Health inspection·November 29, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the enteral pump IV poles that are being used are cleaned occasionally by night shift and she is not sure how often they are supposed to be cleaned. She stated that she cannot recall the last time Resident #1, # 48, and #68 ' s enteral pump IV pole was cleaned and if it was left dirty for too long it can attract dust. Interview on 11/29/23 at 03:41 pm with LVN O revealed that the DME was cleaned by the nurses and it was done once a shift and/or if it becomes soiled. She could not recall the last time the enteral pump IV poles were cleaned; she was not sure why they were not cleaned. She stated that if it was not cleaned it could be an infection control issue for the residents. Interview on 11/29/23 at 5:23 pm with the DON revealed that the nurses were responsible to make sure that the DME was clean and in good working condition. She stated that the enteral pump IV poles were DME and should be cleaned each night shift when the feeding formula and feeding accessories were changed out. She stated it was her expectation, and she had identified today (11/29/23), that it had not been done and there had been no monitoring to ensure it was done. She stated if it was not done it could pose a risk of cross contamination to the resident. Record review of the facility's Cleaning and Disinfection of Resident-Care items and equipment, Policy Statement: Resident care equipment, including re-usable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogen standard . Record review of the facility's Cleaning and Disinfection of Environmental Surfaces policy, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendation for disinfection of healthcare facilities and the OSHA bloodborne pathogens standard .6. A one step process and an EPA-registered hospital disinfectant designed for housekeeping purposes will be used in resident care areas where; uncertainty exists about the nature of the soil or surfaces (e.g., blood or body fluid contamination versus routine dust or dirt .9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 2 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 record review, observations, and interviews, the facility failed to review and revise care plan after each assessment for one (Residents #12) of six residents reviewed for care plans. The facility failed to complete/revise Residents #12's care plan as being a smoker. This failure could place residents at risk of not receiving individualized care, which could result in a decline and function and mental well- being. Findings included: Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed a 53- year- old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment), used a wheelchair with no impaired upper and lower extremities, independent with most ADL care, and occasionally incontinent to bowel and bladder, with 2 or more falls with no injury. Record review of Resident #12's Order Summary Report dated 11/29/23 revealed she took medications for migraines, anxiety, pain, nausea vomiting, depression, schizoaffective (Mood Disorder) disorder, active bladder. Record review of Resident #12's Care plan dated 11/29/23 by MDS C revealed, At risk for injury due to smoking preference .dated initiated and created (Today) 11/29/23 .will not suffer injury related to unsafe smoking practices through the next review period .Educate on risk of smoking and hazards .follow smoking times designated .smoking safety ability and provide appropriate interventions .may or may not use smoking apron during facility smoke times .noted as a safe smoker. Record review of Resident #12's Smoking Safety Evaluation dated 10/27/23 revealed she was a safe smoker . Interviews on 11/29/23 at 1:44 pm, CNA E stated Resident #12 was a smoker that was independent and was able to smoke unsupervised. She stated care plans were used to look at the residents progress to see if any changes had to be made about how they were cared for . Interview on 11/29/23 at 2:09 pm, Medication Aide F stated the resident's Care Plans were used for each resident to know what they were allowed to do or not and what was needed to reach their goals. Interview on 11/29/23 at 3:29 pm, CNA H stated the resident's care plan showed them how to care for the resident, for example, if they can walk or not . Interview on 11/29/23 at 3:44 pm, MDS Coordinator C stated this facility had a comprehensive approach to assessing the residents who smoked. She stated SW I completed the smokers' care plans. She stated that she believed Resident #12 was a smoker and had a smoke assessment on 10/27/23. She stated she was considered a safe smoker and had a care plan for falls but not for being a smoker. She stated she did not see Resident #12's care plan for being a smoker and would do it right now. because she did not know she was a smoker. She stated in Resident #12's care plan there was no mention of her being a smoker and added if care plans were not accurate, the resident may not get the right type of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 3 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 care. She stated they had a binder in place with all of the smokers in it and said she needed to go to the Administrator to review the binder to ensure it was updated so that the resident's care plans were accurate. Interview on 11/29/23 at 4:17 pm, SW I stated care plans were used to guide them on how to best care for the resident. She stated the MDS Coordinator was responsible for completing the care plans and after reviewing Resident #12 EMR she stated Resident #12 had a new smoking care plan added today (11/29/23). She stated from this day forward she would start reviewing the smoker's list and to update the smoker's assessment. She stated they had a care plan meeting with herself, with the ADON, and Rehabilitation Director, but the MDS Coordinator was not in the meeting and should be. Interview on 11/29/23 at 6:22 pm, Former DON A stated Resident #12 was a smoker and she should have had a care plan that said she was. The former DON A said he was not aware she did not have a smoking care plan . Interview on 11/29/23 at 6:48 pm, the Administrator stated they had clinical meetings regularly and that was also when MDS Coordinators updated about the smokers evaluations and care plans. He stated he was surprised about the lack of communication between the department heads and was not sure why MDS Coordinator C did not attend the care plan meetings. He stated Resident #12 was a smoker and she should have a care plan. The administrator added that the care plans were to provide the correct treatment and precautions in the least restrictive environment and instructed the staff on how to care for the resident. He stated if the residents care plan or smoke assessments were wrong it could cause the resident harm, resident could fall, or cigarette butts could fall on the resident. He stated SW I was responsible for giving the info to MDS Coordinator C so that she could input the data and create a care plan. He stated his expectations for care plans were for them to be completed and done in a timely and accurate manner. He stated for a change in condition, the nurse notified SW I for a care plan meeting, and a new smoke evaluation needed to be completed. He stated his plan to prevent this from happening again was to ensure all documentation from admission to discharge were in all of their records and accurate. Record review of the facility's Smoking Policy revised 10/2022 revealed, Safe smoking environment: It is the responsibility of the facility to provide a safe and hazard free working environment for those residents having been assessed as being safe, for facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility's smoking policies through verbal mean, distribution and posting. This policy is intended to minimize the risks to: residents who smoke, including possible adverse effects on treatment, passive smoke and fire . Record review of the Facility's Care plans policy reviewed on [DATE] revealed, Policy Statement: A comprehensive, person-center care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 4 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Residents #20 and Resident #69) reviewed for accidents and hazards, in that: 1. The facility failed to ensure an accurate smoking assessment on Resident #20 was completed and followed. 2. The facility failed to ensure Resident #69's wheelchair was safe for him to use. These failures could place residents that use assistive devices and smoke, at risk of accidents, resulting in a decline in their physical condition, and injury. The findings were: 1. Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with highly impaired vision (object identification in question, but eyes appear to follow objects) .BIMS score was a 15 (no cognitive impairment) and needed extensive assist for transfers and locomotion off unit, occasionally incontinent with bowel and bladder, Alzheimer's, lack of coordination, difficulty walking, legal blindness, two or more falls with no injury and one fall with injury that was not major, taken antipsychotic, hypnotic, antidepressant, and opioid medications . Record review of Resident #20's Order Summary Report dated 11/29/23 revealed Resident #20 took medications for diagnoses osteoporosis (weak bones), schizoaffective disorder (mood disorder), bipolar, chronic obstructive pulmonary disease (negative deviation of organism structure) .taking, carisoprodol, Depakote, lorazepam, losartan, metformin, quetiapine, temazepam, and Tylenol with codeine. Record review of Resident #20's Care Plan dated 08/23/23 by MDS C revealed, Resident is at risk for injury due to smoking preference and requires supervision during smoking hours (date initiated 08/22/23) .Goal: resident will not smoke without supervision .will not suffer injury related to unsafe smoking practices through next review period .interventions: educate resident on the risks of smoking and hazards .may wear smoking apron as needed during designated smoking hours to prevent any injury . Record review of an incident/accident report dated 07/21/23 at 2:00 pm, The resident went outside for a smoke break. Was found minutes later lying prone position on the sidewalk with her wheelchair within reach by the CNA D. Resident stated that she slipped out of her wheelchair and is ok with no pain. Superficial abrasions found on left knee, left elbow, and left forearm .Alert and oriented X4, resident was taken back to her room by wheelchair, .all wounds cleaned and dressed, resident went to bed . Observation and interview on 11/29/23 at 1:23 pm revealed, Resident #20 was outside enclosed gazebo with CNA D present within 1 foot from Resident #20. Resident #20 was sitting in her wheelchair appropriately positioned and smoking a cigarette in her hand, but the resident did not have on a smoke (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 5 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apron. The CNA immediately jumped up and grabbed the Resident's smoke apron behind her wheelchair and put it on the resident. CNA D stated they had just come out and Resident #20 asked for her cigarette, she forgot to put it on her, and knew it was needed to prevent Resident #20 from getting burned. She stated she was told Resident #20 needed the smoke apron on due to her falling three months ago. Record review of Resident #20's Smoking Safety Evaluation dated 08/15/23 by Former DON A revealed, Mobility (range in motion) no limits for upper and lower body .Summary of evaluation: Unsupervised .Resident is deemed a safe smoker facility guidelines reviewed with resident . Interview on 11/29/23 at 1:25 pm, Resident #20 stated said she forgot to have her smoke apron put on and knew she needed it because ½ of her wardrobe had burn marks on them. Interview on 11/29/23 at 1:44 pm, CNA E stated Resident #20 used to be a safe smoker but about two or three months ago, Resident #20 was outside smoking, she fell asleep, and she fell out of wheelchair. She stated Resident #20 had a few scrapes on her arm and added they came up with a plan for staff to go out with her for her smoke breaks. She stated Resident #20's cognition was good at times and other times it was not. She stated mainly the CNA's took her out to smoke and at times the nurses did and her cigarettes and lighter were kept locked up in the nurses medication cart. Interview on 11/29/23 at 2:09 pm, Medication Aide F stated since she started working here in July 2023, Resident #20 smoked cigarettes and staff took her out to smoke. She stated Resident there had not been any issues since July 2023 with her smoking. She stated the resident's Care Plans were used for each resident to know what they were allowed to do or not and what was needed to reach their goals. Interview on 11/29/23 at 2:41 pm, CNA G stated Resident #20 was a smoker and she heard she fell outside a few months ago because she got drowsy and since then they took her out to smoke every 2 hours. She stated Resident #20 had to wear a smoke apron while she smoked to ensure her ashes did not fall on her. She stated the facility kept her cigarettes and lighter and used a sign in sheet on who took her out to smoke. Interview on 11/29/23 at 3:29 pm, CNA H stated Resident #20 was a smoker who did not go out unsupervised because one time she was smoking and some of the ashes fell on her clothes. She stated nursing staff took her out some months ago and she fell outside during the 6:00 am-2:00 pm shift in June or July 2023 while smoking. She stated since then they had to put an apron on her to keep the ashes from burning her Interview on 11/29/23 at 3:44 pm, MDS C stated this facility had a comprehensive approach to assessing the residents who smoked. She stated SW I completed the smoke assessments and smokers' care plans. She stated Resident #20 was a smoker with a history of falling because she liked to do alot of stuff for herself and tried to be independent. She stated she was not aware of her having any falls due to being drowsy, or issues with burning herself, and added she did not attend the resident's care plan meetings SW I conducted. She stated Resident #20 had supervised smoke breaks and she had to wear an apron as well. She stated the Corporate RN or the DON were responsible for ensuring the MDS Assessments were accurate and had not done a significant change for Resident #20 due to her falling and having to have supervised smoke breaks. Resident #20 fell a few months ago and ended up with abrasions to her left knee/elbow and forearm. She stated Resident #20 had a BIMS score of 15 and said she was compulsive and very independent. She stated Resident #20 had a lot of interventions educating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 6 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her and ensuring she was supervised while in the courtyard. She stated SW I or the Activities Director did the residents' smoking care plan on 08/18/22 and the Corporate RN did Resident #20's 08/15/23 smoke assessment. She stated she was not sure why Resident #20's smoke assessment showed she was a safe smoker and deemed safe because she needed assistance with getting around. She stated Resident #20's smoking assessment was not an accurate assessment and when smoking assessments were not accurate it could cause harm to the resident. She stated Resident #20 had a care plan in her EMR showing she was a smoker, who needed staff supervision every two hours to smoke, and needed to wear a smoke apron. She stated they had a binder in place with all of the smoker's in it and would go to the Administrator to review the binder to ensure it was updated so that the resident's evaluations were accurate. Interview on 11/29/23 at 4:17 pm, SW I stated Former DON A did the smoking assessments, but she stopped working here two months ago and the floor nurses usually did them since then. She stated she knew Resident #20's smoking assessment was way past due and needed to be done because her vision was not good, she dozed off at times, and this could cause a problem. She stated she was aware Resident #20 fell in July 2023 while outside smoking and in October 2023 Resident #20 was not a safe smoker after it was discussed. She stated she was not aware that Resident #20 dropped ashes on herself. She stated she did all of the resident's smoke assessments and said to prevent that from happening again she needed to check the nurses notes and then assess the residents. She stated she should have done Resident #20's smoke assessment and thought she had done it. She said when she went to the computer, she was shocked to see Resident #20's smoke assessment showed she was safe. She stated if a resident's assessment was not accurate it made the residents at risk of catching themselves on fire, or the grass, or the building. Interview on 11/29/23 at 6:22 pm, Former DON A stated Resident #20 has had multiple falls and was deemed unsafe, after she fell a few months ago. He stated Resident #20 was unsafe and was not sure why the smoke assessment on Resident #20 said she was safe to smoke and maybe it was an oversight orwas just an error. He stated he could not deem her safe after she fell outside smoking and added a resident could fall or get injured if the resident assessments were inaccurate. He stated the MDS Coordinator went to some of the care plan meetings and could not recall if the MDS Coordinator C was made aware of the resident smokers. Interview on 11/29/23 at 6:48 pm, the Administrator stated he was not aware that Resident #20's smoke evaluation was not consistent. He stated they had department head morning meetings to determine she was not safe to smoke because she could not take herself outside and because of her vision being bad. He stated he was not aware of Resident #20 smoking without her smoke apron until it was brought to his attention today (11/29/23). He stated she fell this past summer and believed her smoke evaluation was accurately showing she was a unsafe smoker and said definitely someone made a mistake. He stated they had clinical meetings regularly and that was also when MDS Coordinators updated about the smokers evaluations and care plans. He stated he was surprised about the lack of communication between his department heads and was not sure why MDS Coordinator C did not attend the care plan meetings. He stated Resident #20 was the only unsafe smoker they had. He stated the smoke assessments were completed to decide whether or not the residents were safe to smoke or safe to smoke unsupervised. He stated if the residents care plan or smoke assessments were wrong it could cause resident harm, fall, or cigarette butts could fall on the resident. He stated the new DON was responsible for doing the smoke assessments and prior to her there was confusion on if the SW or the MDS Coordinator C did them. He stated in July 2023 after Resident #20 fell, the SW should have done the smoke assessment and added SW I was responsible for giving the info to MDS Coordinator C so that she could input the data and create a care plan. He stated his expectations for smoke evaluations were for them to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 7 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complete and done in a timely and accurate manner. He stated for a change in condition, the nurse would notify SW I for a care plan meeting and a new smoke evaluation needed to be completed. He stated his plan to prevent this from happening again was to ensure all documentation from admission to discharge in all of their records are accurate. Record review of the facility's Smoking Policy revised 10/2022 revealed, Safe smoking environment: It is the responsibility of the facility to provide a safe and hazard free working environment for those residents having been assessed as being safe, for facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility's smoking policies through verbal mean, distribution, and posting. This policy is intended to minimize the risks to: residents who smoke, including possible adverse effects on treatment, passive smoke and fire .Smoking Evaluation: Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely . 2. Observation on 11/27/23 at 10:15 am revealed Resident #69 was sitting in his wheelchair watching tv in his room. Stretch gauze tape was observed on the right side of the chair frame above the backrest. The backrest was mashed down about 3 inches below the mounting point. The left side of the wheelchair did not have tape on the arm, but the backrest was torn and mashed down about three inches below the mounting point. Observation on 11/28/23 at 10:40 am, Resident #69 was observed in the resident council meeting sitting in the broken wheelchair. Observation on 11/29/23 at 3:30pm Resident #69 was observed sitting in his room watching television sitting in the broken wheelchair. In an interview on 11/27/2023 at 11:20 am, Resident #69 stated his chair had been torn. He stated he had been asking for a week or more for someone to look at the chair. He stated that he told someone named [NAME]. He stated that he guessed he was too big, broke the chair, and it bothered his back. In an interview on 11/28/23 at 2:46 p.m. Interim Maintenance Director stated he was responsible for some repairs to the wheelchairs. He stated staff were to place the needed repairs in the maintenance log. He stated that the previous Maintenance director left before he came and left everything in a mess. He stated that paperwork was missing, they didn ' t know what work had been completed, what had been requested. The only information he had was the requests in the maintenance book. He stated resident could be harmed or injured by damaged or faulty equipment. He stated he officially starts on 12/01/2023. He stated that he will handle most of the requests around the facility and things he cant handle will be done by contractors. He stated the he makes daily rounds to and fixes things as he encounters them with or with out a work order. Interview on 11/29/2023 at 4:00 pm with the DON revealed that she was unaware that resident ' s #69 wheelchair needed repairs. She looked in the systems and found no orders for repairs to resident #69 ' s chair. While discussing the needed repairs she put an order for the Doctor to review the chair. She stated that she thought that was the resident ' s personal chair. Record review of facility ' s Maintenance log reflected no there were no entries that indicated Resident #69 wheelchair needed any repairs in the last 5 months. The maintenance director is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 8 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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 0689 Level of Harm - Minimal harm or potential for actual harm responsible for repairs to wheelchairs. Staff have a log to enter Maintenance requests. The Maintenance Director checks the log daily. He state the he is aware the broken or damaged equipment could harm or injure a resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 9 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen for food storage. Residents Affected - Many The facility failed to: 1. date, label, and seal food items in the dry storage area of the facility's kitchen. 2. [NAME] J, Dietary Aide K and Maintenance Director washed their hands and put on hair restraints prior to entering or directly after entering the kitchen. 3. keep the kitchen clean and sanitary and free from dirt and food debris and well maintained equipment and exit barrier. These failures could affect residents by placing them at risk of cross contamination and food-borne illness which could cause gastro-intestinal illnesses and increase in pests. Findings included: Observation on 11/29/23 at 11:04 am of the facility's kitchen revealed: -Two 32 ounce bags of clear unlabeled Spaghetti noodles were opened with no open on date . -1 very large 64 ounce bag of clear unlabeled spiral noodles were opened without a received and open on date . -1 very large 64 ounce bag of clear unlabeled Spaghetti noodles were opened with no received and open on date . -1 large white 25 pound bag of Dry black beans was opened with no open on date . -1 32 ounce bag of Mexican seasoning with a received date of 09/28 and no open on date . -1 Small bag of gravy with a receive date 11/18 and brownie mix received date 11/04 were both open and had no open dates . -There was a 15 ounce bag of clear unlabeled cake mix and 10 ounce bag of clear unlabeled corn flakes dated 11/04 without open dates . -There was one 20 ounce bag clear unlabeled of cheerios with a receive date of 10/25 . -There was a large clear bag of clear unlabeled rice crispies dated 11/14 . - 1 Gallon bottle of liquid browning seasoning had 7 dried up brown rings inside of it and dried up sauce was all around the top of the bottle and it did not have an open date . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 10 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -The flooring in the dry pantry room had a torn piece of cardboard, paper and pieces of debris and there were several areas of blackish colored dirt on each side of the entrance of the storage room . Level of Harm - Minimal harm or potential for actual harm -1 white foot pedal trash can had a greasy layer of film on it and the sink had a greasy dusty texture on it. Residents Affected - Many -There was dried brownish stained splash marks on the counter next to the tea maker, -2 white wooden planks holding up the food steam had 2 inches of blackish discoloration on them . -Inside of the utility room in the kitchen, a yellow mop bucket had dried brownish blackish stains around the sides of it and a small amount of brownish water in it .the floor mop sink was covered with dried blackish and browns .the floor had several layers of dried blackish dirt around the base board and a paper towel was on the floor and there was several areas of the door frame had brownish rust stains on it . -The flooring next to the large, grey and metal ice machine in the kitchen had very large dried whitish stains. -The black swing top trash can had a lot of whitish and brownish dried food and drink stains on it. -The small greyish ice machine on the countertop of the dining room with leaking water from the dispenser into a tray that was full and the grey tray had brownish and whitish splash stains on it . -The south door of the dining had sunlight shining through a large size hole approximately 3 inches in diameter at the bottom corner of the door .and next to the door the base board and door frame had broken blackish particles which appeared crumbled. Interview on 11/27/23 at 11:25 am, the Dietary Director stated she was not sure why these food items identified in the storage room did not have opened on dates and was not sure when they needed to be used by. She stated the staff knew better and she would do an Inservice training today (11/27/23) to make sure everyone labeled the food items properly. She stated when food items was not labeled correctly she was not sure how it could affect the residents. She stated her expectations was for the kitchen staff to put the received and open on dates on all food items opened and rotate them on the shelf. Interview and Observation on 11/27/23 at 11:30 am, [NAME] J walked into the kitchen without a hairnet or face mask on and she did not wash her hands. She walked straight to the supply room on the other side from the sink and to where the residents cups were stored. She stated she had just started her shift and was going to put her purse up then put a hairnet and face mask on and wash her hands. Interview and observation on 11/27/23 at 11:33 am, Dietary Aide K walked into the kitchen directly to the supply room where the resident's cups were stored, and he did not wash his hands or had on a hair net he stated he just started working at this facility and should have washed his hands and have on a hairnet when once intering the kitchen. Interview and observation on 11/27/23 at 11:46 am, Maintenance Director walked into the kitchen from the back door to the Dietary Directors office without washing his hands or having on a hairnet and began talking to her about something. He stated he just came to the kitchen to tell the Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 11 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Director the plumber was at the facility to fix something. He stated he was supposed to have on a hair net and wash his hands in the kitchen to prevent from getting any hair on the food and equipment, to not get anything dirty and said he was not sure where the hairnets were kept. Interview on 11/27/23 at 11:55 am, the Dietary Director stated they did not have any hairnets by the front entrance doors because they box was taken down after they remodeled and she was not sure why it was not put back up. She stated she was not sure why the [NAME] J, Dietary Aide K and the Maintenance Director did not wash their hands and have on hairnets in the kitchen. She stated [NAME] J and dietary aide K wanted to put their stuff down first then they were going to wash their hands. She stated she was not aware there was whitish colored splash stains next to the ice machine, the dirty sink, dirty trash can, dirty countertops by the coffee maker and dirty floor drain. She stated she was unaware the small ice machine on the counter in the dining room was leaking and the drain was full of water but stated she would notify the Maintenance Director to repair. Interview on 11/27/23 at 12:13 am, the Administrator stated he was not aware of the kitchen being dirty and unsanitary or the food not being labeled correctly. He stated he was not aware of the drink dispenser leaking water and was not aware of the chipped exit door with the hole in the corner area in the dining room. He stated would talk to the Maintenance Director about repairing. Interview on 11/27/23 at 11/29/23 at 2:28 pm, [NAME] L stated she cleaned the stove, the fryer and freezer once a week and the other cook cleaned the fryer oven and food steamer. She stated normally the dishwasher and dietary aide cleaned the trash cans and added she swept and mopped after every meal. She stated whoever was the dietary aide that day, cleaned the kitchen and signed off on the cleaning schedule what was cleaneed. She stated not having an unsanitary kitchen could make people sick. She stated they needed more staff, 1 dishwasher and a weekend cook. She stated everybody was responsible for ensuring the kitchen was cleaned and ultimately the Dietary Director was responsible. She stated there were no issues with the storage area and was not aware of spaghetti and other items not labeled correctly. She stated once the food and drinks were delivered to the facilty, they dated when they were received and when something was opened they had to put an open date on it. She stated it was important to date food because it could get old and expire. She stated if food was expired, the residents could get sick and maybe get food poisoning. She stated the last time she had a label and storage inservice training was a few months ago. Interview on 11/29/23 at 6:48 pm, the Administrator stated the Dietary Director was responsible for ensuring the kitchen was clean and sanitary and handwashing and hairnets are on. He stated he would start doing weekly checks of the kitchen and was pending having a professional cleaning service do a deep clean of the whole kitchen. Record review of the facility's Kitchen Equipment Cleaning and Sanitation policy revised 12.2020 revealed, Policy: The kitchen and dining equipment and food contact surfaces shall be maintained in a clean and sanitized condition .Procedure: Dining Services staff should be trained on cleaning and sanitizing processes .The Dietary Manager shall provide cleaning assignments to indicate the time and task to be completed by dining services staff. The Dietary Manager is responsible to ensure that cleaning assignments have been timely completed .Equipment food contact surfaces and utensils shall be kept free of encrusted grease deposits and other accumulations .Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Record review of the facility's Food Receiving and Storage policy dated October 2022 revealed, Policy Statement: Food shall be stored in a manner that complies with safe food handling practices (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 12 of 13 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm .Policy Interpretation and implementation: 1. Food services, or other designated staff will maintain clean food storage areas at all times .14.e other opened containers must be dated and sealed or covered during storage. Review of the Food and Drug Administration Food Code, dated 2022, reflected: Residents Affected - Many 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture .2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675703 If continuation sheet Page 13 of 13