Inspection·June 17, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm approaches included for Resident #1 to ambulate 100 feet using a walker for safety and for 10 sit to stands and 5 wheelchair pushups and 5 weight shifting. During an interview on 06/17/2024 at 9:44 AM, Resident #1 said she was receiving therapy to help her legs get stronger. Resident #1 said sometimes she received it and sometimes she did not. Residents Affected - Few 2. Record review of a face sheet dated 06/17/2024 indicated Resident #2 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included muscle weakness, abnormalities of gait and mobility, and reduced mobility. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was usually able to make herself understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had functional limitation in range of motion in both upper extremities and on one side on the lower extremity. The MDS assessment indicated Resident #2 was dependent with dressing, bathing, and toileting hygiene and required partial to moderate assistance with personal hygiene. The MDS assessment did not indicate Resident #2 received a restorative program. Record review of Resident #2's care plan with date initiated 06/06/2024 did not address Resident #2's restorative program. Record review of Resident #2's Order Summary Report dated 06/17/2024 did not indicate any orders for the restorative program. Record review of Resident #2's active range of motion and bed mobility Nursing Restorative Care Program plan of care with date restorative initiated 05/01/2024 for the month of June 2024 indicated goals to increase/maintain upper and lower extremity strength and range of motion one time a day or as tolerated. The approaches included 10 upper extremity range of motion 2 times, 10 bicep curls 2 times, 10 punches 2 times, 10 foot rotations 2 times, 10 knee highs 2 times, 10 side to side 2 times with assistance when needed and turn in the bed 5 times with maximum assistance to both sides. During an interview on 06/17/2024 at 5:11 PM, the DON said he was responsible for overseeing the restorative program. The DON said usually the MDS Coordinator placed the restorative care in the residents' care plans. The DON said Resident #1 and Resident #2's care plans should have their restorative program in their care plans. The DON said he assumed the MDS Coordinator had put it in Resident #1 and Resident #2's care plans. The DON said it was his responsibility to ensure the process was followed through completely for the restorative program. During an interview on 06/17/2024 at 5:38 PM, the MDS Coordinator said if he knew residents received restorative care himself or therapy added it to the resident's care plan. The MDS Coordinator said he was not aware Resident #1 and Resident #2 received restorative care. The MDS Coordinator said he was not sure if it was his responsibility to ensure the residents restorative care was included in their care plan. The MDS Coordinator said he was new to the MDS position he had only been MDS Coordinator for 3 months and he was still learning his roles. The MDS Coordinator said it was important for the residents' restorative care to be included in their care plan, so the staff were aware the resident required restorative care and provided it. Record review of the facility's policy titled, Restorative Nursing Program Guidelines, revised 06/2020, indicated, . The care plan wlll reflect the restorative needs of each resident Including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 2 of 7 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 06/17/2024 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 problems/needs, measurable goals and individualized approaches. I. The care plan for each resident will be reviewed quarterly or as needed by the Interdisciplinary Team. D. The Restorative Nurse's Aide (RNA) carries out the restorative program according to the care plan and documents daily. In addition, the RNA completes a written weekly summary for residents on a Restorative Nursing Program . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 3 of 7 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 06/17/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 2 of 4 residents (Resident #1 and Resident #2) reviewed for range of motion. The facility failed to ensure CNA A provided restorative care to Resident #1 and Resident #2 according to their Nursing Restorative Care Program plan of care. These failures could place residents at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 06/17/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, unsteadiness on feet, reduced mobility, and difficulty walking. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 did not have limitation in range of motion to her upper or lower extremity. The MDS assessment indicated Resident #1 required maximum assistance with dressing, showering, bathing self, and was dependent for toileting. The MDS assessment did not indicate Resident #1 received a restorative program. Record review of Resident #1's care plan date initiated 01/09/2024 did not address Resident #1's restorative program. Record review of Resident #1's Order Summary Report dated 06/17/2024 did not indicate any orders for the restorative program. Record review of Resident #1's Task documentation in the electronic health record on 06/17/2024 did not indicate any documentation for the nursing restorative program. Record review of Resident #1's ambulation and transfer Nursing Restorative Care Program plan of care with date restorative initiated 05/29/2024 for the month of June 2024 indicated goals to increase/maintain ability to ambulate 100 feet safely using a walker one time a day as tolerated and to increase/maintain ability to transfer to and from with minimal to moderate assistance as tolerated. The approaches included for Resident #1 to ambulate 100 feet using a walker for safety and for 10 sit to stands and 5 wheelchair pushups and 5 weight shifting. Resident #1's Nursing Restorative Care Program indicated: 06/01/2024-06/06/2024 no documentation. 06/07/2024 Resident #1 refused documented by CNA A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 4 of 7 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 06/17/2024 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 0688 06/08/2024-06/12/2024 no documentation. Level of Harm - Minimal harm or potential for actual harm 06/13/2024 and 06/14/2024 15 minutes of restorative program were provided documented by CNA A. 06/15/2024-06/16/2024 no documentation. Residents Affected - Few During an interview on 06/17/2024 at 9:44 AM, Resident #1 said she was receiving therapy to help her legs get stronger. Resident #1 said sometimes she received it and sometimes she did not. 2. Record review of a face sheet dated 06/17/2024 indicated Resident #2 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included muscle weakness, abnormalities of gait and mobility, and reduced mobility. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was usually able to make herself understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had functional limitation in range of motion in both upper extremities and on one side on the lower extremity. The MDS assessment indicated Resident #2 was dependent with dressing, bathing, and toileting hygiene and required partial to moderate assistance with personal hygiene. The MDS assessment did not indicate Resident #2 received a restorative program. Record review of Resident #2's care plan with date initiated 06/06/2024 did not address Resident #2's restorative program. Record review of Resident #2's Order Summary Report dated 06/17/2024 did not indicate any orders for the restorative program. Record review of Resident #2's Task documentation in the electronic health record on 06/17/2024 did not indicate any documentation for the nursing restorative program. Record review of Resident #2's active range of motion and bed mobility Nursing Restorative Care Program plan of care with date restorative initiated 05/01/2024 for the month of June 2024 indicated goals to increase/maintain upper and lower extremity strength and range of motion one time a day or as tolerated. The approaches included 10 upper extremity range of motion 2 times, 10 bicep curls 2 times, 10 punches 2 times, 10 foot rotations 2 times, 10 knee highs 2 times, 10 side to side 2 times with assistance when needed and turn in the bed 5 times with maximum assistance to both sides. Resident #2's Nursing Restorative Care Program indicated: 06/01/2024-06/05/2024 no documentation. 06/06/2024-06/07/2024 15 minutes of restorative program were provided documented by CNA A. 06/08/2024-06/11/2024 no documentation. 06/12/2024-06/14/2024 15 minutes of restorative program were provided documented by CNA A. 06/15/2024-06/16/2024 no documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 5 of 7 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 06/17/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/17/2024 at 10:30 AM, the DOR said the DON was responsible for overseeing the restorative program. The DOR said therapy assisted with writing the plan of care for the nursing restorative program and provided education for it. The DOR said CNA A was the restorative nurse aide. During an interview on 06/17/2024 at 1:16 PM, CNA A said she was responsible for providing the restorative exercises to the residents in the restorative program. CNA A said the DON was the one who provided oversight. CNA A said therapy wrote the orders and she followed them. CNA A said she was supposed to document when she provided restorative care to the residents, the length of time she provided it, and if they refused on the plan of care form and in the electronic health record. CNA A said she was supposed to document in the electronic health record, but some of the residents did not have an area to document it in under their tasks. CNA A said she was supposed to offer Resident #1 restorative care daily. CNA A said Resident #2's schedule was changed by the DON to three times a week instead of daily, but she was unable to recall when it was changed. CNA A said the DON should have updated the nursing restorative plan of care to three times a week when it was changed, but she did not know why it was not updated. CNA A said if she was weighing residents or was having to work the floor she was not offering restorative care to the residents. CNA A said she had not been offering Resident #1 to perform the restorative care daily. CNA A said she had missed Resident #2's restorative care as well. CNA A said when she had to weigh residents, she forgets about the restorative care. CNA A said if it was not documented on the sheet she did not offer or complete the restorative care. CNA A said it was important for the residents to receive restorative care, so the residents did not decline. During an interview on 06/17/2024 at 1:24 PM, Resident #2's family member said Resident #2 had not been receiving restorative care daily. Resident #2 said she had been having issues with CNA A not providing restorative care and had notified the Administrator, and the Administrator said it would be changed to Wednesday, Thursday, and Friday. Resident #2's family member said prior to notifying the Administrator she had notified the DON, but he had not addressed the issue. Resident #2's family member said the DON had told her the restorative care was not completed because CNA was on vacation or because CNA A was weighing the other residents. During an interview on 06/17/2024 at 2:28 PM, the DOR said the frequency of one time a day as tolerated on the restorative plan of care indicated the restorative care should be offered daily to the residents. The DOR said the purpose of the restorative care program was to maintain the resident's function. The DOR said if the restorative care program was not being done the residents could have a decline in function. During an interview on 06/17/2024 at 5:11 PM, the DON said he was responsible for overseeing the restorative program. The DON said the therapy team assisted with writing the restorative plan of care, then he looked at it and signed it. The DON said he was not aware the restorative program was not being followed properly. The DON said he had glanced at the book in the past but he was not reviewing it on a routine basis. The DON said he randomly reviewed the restorative program logs. The DON said he was not sure how frequently he should be reviewing the restorative program logs to ensure the restorative care was being provided, but he believed the policy said on a regular interval. The DON said he assumed the MDS Coordinator was adding the restorative care to the resident's electronic health record for the CNAs to document in the electronic health record. The DON said any CNA could complete restorative care with the residents. The DON said Resident #2's restorative plan of care did not need to be updated to reflect she was to receive restorative care on Wednesday, Thursday, and Friday because he believed the one-time day covered it. The DON said it was important for restorative care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 6 of 7 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 06/17/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be provided to the residents to continue with strength training, keep up with the level of strength the residents had built up, and to minimize loss of ability. During an interview on 06/17/2024 at 5:38 PM, the MDS Coordinator said if he knew residents received restorative care himself or therapy added it to the resident's care plan. The MDS Coordinator said he was not aware Resident #1 and Resident #2 received restorative care. The MDS Coordinator said he was not sure if it was his responsibility to ensure the residents restorative care was included in their care plan. The MDS Coordinator said he was new to the MDS position he had only been MDS Coordinator for 3 months and he was still learning his roles. The MDS Coordinator said it was important to ensure the residents received restorative care so their strength would be maintained. During an interview on 06/17/2024 at 5:46 PM, the Administrator said the DON was responsible for the restorative program. The Administrator said she expected for the DON to know what the policy required for the restorative program and the necessary systems to have in place to ensure it was being provided to the residents. The Administrator said she expected the DON to monitor the restorative program according to the policy. The Administrator said it was important for restorative care to be provided to the residents to maintain their functional abilities and prevent the residents decline. Record review of the facility's policy titled, Restorative Nursing Program Guidelines, revised 06/2020, indicated, Purpose The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning .II. The Director of Nursing Services (DNS), or their designee, manages and directs the Restorative Nursing Program. Licensed rehabilitation professionals, (physical therapists, occupational therapists, and speech therapists) provide ongoing consultation and education for the Restorative Nursing Program . Documentation A Restorative program developed by therapy will be completed on paper and the facility wlll enter RNP In PCC as appropriate B. The documentation will be done in Point Click Care (PCC) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675664 If continuation sheet Page 7 of 7