitoring orders during the clinical morning meeting. The Administrator stated it was important to ensure orders were placed in the computer to ensure the facility staff are following all physician's orders and provide treatment that was required. 2. Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), acute respiratory failure with hypoxia (not enough oxygen in blood), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was an 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident #75 was receiving oxygen therapy. Record review of Resident #75's care plan with date initiated 07/11/2023, indicated he had altered respiratory status/difficulty breathing related to a pulmonary nodule (small growth in the lungs that can be non-cancerous or cancerous) with an intervention to provide oxygen as ordered. Record review of Resident #75's order summary report dated 07/11/2023, indicated an order to check oxygen saturation three times a day, as needed, and every shift, and apply oxygen at 2 liters per minute via nasal canula for oxygen saturation less than 90% with a start date of 06/30/2023. During an observation on 07/10/2023 at 11:02 AM, Resident #75 was sitting on the side of the bed with oxygen on via nasal canula at 4 liters per minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 39 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 07/12/2023 at 9:05 AM, Resident #75 was in bed with oxygen via nasal canula on, set between 3-4 liter per minute. During an interview on 07/12/2023 at 5:48 PM, RN B said oxygen should be administered per the physician's orders. RN B said Resident #75's oxygen should have been set at 2 liter per minute per the physician's order, and he only used it as needed. RN B said setting the oxygen higher than the prescribed rate could make the residents sicker. During an interview on 07/13/2023 at 9:01 AM, the ADON said the nurses were responsible for making sure oxygen was administered per the physician's order. The ADON said the nurses should be checking the oxygen to make sure it was set at the correct prescription. The ADON said if the oxygen was set higher than the prescribed rate it could be counterproductive for certain diseases and could cause more harm than good. During an interview on 07/13/2023 at 10:40 AM, the DON said the nurses were responsible for ensuring oxygen was administered per the physician's order. The DON said Resident #75's oxygen via nasal canula was as needed, and he could put it on himself when he felt short of breath. The DON said setting the oxygen higher than the physician's order could cause lightheadedness and dizziness. During an interview on 07/13/2023 at 2:34 PM, the Administrator said the charge nurses were responsible for making sure oxygen was administered per the physician's order. The Administrator said he expected the nurses to follow the physicians' orders. The Administrator said it was important that oxygen be administered per the physician's order to avoid respiratory distress. Record review of the facility's policy titled, Oxygen Administration, with date revised 06/2020, indicated, . Initiation of oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: i. Oxygen flow rate ii. Method of administration (e.g., nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication of use . Explain the procedure to the resident II. Check the physician's order . VI. Turn on oxygen at the prescribed rate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 40 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #75) reviewed for dialysis. Residents Affected - Few The facility failed to have physician's orders for the care of Resident #75's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access). The facility failed to care plan Resident #75's central venous catheter used for dialysis. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (chronic condition that affects the way the body processes blood sugar with progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #75 was usually understood and usually understood others. The MDS assessment indicated Resident #75's BIMS was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #75 received dialysis while a resident at the facility. Record review of Resident #75's care plan with date initiated 06/26/2023 did not indicate his central venous catheter was care planned. Record review of Resident #75's order summary report dated 07/11/2023 did not indicate physician orders for his central venous catheter. During an observation and interview on 07/10/2023 at 10:15 AM, Resident #75 was in his bed central venous catheter observed to right chest, dressing was not adhered from the bottom, and it had brownish-tinged spots on it. Resident #75 said he was going to dialysis later that day. During an interview on 07/12/2023 at 3:34 PM, Dialysis RN G said the Resident #75 should have orders to monitor the central venous catheter due to the risk of infection. Dialysis RN G said if the central venous catheter dressing was not completely adhered the facility needed to contact the dialysis clinic for further instructions. During an interview on 07/12/2023 at 6:28 PM, LVN A said she was aware Resident #75 had a central (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 41 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few venous catheter to his right chest and it was used for his dialysis. LVN A said she had not noticed on 07/10/2023 that his dressing was soiled and not completely adhered. LVN A said she had been checking Resident #75's catheter. LVN A said she was not aware Resident #75 did not have physician orders for his central venous catheter. LVN A said the admitting nurse should have obtained physician orders for the central venous catheter. LVN A said it was important for Resident #75 to have physician orders for his central venous catheter because of the risk of infection. During an interview on 07/13/2023 at 8:45 AM, the ADON said on admission the nurse was supposed to call the doctor to get orders for Resident #75's central venous catheter used for dialysis. The ADON said she was not sure why Resident #75 did not have physician orders for his central venous catheter. The ADON said Resident #75's central venous catheter should have been care planned. The ADON said the MDS Coordinator should have care planned Resident #75's central venous catheter. The ADON said it was important to have physician orders for the central venous catheter for prevention of infection and to prevent dislodgment. The ADON said it was important for Resident #75's central venous catheter to be included in his care plan, so that everybody knew it was there and how staff should take care of it. During an interview on 07/13/2023 at 9:16 AM, the DON said Resident #75 should have had orders for his central venous catheter to monitor for signs and symptoms of infection and for dressing changes. The DON said the physician orders should have been obtained on admission. The DON said it was important to have orders for the central venous catheter because of the risk of infection. The DON said Resident #75's central venous catheter should have been included in his care plan. The DON said the MDS Coordinator was responsible for including Resident #75's central venous catheter in the care plan. The DON said it was important for Resident #75's central venous catheter to be included in the care plan for the staff to know how to care for the central venous catheter. During an interview on 07/13/2023 at 2:28 PM, the Administrator said the charge nurses were responsible for obtaining physician orders for a central venous catheter. The Administrator said the DON and ADON should make sure the central venous catheter was included in the care plan. The Administrator said he expected the nurses to obtain physician orders for the care of a central venous catheter, and he expected for the care plan to include a central venous catheter. The Administrator said it was important to have physician orders and care plan a central venous catheter to appropriately care for the residents and because of the risk of infection. During an interview on 07/13/2023 at 3:58 PM, the MDS Coordinator said a central venous catheter used for dialysis should be included in the resident's care plan. The MDS Coordinator said she was responsible for including a central venous catheter in the care plan. The MDS Coordinator said Resident #75's central venous catheter was not included in his care plan because he had no physician orders for the central venous catheter. The MDS Coordinator said when she created the residents care plans, she used the MDS assessment and the physician orders. The MDS Coordinator said it was important for Resident #75's central venous catheter to be included in his care plan because the staff needed to monitor the site, perform dressing changes, and monitor for signs and symptoms of infection. Record review of the facility's policy titled, Dialysis Care, last revised 06/2020, indicated, .The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment . The Licensed Nurse will monitor the integrity of the catheter dressing every shift and reinforce the dressing with tape as needed . The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 42 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 13 residents reviewed (Resident #4) for anticoagulant monitoring and skin assessments. 1. The facility did not ensure the physician orders for anticoagulant monitoring on Resident #4 were adequately followed, when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots). 2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessment's resulting in no documentation of Resident #4's bruising. These failures could place residents at an increased risk for bleeding, bruising, and not receiving the care and services to meet their individual needs. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 43 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0726 Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. Level of Harm - Minimal harm or potential for actual harm Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. Residents Affected - Few Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L said she was unable to call the discoloration a bruise because bruising is usually blue, green, or reddish-purple and the discoloration on Resident #4 was reddish burgundy. LVN L stated when she completed the weekly skin assessments, she was only documenting skin impairments on the form. LVN L stated a skin impairment was areas on the skin that required a treatment. LVN L stated she did not document areas on the skin that did not require a treatment, such as bruising. LVN L stated she was asked by the DON to reopen her skin assessment and document a complete head to toe assessment because the state agency wanted them to. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration comes and goes frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff was aware of Resident #4's skin status because it has been discussed several times, especially regarding transfers. LVN L stated the discoloration had been present since she started working there but had come and gone in the same area. LVN L was unable to say if the discoloration were the same ones or were in the same area. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. During an interview on 07/12/23 at 1:44 PM, the DON stated the treatment nurse was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 44 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ensuring weekly skin assessments were completed. The DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated she did not ask the treatment nurse to reopen her skin assessment. The DON stated it was a miscommunication because she thought it was requested by the state agency. The DON stated a one-on-one in-service on accurately completing and documented skin assessments was given to the treatment nurse on 07/12/23 and prior to that she was provided training by the ADON on how to perform skin assessments when she was hired at the facility. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for increased bruising, especially if a resident was taking a blood thinning medication. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 45 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0726 would want to be aware. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/13/23 at 2:18 PM, LVN L stated she had been trained and checked off on skin assessments. LVN L said the last check off, before the one-on-one in-service provided 07/12/23, was during the mock survey performed by the corporate staff in the earlier part of the year. LVN L stated she had been trained on monitoring for residents taking a blood thinning medication and change of condition. LVN L stated bruising was normal for residents taking a blood thinning medication. LVN L stated the smallest touch to a resident taking a blood thinning medication could have left a bruise. LVN L stated when monitoring resident's taking a blood thinning medication, bruising should have been documented and reported. LVN L stated it was important to perform complete skin assessments to monitor skin problems and address any new skin issues. Residents Affected - Few During an interview on 07/13/23 at 3:43 PM, the DON stated anticoagulant monitoring training was upon hire while going over orders in the electronic charting system. The DON stated what to monitor for was learned in nursing school and all nurses should have been aware. The DON stated adequately monitoring residents that took a blood thinning medication was important for the safety and wellbeing of the residents. During an interview on 07/14/23 at 12:04 PM, the Administrator stated bruising was normal for a resident who was taking a blood thinning medication. The Administrator stated he expected clinical staff to monitor for signs of bleeding, which included bruising, and report any changes to the physician. The Administrator stated the nursing management was responsible for monitoring clinical staff. The Administrator stated it was important to ensure residents taking a blood thinning medication were monitored and adequately assessed to ensure residents received the care they required. Record review of the Inservice Schedule, undated, revealed no in-service training was scheduled regarding skin assessments or anticoagulant monitoring. Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising. Record review of the Care Standards policy, revised 06/2020, revealed I. The Director of Nursing Services (DON) ensures care and services are delivered according to accepted standards of clinical practice. Unless specifically addressed in an individual facility policy, the Facility defers to the accepted national standards of clinical practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 46 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #68) reviewed for hospice services. The facility did not ensure Resident #68's hospice records were a part of their records in the facility This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets can lead to muscle loss, fat loss, and your body not working as it usually would), cerebral infarction unspecified (damage to tissues in the brain due to a loss of oxygen to the area), and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. The MDS assessment indicated Resident #68 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #68 received hospice services while a resident at the facility. Record review of the care plan with date initiated 03/21/2023, indicated Resident #68 had a terminal prognosis related to severe protein calorie malnutrition with a goal of dignity and autonomy will be maintained at the highest level through the review date. Interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Record review of the order summary report dated 07/11/2023 indicated Resident #68 had an order to admit to hospice under the diagnosis of severe protein calorie malnutrition with start date of 03/10/2023. Record review of Resident #68's electronic health record did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) hospice medication information; (e) hospice physician orders; and (f) any progress notes from any hospice visits. During an interview on 07/12/2023 at 9:39 AM, LVN E said the residents hospice records were kept in a binder at the nurse's station. LVN E said Resident #68 did not have a binder with her hospice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 47 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 0849 records in it. LVN E said she would call the hospice to have them bring the hospice records to the facility. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/12/2023 9:43 AM, Hospice RN F said she was Resident #68's hospice case manager. Hospice RN F said she thought she had sent them by e-mail to someone at the facility, but she must have sent it to the wrong email (she was unable to specify to who she had sent them). Hospice RN F said the facility had not requested that she take Resident #68's hospice records to the facility. Hospice RN F said she should have made sure the hospice records were taken to the facility. Hospice RN F said it was important for the facility to have the hospice records so the staff could refer to them and reference back to the nurses' visits, aide visits, the medication list and have the hospice diagnosis and hospice orders. Residents Affected - Few During an interview on 07/13/2023 at 08:56 AM, the ADON said the resident's hospice records were kept in a hospice binder. The ADON said the nurses should be making sure the hospice records were in the facility. The ADON said that she was aware there was no system in placed to ensure the hospice records were in the facility. The ADON said she was not aware Resident #68's hospice records were not in the facility. The ADON said it was important for the hospice records to be in the facility to make sure the care was matching, the medications were correct, the facility knew of the hospice scheduled visits, and to ensure any new orders given by the hospice were implemented. During an interview on 07/13/2023 at 10:02 AM, the DON said the hospice residents had hospice binders containing all the hospice records. The DON said the charge nurses were responsible for making sure the hospice records were in the facility. The DON said she did not know why Resident #68's hospice records were not in the facility. The DON said it was important for the residents' hospice records to be in the facility to be able to work in collaboration with the hospice and so all the staff would be on the same page with the residents' plan of care. During an interview on 07/13/2023 at 1:54 PM, LVN A said the residents' hospice records were kept in binders. LVN A said she did not know who was responsible for making sure the residents' hospice records were in the facility. LVN A said she had not noticed Resident #68 did not have a hospice binder with her hospice records. LVN A said it was important to have the residents' hospice records, so the facility staff knew what was going on and the hospice staff knew what was going on. During an interview on 07/13/2023 at 2:32 PM, the Administrator said nursing management was responsible for making sure the residents hospice records were in the facility. The Administrator said the nurses should have requested the hospice records from the hospice provider. The Administrator said it was important for the facility to have the residents' hospice records for coordination of care. Record review of the Hospice and Long Term Care Facility Agreement, with an effective date of September 20, 2021, indicated, . Each Party shall allow reasonable access to the records of the other party in order to carry out their respective rights, duties, and obligations under this agreement. Insofar as Plans of Care, clinical records notes, meeting minutes IDG/IDT records, orders, reassessments and updates to the Plans of Care and similar documents have been integrated by Hospice and Provider, each party shall retain a copy of such records . Record review of the facility's Nursing Policy and Procedure, Palliative Care, with an effective date of 05/2017, did not address obtaining the residents hospice records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 48 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 staff (NA H) reviewed for infection control. Residents Affected - Few The facility did not ensure NA H performed hand hygiene while providing incontinent care to Resident #26. The facility did not ensure NA H cleaned Resident #26 peri-anal area before placing a clean brief underneath her. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 07/11/2023 at 1:50 p.m., NA H and CNA K provided incontinent care to Resident #26. NA H and CNA K performed hand hygiene and put on gloves. NA H unfastened Resident #26's brief. NA H cleaned Resident #26's front peri area. NA H removed her gloves and put on new gloves without performing hand hygiene. NA H rolled Resident #26 to the left side, removed the soiled brief, and placed a clean brief underneath her. NA H removed her gloves, performed hand hygiene, and put on new gloves. NA H cleaned Resident #26's peri-anal area. NA H removed her gloves, performed hand hygiene, and put on new gloves. NA H and CNA K finished incontinent care. During a telephone interview on 07/12/2023 at 4:07 p.m., NA H stated she should have sanitizer her hands between glove changes. NA H stated she should have cleaned her buttocks first before placing the new brief under Resident #26. NA H stated she had been checked off for incontinent care. NA H stated she knew the correct way to provide care but got nervous when others she was not comfortable with watched. NA H stated it was important to perform hand hygiene while providing incontinent care and cleaning the peri-area first before placing a new brief under Resident #26 to prevent cross contamination and an infection. During a telephone interview on 07/12/2023 at 4:17 p.m., CNA K stated NA H should have sanitized her hands between gloves changes. CNA K stated NA H should have cleaned the peri-area first before putting the clean brief under Resident #26. CNA K stated the failure could cause a UTI or skin breakdown. During an interview on 07/13/2023 at 2:58 p.m., the ADON stated she was responsible for making sure the CNAs provided proper incontinent care. The ADON stated she monitored the CNAs to ensure they were providing proper incontinent care by performing yearly and as needed competencies. The ADON stated hand hygiene should be performed anytime they moved from dirty to clean gloves. The ADON stated the dirty brief should be left under the resident, folded over until the back peri area has been wiped and cleaned, then the clean brief should be placed on resident. The ADON said it was important to provide prompt incontinent care to prevent skin breakdown. The ADON stated not performing hand hygiene and not ensuring the resident is cleaned prior to placing the clean brief on the resident placed the resident at risk for infection and cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 49 of 50 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 675664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482 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 Residents Affected - Few During an interview on 07/13/2023 at 3:08 p.m., the DON stated the CNAs should performed hand hygiene between glove changes. The DON stated proficiencies for the CNAs on incontinent care were performed yearly, quarterly and PRN by the ADON. The DON stated a clean brief should not be placed under a soiled buttock. The DON stated she randomly went into rooms to observe the CNAs provide incontinent care. The DON stated she has not observed NA H providing incontinent care. The DON stated it was important to provide prompt and proper incontinent care to prevent infections and skin breakdown. During an interview on 07/14/2023 at 12:00 p.m., the Administrator stated he expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator stated the ADON/DON or designee should make sure the CNAs were providing proper incontinent care. The Administrator stated a clean brief should not be placed under a soiled buttock. The Administrator stated it was important to provide proper incontinent care and to perform hand hygiene to reduce the risk of infection. Record review of the facility's policy titled, Perineal Care, last revised 06/2020, indicated to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. VII. Turn resident to side, VIII. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area. IX. Remove wet linen. X. Place dry linens or brief or both underneath resident . Record review of the facility's policy titled, Hand Hygiene, last revised 06/2020, indicated, to ensure that all individuals use appropriate hand hygiene while at the facility . III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors VI. Hand hygiene is always the final step after removing and disposing of personal protective equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 50 of 50