Health inspection·September 3, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/2/23 at 4:00 p.m., Resident #3 said she was Resident #2's roommate. Resident #3 said she (Resident #2) had not been assisted out of the bed all day on Sunday (8/27/23). During an observation on 9/2/23 at 4:10 p.m., Resident #2 was sitting in her wheelchair. LVN C and an NA D performed a hoyer transfer from her (Resident #2's) wheelchair to her bed. There were no issues with the transfer. Resident #2 did not display any refusal of care, or behavior of swinging in the lift. Record review of the EMR ADL documentation for Resident #2 transfers for 8/26/23 did not document any transfer to or from: bed, chair, wheelchair, or standing position had taken place. Record review of the EMR ADL documentation for transfers for 8/27/23 at 3:29 a.m., indicated Resident #2 required two-person physical assistance for transfers to or from: bed, chair, wheelchair, or standing position had taken place. Record review of the EMR ADL documentation for Resident #2 transfers for 8/27/23 at 22:57 p.m., documented not applicable. Record review of the nursing notes for Resident #2 from 8/1/23 to 9/2/23 did not document any instances of refusal of care. During an interview on 9/3/23 at 9:50 a.m., Resident #2 said she could not remember if she got out of the bed on 8/26/23. Resident #2 said she did not think she had gotten out of bed last Saturday (8/26/23) because she did not get her shower on 8/26/23 but could not say for sure. Resident #2 said she knew she did not get out of bed all day on 8/27/23 because she asked multiple times and staff would say they would come back to get her up but never did. During an interview on 9/3/23 at 10:00 a.m., CNA F said dependent residents like Resident #2 should be assisted out of the bed when they request it. CNA F said it was important for dependent residents to be assisted out of the bed because it was their right to get up when they wanted to get up. CNA F said sometimes when a resident that required a hoyer lift requested to get up they might have to wait for a short time while another staff member was obtained to use the hoyer lift. CNA F said there was no reason for a resident who wanted to get up to have stayed in the bed all day long. During an interview on 9/3/23 at 11:00 a.m., LVN C said she expected nurse aides to get dependent residents up when they requested to get up. LVN C said Resident #2 should not have laid in the bed all day on 8/27/23. LVN C said it was important for Resident #2 to get up when she wanted for socialization and to feel human. During an interview on 9/3/23 at 11:56 a.m., NA E said last Saturday and Sunday (8/26/23 and 8/27/23) Resident #2 did not get out of the bed. NA E said she was the nurse aide for Resident #2 on Saturday (8/26/23) and she did not get Resident #2 out of the bed because she did not have time. NA E said Resident #2 was a hoyer lift and the hoyer lift required two staff to operate it. NA E said the other nurse aides did not have the opportunity to help her get Resident #2 up on Saturday (8/26/23). NA E said on Sunday she was not assigned to Resident #2 and was working in another area of the facility. NA E said she attempted on two instances to come assist with getting Resident #2 up out of the bed but was sent back to the unit which she had been assigned. During an interview on 9/3/23 at 12:05 p.m., the ADON said it was Resident #2's right to get out of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 2 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the bed when she wanted to get out of bed. The ADON said at times a Resident that was a Hoyer lift may have to wait a little bit for the nurse aide to get another staff member to assist with the lift. The ADON said under no circumstances should Resident #2 have laid in the bed all day on 8/27/23. During an interview on 9/3/23 at 12:29 p.m. the corporate RN said Resident #2 was not always cooperative with care. The corporate RN said there were times staff offered to get Resident #2 up and she would refuse. The corporate RN said Resident #2 would then request to get up at busier times, like during meal service, when aides were not available to get her up. The Corporate RN said it was important for dependent residents like Resident #2 to be assisted out of bed and that there was no reason Resident #2 should have went all day on 8/27/23 without having been assisted out of the bed. During an interview on 9/3/23 at 12:32 p.m., the Administrator said Resident #2 refuses care and refuses to get up at times. The Administrator said the refusals were care planned. The Administrator said Resident #2 scared her with how she (Resident #2) acted in the hoyer lift sometimes. The Administrator explained she (Resident #2) had swung herself while in the lift and it caused a nurse aide to injure her (the nurse aides) hand. The Administrator said Resident #2 should be assisted out of her bed when she requested. Record review of the undated facility policy and procedure, titled Resident Rights, stated, The resident has a right to a dignified existence, self-determination . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition . (7) b. The resident's wishes and preferences must be considered in the exercise of rights by the representative. c. To the extent practicable, the resident must be provided with opportunities to participate in the care planning process. Planning and implementing care - The resident has the right to be informed of, and participate in, his or her treatment, including: . d. The right to receive the services and/or items included in the plan of care . Respect and dignity - The resident has a right to be treated with respect and dignity, including: .(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents . Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. (2) The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. (3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 3 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 1 of 5 residents reviewed for ADLs (Resident # 2). Residents Affected - Some The facility did not provide Resident #2 with her scheduled showers/baths. This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life. Findings Included: Record review of the face sheet for Resident #2 indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), type II diabetes, muscle weakness, depression, anxiety, and obesity. Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated Resident #1 had intact cognition (BIMS of 13). The MDs indicated she had no behavior of rejecting care. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, eating, toilet use, and personal hygiene. The MDS indicated she was totally dependent on staff for bathing. The MDS indicated Resident #2 had a functional limitation in range of motion to her right and left upper extremities as well as her right and left lower extremities. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of the care plan revised on 6/14/23 indicated Resident #2 had diagnoses of cerebral palsy and paraplegia (paralysis of the legs/ lower body). The care plan interventions included, assist resident with ADLs and locomotion as required, encourage resident to perform as much as possible of these activities (ADLs). The care plan did not indicate Resident #2 resisted or refused care. During an observation and interview on 9/2/23 at 11:00 a.m., Resident #2 laid in her bed. Resident #2 said she could not take a shower or get a bed bath without the assistance of staff. Resident #2 said last Saturday (8/26/23) she did not receive a shower or a bed bath. Record review of the EMR ADL documentation for Resident #2 indicated her shower days were Tuesday, Thursday, and Saturday on the 2:00 p.m. to 10:00 p.m. shift. Record review of the EMR ADL documentation for REsident #2 on 9/2/23 indicated Resident #2 had not been provided a shower or bed bath since 8/19/23. On 8/24/23 it was documented Resident #2 refused a bed bath or shower. There were no other documentations of refusal between 8/19/23 and 9/2/23. The EMR ADL documentation indicated Resident #2 did not receive a shower or bath on the following dates; 8/19/23; 8/22/23; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 4 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 8/24/23 (documented refusal); Level of Harm - Minimal harm or potential for actual harm 8/26/23; 8/29/23; and Residents Affected - Some 8/31/23. Record review of the nursing notes for Resident #2 from 8/1/23 to 9/2/23 did not document any instances of refusal of care. During an interview on 9/3/23 at 9:50 a.m., Resident #2 said her scheduled shower days were Tuesday, Thursday, and Saturday. Resident #2 said she usually received her showers in the evening. Resident #1 said she did not get her shower on Saturday. Resident #1 said she did not refuse a shower on Saturday. Resident #2 said she could not remember who the nurse aide was on Saturday (8/26/23) and thought it might have been NA E, but could not say for sure. Resident #2 said she did not get a shower on Tuesday (8/29/23) but did receive a shower on Thursday (8/31/23). Resident #2 said she could not say for sure how many showers or baths she had been given in the last 2 weeks. Resident #2 said she had maybe 3 -4 showers/baths in the past two weeks. During an interview on 9/3/23 at 10:00 a.m., CNA F said dependent residents like Resident #2 received scheduled bathing/showers in order to maintain hygiene and identify any skin changes. CNA F said the administration of showers/baths were documented in EMR record. CNA F said if a resident refused a bath, the CNA or NA should notify the nurse. CNA F said there were also shower sheets filled out by CNAs/NAs. During an interview on 9/3/23 at 11:00 a.m., LVN C said she expected CNAs to administer showers as they were scheduled. LVN C said it was important for residents to receive showers/baths to ensure good hygiene and make the resident feel better. LVN C said showers/bathing were also a good opportunity to assess a resident's skin. LVN C said if a resident refused a shower/bath the CNA or NA, should attempt at a later time in the day. LVN C said if the resident still refused the CNA or NA should notify the nurse. LVN C said the nurse should then speak to resident to see if they could identify the reason for the refusal. During an interview on 9/3/23 at 11:56 a.m., NA E said Resident #2's shower days were Tuesday, Thursday and Saturday. NA E said last Saturday (8/26/23) Resident #2 did not get a shower or bath. NA E said she was the nurse aide for Resident #2 on Saturday (8/26/23) and she did not give Resident #2 a shower because she did not have time. NA E said Resident #2 was a hoyer lift and the hoyer lift required two staff to operate it. NA E said the other nurse aides did not have the opportunity to help her get Resident #2 up for a shower on Saturday (8/26/23). Shower sheets were requested from the Administrator on 9/3/23 at 12:30 p.m. but were not provided before exit and had not been sent as of 9/7/23. During an interview on 9/3/23 at 12:05 p.m., the ADON said it was important for residents to receive their scheduled showers because it decreased their risk of skin infections. The ADON said she expected CNAs/NAs to administer residents their showers/baths as scheduled. During an interview on 9/3/23 at 12:29 p.m. the Corporate RN said Resident #2 was not always (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 5 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cooperative with care and would refuse showers/baths at times. The Corporate RN said if a resident refuses a shower or bath the CNA/NA should notify the nurse and the nurse should document the refusal. The Corporate RN said it was important for dependent residents like Resident #2 to be administered showers/baths three times a week to promote hygiene. During an interview on 9/3/23 at 12:32 p.m., the Administrator said Resident #2 refuses care and refuses to get up at times. The Administrator said the refusals were care planned. The Administrator said residents should be offered showers/baths when they were scheduled. The Administrator said when the DON quit on 8/31/23 she (the DON) threw a lot of items in the shred bin. The Administrator said she was going through the shred bin now trying to find shower sheet documentation. Record review of the facility policy and procedure dated 2003, titled Bath, Tub/Shower, stated Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 6 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 3 residents reviewed for pressure injuries (Resident #1). Residents Affected - Some The facility did not complete weekly skin assessments on Resident #1. The facility did not promptly identify and initiate treatment for the Stage II pressure injury to Resident #1's sacrum. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: Record review of the face sheet for Resident #1 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, anxiety, lack of coordination, High blood pressure, malnutrition, muscle weakness and unstageable pressure ulcer of the left heel. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated Resident #1 was cognitively intact (BIMS of 14). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, locomotion with her walker, dressing, toilet use, personal hygiene, and bathing. The MDS indicated she required limited assistance with walking and eating. The MDS indicated Resident #1 was always incontinent of bowel and bladder. The MDS indicated Resident #1 was at risk for developing pressure injuries and had one unhealed, unstageable deep pressure injury. The MDS indicated Resident #1 received the following skin and ulcer/Injury treatments; pressure reducing device for her bed, pressure ulcer/injury care, and application of ointments/medications (other than to feet). Record review of the care plan revised on 5/10/23 indicated Resident #1 had a DTI to the left heel with an onset date of 5/8/23. The care plan interventions included; follow the facility policies/protocols for the prevention/treatment of skin breakdown and notify the nurse immediately of any new areas of skin breakdown (open area, redness, blisters, bruises, discoloration noted during bath or daily care). Record review of the weekly ulcer assessment on 5/8/23 indicated Resident #1 had a Deep tissue injury to her Left heel measuring 4 centimeters in length, 5 centimeters in depth, and an undetermined depth. The weekly ulcer assessment indicated there were no signs or symptoms of infection. Record review of the weekly ulcer assessment on 8/31/23 indicated Resident #1 had a Deep tissue injury to her Left heel measuring 0.3 centimeters in length, 0.2 centimeters in depth, and an undetermined depth. The weekly ulcer assessment indicated there were no signs or symptoms of infection. Record review of Resident #1's skin assessments from 7/1/23 to 9/2/23 indicated Resident #1 did not have a weekly skin assessment completed on the following weeks; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 7 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 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 0686 *the week of 7/3/23; Level of Harm - Minimal harm or potential for actual harm *the week of 7/10/23; *the week of 7/31/23; and Residents Affected - Some *the week of 8/13/23. Record review of the skin assessment on 7/27/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. Record review of the skin assessment on 8/9/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. Record review of the weekly ulcer assessment on 8/9/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. Record review of the weekly ulcer assessment on 8/17/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. Record review of the skin assessment on 8/20/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. This skin assessment was completed by LVN A. Record review of the weekly ulcer assessment on 8/24/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. This skin assessment was completed by LVN A. Record review of the skin assessment on 8/31/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. This skin assessment was completed by LVN A. Record review of the weekly ulcer assessment on 8/31/23 for Resident #1 did not indicate she had a pressure injury to her sacrum. This skin assessment was completed by LVN A. During an observation on 9/2/23 at 2:08 p.m., Resident #1 laid in her bed. NA B positioned Resident #1 on her right side. When NA B removed Resident #1's incontinent brief, it was observed Resident #1 had a small area (measuring approximately 1 centimeter in length and 1 centimeter in width) of broken skin on the sacral area (the sacral spine (sacrum) are of bony prominence located below the lumbar spine and above the tailbone, which is known as the coccyx). The wound bed was bright red. There were no signs and symptoms of infection. There was no adipose (fat) tissue visible. During an interview on 9/2/23 at 2:09 p.m., Resident #1 said she didn't know she had a wound on her sacrum. Resident #1 said the area did not hurt. During an interview on 9/2/23 at 2:10 p.m., NA B said the area to Resident #1's sacrum was looking better. NA B said the area had been present a couple of weeks. NA B said she told a nurse when she found the area but could not say what nurse she notified. NA B said she had only been at the facility about a month and did not know all of the nurse's names. NA B said it was important to notify the nurses promptly when resident skin changes were identified because they would get orders for treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 8 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 9/2/23 at 3:00 p.m., LVN A said she was providing care for Resident #1 this weekend and regularly took care of her on the weekends (from 6:00 a.m. to 10:00 p.m.). LVN A said she was not aware Resident #1 had any wounds to her sacrum. During an interview and observation on 9/2/23 at 3:05 p.m., Resident #1 laid in her bed. LVN A and LVN C positioned Resident #1 on her left side. When LVN A removed Resident #1's incontinent brief, it was observed Resident #1 had a small area that measured 1 centimeter in length and 1 centimeter in depth of broken skin. The area was not blanchable. The wound bed was bright red. LVN A said the area was too shallow to measure a depth. There were no signs and symptoms of infection. There was no adipose (fat) tissue visible. LVN A said she could not stage the wound because she was an LVN. During an interview on 9/2/23 at 3:10 p.m., LVN A said NA B had not reported the area on Resident #1's sacrum to her. LVN A said she had not been notified by any other nurse that Resident #1 had a wound to her sacrum. LVN A said there were no treatment in orders in place for the wound to Resident #1's sacrum because the wound had not been identified. LVN A said she would obtain orders immediately. During an interview on 9/2/23 at 3:12 p.m., LVN C said NA B had not reported the area in Resident #1's sacrum to her. LVN C said all residents should have a weekly skin assessment performed. During an interview on 9/3/23 at 10:55 a.m., NA D said any CNA or NA who find an area of redness, broken skin, bruising or any type of skin changes should promptly notify the resident's nurse. NA D said it was important for nurses to be notified promptly so that any needed interventions could be put in place right away. During an interview on 9/3/23 at 11:10 a.m., LVN A said she had performed a head-to-toe skin assessment on Resident #1 last Thursday (8/31/23). LVN A said the pressure injury to Resident #1's sacrum was not present and there was no area of redness when she performed her (Resident #1's) skin assessment on 8/31/23. LVN A said the aides were the eyes and ears of the nurses because they provided so much of the direct resident care (incontinent care and bathing). LVN A said between skin assessments if a nurse aide does not notify us (nurses) of skin changes/breakdown they will not be aware until the next skin assessment was completed. LVN A said it was important that nurse aides promptly notify nurses of skin changes/breakdown so the appropriate interventions can be put in place. LVN A said if we (nurses) were not notified promptly things can spin out of control quickly. During an interview on 9/3/23 at 12:05 p.m., the ADON said nurses should complete skin assessments weekly for every resident. The ADON said nurse aides should promptly report any area of redness or skin breakdown to the nurse caring for the resident. The ADON said there had not been any procedure in place to ensure weekly skin assessments were being completed. The ADON said she performed a skin sweep (performed skin assessments on every resident in the building) last night (9/2/23-9/3/23). During an interview on 9/3/23 at 12:29 p.m. the corporate RN said nurses should complete skin assessments weekly for every resident. The corporate RN said nurse aides should promptly report any area of redness or skin breakdown to the nurse caring for the resident so that interventions could be initiated. During an interview on 9/3/23 at 12:32 p.m., the Administrator said all residents should receive skin assessments weekly. The Administrator said LVN A had performed a skin assessment on 8/31/23 and there was no wound at that time. The Administrator said NA B should have immediately communicated to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 9 of 10 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 675801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the nurse taking care of Resident #1 of the area on her (Resident #1's) sacrum. The Administrator said there had not been any procedure in place to ensure weekly skin assessments were being completed or that nurse aides were communicating skin changes to the nurses, but the ADON performed skin assessments on all of the facility residents last night (9/2/23-9/3/23). Record review of the facility policy and procedure, revised on 8/12/16, titled Pressure Injury: Prevention, Assessment and Treatment, stated Procedure: (1) Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. (2) Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs .(9) Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin . Staging definitions are per the guidelines of the National Pressure injury Advisory Panel February 2016 definitions . Stage 1 Pressure Injury: Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . Event ID: Facility ID: 675801 If continuation sheet Page 10 of 10