Health inspection·October 4, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 2 of 41 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 10/04/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about 27 years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 3 of 41 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 10/04/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 2.Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 4 of 41 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 10/04/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. Residents Affected - Some 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 5 of 41 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 10/04/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F600 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. Resident #1 was assessed for pain by the charge nurse on 10/3/23. Resident #1 was offered a shower by the charge nurse on 10/3/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 6 of 41 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 10/04/2023 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 0600 Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. Level of Harm - Immediate jeopardy to resident health or safety All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Residents Affected - Some Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and Resident #1 care plans were reviewed and updated. Social Worker assessed Resident #13 and other African American Male on the Unit on 10/04/23 and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 7 of 41 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 10/04/2023 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 0600 The medical director was notified of the immediate jeopardy situation on 10/3/23.?? Level of Harm - Immediate jeopardy to resident health or safety An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: Residents Affected - Some The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Resident #'s 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling services. Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 8 of 41 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 10/04/2023 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 0600 pain. Level of Harm - Immediate jeopardy to resident health or safety Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Residents Affected - Some Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 9 of 41 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 10/04/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify the nurse of all behaviors. The staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them, they would report to the Abuse Coordinator the Administrator. During an interview on 10/4/23 at 7:05 p.m., the Administrator said she was in serviced on the abuse neglect policy. She said as the Abuse Coordinator it was her responsibility to identify and act on any allegation of abuse or neglect. She said she would suspend immediately the individual, follow policy, and follow the policy. She said with LVN C she did not feel that Resident #12 was abused because Resident #12 said she loved LVN C and LVN C was usually the only one that can get her to take her medications. The Administrator said she received in service on ADLs. She said as the administrator her part was to monitor the system they have that tracks ADLs. She said they conducted morning meeting have assignments discussed. They also conducted Champion Rounds (where each department head had a section of the facility, they questions residents about their care). They would ask the residents how they were treated, if they got showers, beds made, and if they were getting t[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 10 of 41 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 10/04/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement written polices and procedures to prohibit abuse by ensuring residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14). Residents Affected - Some Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. The LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. The Administrator did not follow the abuse policy when she unfounded the abuse when the LVN admitted she had abused the resident. LVN C was suspended for part of her shift and returned to work the following day. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit Resident #13 and Resident #14. The facility did not follow their abuse policy and continued to allow Resident #12 with a history of abusive behaviors to continue to abuse residents. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 10/4/23 at 6:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could caused emotional and physical harm and could lead to additional pain and suffering. Finding included: Record review of the facility's Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility will be responsible to identify, correct, and intervene in situations of possible abuse or neglect. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1.Record review of Resident #12's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia (impairment of memory) with other behavioral disturbances, psychotic disorder (a mental problem that causes people to perceive or interpret things differently from those around them), with delusions, cognitive communication deficit, and major depression. Record review of Resident #12's quarterly MDS dated [DATE] indicated her cognitive status was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 11 of 41 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 10/04/2023 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 0607 severely impaired. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #12's Care Plan dated 9/7/22 indicated a focus area of impaired cognition due to dementia or impaired thought processes. Some of the interventions were, use the residents preferred name, identify self at each interaction, face resident, and make eye contact when speaking and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Residents Affected - Some Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 12 of 41 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 10/04/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about 27 years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 13 of 41 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 10/04/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. 2. Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 14 of 41 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 10/04/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 15 of 41 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 10/04/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F607 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 16 of 41 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 10/04/2023 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 0607 Resident #1 was assessed for pain by the charge nurse on 10/3/23. Level of Harm - Immediate jeopardy to resident health or safety Resident #1 was offered a shower by the charge nurse on 10/3/23. Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. Residents Affected - Some All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and resident #1 care plans were reviewed and updated. Social Worker assessed on 10/4/23 residents #13 and other African American Male on the Unit, and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 17 of 41 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 10/04/2023 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 0607 The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. Level of Harm - Immediate jeopardy to resident health or safety The medical director was notified of the immediate jeopardy situation on 10/3/23.?? Residents Affected - Some An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Residents 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 18 of 41 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 10/04/2023 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 0607 services. Level of Harm - Immediate jeopardy to resident health or safety Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any pain. Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Residents Affected - Some Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 19 of 41 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 10/04/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 20 of 41 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 10/04/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out ADLS received necessary services to maintain personal hygiene were provided for 13 of 18 residents reviewed for ADLs (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 14, 16, and # 18.) Residents Affected - Some The facility failed to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to provide showers for 26 residents on 9/18/23. The facility failed to provide routine showers for Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18. This failure could place dependent residents at risk for poor hygiene, skin infections and decreased quality of life. Findings included: 1. Record review of Resident #1's face sheet dated 9/19/23 indicated she was a [AGE] year-old female initially admitted to the facility 10/4/23. Some of her diagnoses were Spinal Stenosis (narrowing of the spinal column that causes pressure on the spinal cord. Morbid obesity disease of upper respiratory tract, pain of unspecified joint, unsteadiness on feet, abnormalities of gait and mobility. She had anxiety disorder, and history of heart attack. Record review of Resident #1's quarterly MDS dated [DATE] indicated she was cognitively intact. Resident #1's bed mobility and transfer assistance were listed as extensive assistance with two people physical help. Record review of Resident #1's care plan dated 8/29/23 indicated a potential for pressure ulcer development and one of the interventions was to ensure incontinent care was provided after each episode. One Focus was the resident had the potential for uncontrolled pain. One of the interventions was to monitor the probable cause of each pain episode, remove or limit the cause if possible. Resident #1 had a focus area of desired independence in activities and would attend activities of choice. The resident loved the appetizer(snacks) program, Bingo and helping the Activity Director. She also liked therapy. Resident #1 had a focus are of bladder incontinence and one of the interventions was to apply barrier cream after each incontinent episode, and incontinence care at least every two hours. Resident #1 had a focus are of self-care performance deficit. Resident #1 required assisted of one staff for bed mobility, dressing, toileting, encourage the resident to use call light for assistance, and she used a wheelchair for ambulation. Record review of Resident #1's physician order dated 11/15/21 indicated the resident needed to be up in chair for all meals. An order dated 2/5/23 may use oxygen at 4 liters by nasal cannula, every shift. An order dated 7/23/23 for acetaminophen 500 mg give two tables by mouth as needed for pain. During an observation and interview on 9/18/23 at 2:57 p.m. Resident #1's call light was on. The Activity Director went in the room and turned the call light off. She came out and told CNA A who was at the cart gathering supplies that Resident #1 said she need assistance. The Activity said Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 21 of 41 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 10/04/2023 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 # 1 was waiting on an aide to come and change her. CNA A said she was going to assist a resident in another room and then she would help Resident #1. Level of Harm - Actual harm Residents Affected - Some During an observation and interview on 9/18/23 beginning at 3:02 p.m. Resident #1 was observed lying in bed. Resident #1 said she was soaking wet, her bed was wet, the sheets, the gown, and she had been laying in urine since early this morning. She said the last time she was changed was about 8:00 a.m. Resident #1 said she knew they were short staffed and doing the best they could. However, she was told before 11:00 a.m. they were going to try and get her up and then before 2:00 p.m. they were going to get up. Resident #1 said she had been waiting all day. Resident #1 started to cry. The Resident said she knew she was not the easiest person to provide care for. She said CNA A had come in her room only to turn off her call light and say they would be back. She said they had told her she was getting up by 11:00 a.m. to be a part of activities. They have appetizers at 11:00 a.m. and she had missed the appetizers, and she really enjoyed that activity. Resident #1 said she did not like to stay in bed all day and she had been made to miss all activities. Resident #1 said she was out of oxygen on her chair and aide came in and said she would bring some back. Resident #1 stated the aide brought in a brief, put it on the dresser and said they would be back. She told them to just put her in a gown because the day was mostly gone, the aide took down a gown and put it on the bed side table. Resident #1 said CNA A sit the gown on the bedside table and left and promised her they were coming back. Observation showed the brief on the dresser and the gown on the bedside table. Resident #1 said she was supposed to have a shower today. She said the aide told her she was not giving her a shower on today, because the shower aide was out. Resident #1 said she did not always get her showers like they are scheduled. She should get them on MWF and often only got two a week instead of three. She said most days they get her up and provide care like they are supposed to, but it depended on who was working or not working that day. Resident #1 said they would often come in and turn the call light off and say they would be back in a minute, and it would be a long time before they did. She said she would usually have to put the call light on again to receive assistance. Observation of Resident #1 with the ADON P revealed she had on a brief; the brief was wet and soggy. The draw sheet, and sheet had a large wet area, and her gown was wet. Resident #1 said she had to eat her lunch in a wet soiled bed, and she was very uncomfortable. She said because she had laid down so long, she was hurting and asked the ADON P for some Tylenol. During an observation and interview on 9/18/23 beginning at 3: 20 p.m. ADON P was seen with a medication cup taking medication to Resident #1's room. The ADON P said she had Resident #1 requested Tylenol. During an interview on 9/18/23 beginning at 3:47 p.m., the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. During an interview on 9/18/23 at 4:12 p.m., CNA A said this was her third day on the job. She started to work at 6 a.m. this morning and it was just her and CNA B today, all day long. She said she had not given any showers and had a hard time trying to answer call lights. She said that Resident #1 had requested to get up all day and changed but she was just trying to keep up as best she could. She said she had apologized to Resident #1 but was doing the best she could. There were a few residents she had not gotten up today. She said she did not have any Hoyer lifts on that hall but Resident #1 should be a Hoyer lift transfer. She said that she had the short hall today and it had 25 residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 22 of 41 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 10/04/2023 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 - Actual harm Residents Affected - Some During an interview on 9/19/23 at 8:45 am., the Activity Director said Resident #1 liked to come to activities every day. The Activity Director said she had something called appetizers where they offered different foods and all the residents loved that. She said Resident #1 liked to be up by 11 a.m. During an interview and observation on 9/19/23 beginning at 9:00 a.m. Resident #1 was laying in her bed. She said staff had promised her today they would get her up by 10:00 a.m. She said she had to be weighed every day and would like to get a shower today since she missed yesterday. She said that it was painful for her to lay in bed all day and night. Resident #1 said she felt agitated, angry, and hopeless because she was dependent on someone else for help. She said her feelings were hurt that the staff basically lied to her all day. 2. During an observation and interview on 9/18/23 beginning at 3:13 p.m. Resident #2 was sitting on his bed, fully dressed, and said he did not get a shower today. They are short staffed, and he was supposed to get one on Saturday, but Thursday was his last shower. He said he did not know what his regular scheduled shower days were because, he may or may not get one. Resident #2 said some days they would offer, and it might be any day of the week. Resident #2 said he usually only got about two showers a week and sometimes one. Resident #2 said that was his only problem he goes to the bathroom unassisted and did not really need anything else. 3. During an observation and interview on 9/18/23 beginning at 3:24 p.m. Resident #3 was observed in bed. Resident #3 she had not been changed since early this morning, but the pads hold a lot, and they would probably be in in another hour to change her. Observation of her brief with the ADON's assistance revealed it was wet and soggy, but the sheets were not wet. Resident# 3 said she did not receive a shower today and she was supposed to have them on MWF. Resident # 3 said no one asked her if she wanted a shower today, she knew they were short staffed and at least once a week missed a shower. Resident #3 said she did get a shower on Friday. 4. During an observation and interview on 9/18/23 at 3:40 p.m. said Resident #5 said the aides did not get her up today they were short staffed. Resident #5 said she liked to eat breakfast in the dining room. She said a staff was trying to put two briefs on her and she said no. Resident #5 said the CNA had recently changed her. Resident #5 said she required a Hoyer lift and they have not gotten up since Friday. Resident #5 said she stayed in bed all weekend because they did not have staff to get her up or they were too lazy to do so. Resident #5 said she did not take a shower today said there was not anyone here to give a shower. Resident #5 said she liked to go to some of the activities and see some of her friends. Resident #5 said she had pulled her call light and told the aide she needed help to straighten up in bed. She said she was told by the aide she needed some help and did not come back. Resident #5 said the facility needed more help. During an interview and observation on 9/18/23 beginning at 3:47 p.m. the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. 5. During an interview and observation on 9/18/23 at 3: 56 p.m. inidcated Resident #6 had her call light on. Resident said she had been waiting a while. She said the aide had come in at least once and turned the off the light. Resident #6 refused to allow the interim DON and the investigator to see how wet she was. She said she had a BM also. Resident #6 started to cry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 23 of 41 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 10/04/2023 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 - Actual harm Residents Affected - Some During an interview on 9/18/23 at 3:58 p.m. CNA B said she had been in Resident #6's room, but had not changed her since about 11:00 a.m. She said she knew she should have been in the room more frequently to change Resident #6 and she was trying to get to her as quickly as she could. She said it was just her and another aide in the building. CNA B said she came in at 6:00 a.m. this morning and it had just been her and one other aide all day. She was trying as hard as she could to take care of all the residents, but she was overwhelmed. She had the long hall with 20 residents, she also had 17 residents on the unit. She said on the unit they had about 3 residents that went to the bathroom themselves, but all the residents needed to be assisted with toileting. She said there were 3 residents on the hall at the back that were assigned to her. CNA B said she had 9 residents that required Hoyer lift transfers or two people assist and she had gotten up who she could today. She said the administrative staff were aware they were short staffed. She said some of the office staff had helped to pass breakfast and lunch trays and pick up trays. She said all staff were answering call lights but if the residents needed changing the staff usually just turned off the light and informed her what they needed. She said she had not given any showers today. She said she had about 40 residents total to take care of. CNA B said some days they have 4 or 5 aides on the halls and some like today they were short staffed. She began to cry and said she was tired and overwhelmed. During an interview on 9/18/23 at 4:12 p.m. CNA A said it took her about 10 minutes a resident to clean them up but if they had had a large or runny BM it could take her longer and in-between, she was trying to keep most of the residents satisfied. She said by the time she got to one end of the hall it was past time to start on the other end of the hall. She said every resident that required assistance had been assisted at least once today. However, there had not been every two-hour care today. The administration was aware they were short staff. Some of the office staff had helped to pass and take up breakfast and lunch trays. If they had not done so it could have been worse. She said the administrative staff had also helped to answer call lights with small things, but if care needed to be provided. She had done the care as best she could manage. During an interview on 9/18/23 at 4:20 p.m. the ADON said short hall had 25 residents and CNA A was working that hall today. She said the long hall had 20 residents and CNA B was working that hall today. She said on the secure unit they had 17 residents and SNA H who was on restricted duty due to having a sling on her arm was on the secured unit. The ADON said when SNA H needed help, she would come and get someone. She said on the unit some were continent, but all the residents needed supervision. During an interview on 9/18/23 at 4:35 p.m. SNA H she said she had been hurt on the job while trying to assist a resident. She will not see the doctor until 10/14/23 for a release and mean while she was not supposed to lift more than 5 pounds. She had been assigned to the secured unit today. She said she was not familiar with the residents on the unit she usually worked up front. She said the only thing she could do was turn off lights, and try to make beds. During an interview on 9/18/23 at 4:45 p.m. LVN C said that all together she had worked at the facility for about 29 years. She said they had 17 residents on the unit. She said that they had about 3 that were continent, but they all required supervision, with toileting. LVN C said she helped when she could. She said they needed more staff. During an interview on 9/18/23 at 5:50 p.m. ADON said they get shower sheet check offs when showers are complete. She said there are no shower sheets for today. 6.During an interview on 9/18/23 at 6:02 p.m. Resident #18 had his call light on. He said he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 24 of 41 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 10/04/2023 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 - Actual harm wet and needed to be changed. Resident #18 said that he has no idea when his showers are scheduled. Resident #18 stated there was no rhyme or reason to when he gets a shower. He said on Saturday he got a shower because he had bad diarrhea. He did not know when he had received one before then. Two aides from day shift went to change him. Residents Affected - Some During an interview on 9/19/23 at 4: 57 a.m. CNA K said she was leaving at 5a.m., she had completed her rounds, and SNA D was taking over. During an interview on 9/19/23 at 5:00 a.m. SNA J said she had not done any showers the night before. 6.During an interview and observation on 9/19/23 beginning at 5:05 p.m. SNA D said she was getting residents up on the secured unit. She said CNA K said the night shift had not gotten anyone up. Observation of Resident #15's room showed Resident #15 standing beside the bed with the aide trying to direct him. Resident #15 had his right leg behind him and could not seem to understand he needed to turn to sit in the wheelchair. He sat down on the wet bed several time before he was able to turn around and sit in the wheelchair. SNA D said the night shift staff had left the resident wet. Observation of the sheets on the bed showed they were wet, and the plastic mattress had a pool of liquid in on the mattress. SNA D said the Resident #15 was that wet with urine. Resident #15 would not speak when spoken to him, he would only smile and nod. SNA D said she was mad because the resident should not have been left in that kind of condition. Observation of the bag where Resident #15's brief was showed a wet and soggy brief. SNA D said it took her about 10 to 15 minutes to get each resident cleaned up and dressed. It depended on how soiled they were or like Resident #14 how confused they were. She said she would take the solid brief and sheets and come back later to make the bed. The beds had to be sanitized and let dry and then put the sheets on them. 7.Observation and interview on 9/19/23 beginning at 8:30 a.m. of Resident #16 showed in in the bed with his bed facing the door. He said that he had told the aides he wanted to be turned around and straightened up in the bed. They had come in and tuned off the call light and said they would be back. He said he was uncomfortable, and he could not watch his TV from the way the bed was turned. During an observation and interview on 9/19/23 beginning at 9:21 a.m. Resident #16 said he had pulled his call light again. He said the staff were supposed to be coming to turn him around but had not. At 9:31 a.m. CNA M went in to assist the resident. SNA E and CNA M said that they were aware the resident wanted to be turned but they had to do some else first. During an interview on 9/19/23 at 10:10 a.m. the Corporate RN said residents should have their showers completed according to their shower schedule. She said if the shower showed not applicable it either was not done or it was on the shower sheet tool and did not get transcribed over. She said showers should be completed in the computers under the task, and they could be scheduled or PRN showers. Reviewed bath sheets from the computer system for 9/2023 indicated: Resident #7 should have had a shower/bath on 9/6, 9/11, 9/15, 9/18/23 a shower was done on 9/13/23. PRN bath 9/8/23. Clinical alert showed no showers 3 days prior to 9/7, 9/12, and 9/16/23. Resident #4 did not received bath on 9/8/23 and 9/13/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 25 of 41 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 10/04/2023 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 Resident #8 had no showers on 9/12, 9/14, 9/16/23. Last shower was 9/15/23 PRN Level of Harm - Actual harm Resident #9 had no showers noted 9/5/23-9/19/23. Showers should be TTHS Residents Affected - Some Resident #10 had 1 shower on 9/16/23, no other showers. Showers should be TTHS Resident #11 had shower on 9/7/23 and 9/12/23, no other showers. Showers should be TTHS Record review of the facility Care Plan Task Listing Report indicated they had 26 residents that were to receive showers on MWF and 39 that were to receive showers on TTHS. . During an interview on 9/19/23 at 1:25pm Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said when he pulled the call light staff would come in and turn the light off tell him they will come back but don't always come back to help him. During an interview on 9/19/23 at 1:40pm LVN C said it was hard to get showers for the secured unit due to resident cognition and behaviors, most residents received showers. LVN C said she believed Resident # 8 and Resident # 9, and Resident # 10 refused the showers today. CNAs will report when residents refused showers. During an interview on 9/19/23 at 1:45pm SNA D said Resident # 8 refused his shower today but let her shave him. She said most likely he would take a shower tomorrow. She documented refusals. She said Resident # 9 got a shower today but was unsure of the rest of the month. Resident # 10 got a shower today, but she was sure of the rest of the month- she was out (not at work) over 10 days this month. Sometimes SNA E would shower residents for her when she helped in the secure unit, but she was not sure about her documentation. During an interview on 9/19/23 at 1:50 p.m. SNA E said she worked in the secured unit sometimes. She said she gave showers to Resident #9 and Resident #10 last week, she thought she documented them on the computer. SNA E said she worked the unit with SNA D. She struggles to give showers on both units because of lack of staff. During an interview on 9/19/23 at 2:20 p.m. Corporate RN, Interim DON, and Administrator are trying to cover the schedules. She was unsure what shifts/positions the facility currently has open because she does not normally cover this facility. She said she talked with upper management today on trying to get agency in to help with staffing concerns until the facility gets stabilized. During an interview on 9/20/23 at 9:00 a.m. the Administrator and Area Director of Operations were informed of the concerns with ADL care and residents not receiving showers. They said they had gotten the ADL deficiency on 9/3/23 and had not had a chance to correct the problem. They had just received their deficiencies. They said they were aware of the problem on 9/3/23 and had conducted an in-service. They said the deficiency had already been cited; however, they could not say why the ADL issues had not been fixed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 26 of 41 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 10/04/2023 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 - Actual harm Residents Affected - Some Record review of an in-service dated 9/3/23 indicated staff were informed showers are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower was missed on the day shift it should be given on the 6p to 6a shift. It will be reported to the oncoming nurse and aide. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern wasis there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. Family member said the way they treat the residents by making them stay in bed all day was cruel and abusive. Record review of an in serviced dated 9/18/23 indicated staff was informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift. Record review of the facility Bath Shower procedure dated 2003 indicated a daily shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed. The goals are the resident will experience improved comfort and cleanliness by bathing, maintain intact skin integrity, be free form soil, odor, dryness and pruritus' following bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 27 of 41 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 10/04/2023 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staff to provide nursing related ser ices to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 13 of 18 residents reviewed for sufficient staff (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18.) The facility failed to have sufficient staff to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to have sufficient staff to provide showers for 26 residents on 9/18/23. The facility failed to have sufficient staff to provide routine showers for Resident #'s 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and 18. This failure placed dependent residents at risk for poor hygiene, not receiving care in a timely manner, and decreased quality of life. Findings included: Record Review of Time Sheets 9/1-9/19/23 indicated: 9/1/23: 2 CNAs from 5:45 am-5pm, 1 CNA from 6:26 am-5:04 pm; 2 SNAs from 6 am-6 pm, 1 SNA from 8 am-3pm, 1 CNA from 4 pm-11 pm, 1 SNA from 6 pm-6:30am; 9/2/23: 1 CNA from 5:45 am-6:15p., 1 CNA from 5:54 am-4:20pm, 1 SNA from 6 am-5:21 pm, 2 SNAs from 6 am-6 pm, 5 SNAs from 6 pm-6 am, 1 CNA from 6 pm-12 am; 9/3/23: 1 CNA from 6 am-4 pm, 1 CNA from 6 am-6:45 pm, 2 SNAs from 6 am-6pm, 2 SNAs from 3:30 pm-6:30 am, 1 SNA from 4:45 pm-6:20 am, 2 SNAs from 6 pm-6 am; 9/4/23: 2 CNAs from 6am-6pm, 1 CNA from 6 am-3 pm, 2 SNAs from 6 am-6 pm, 1 CNA from 8:45 a.m-4 pm, 2 SNAs from 5 pm-6 am, 1 SNA from 5:23 pm-6:39 am, 2 SNAs from 6 pm-6 am; 9/5/23: 2 CNAs from 6 am-8 pm, 1 CNA from 6 am-6 pm, 1 SNA from 6 am-8:46 pm, 1 SNA from 8 am-6 pm, 1 CNA from 9:29 pm-2:39 am, 1 SNA from 6 pm-6 am, 1 SNA from 8 pm-10:47 pm, 2 SNAs from 8 pm-12 am; 9/6/23: 1 CNA from 5:45 am-6:10 pm, 2 CNAs from 6 am-6:10 pm, 1 SNA from 6 am-8:28 pm, 1 SNA from 6:22 am-8:07 am, 1 SNA from 7:45 am-6:14 pm, 1 SNA from 6 pm-6:17 am, 1 SNAs from 10 pm-3:22 am; 9/7/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am-4 pm, 2 SNAs from 6 am-6 pm, 1 SNA from 7:42 am-8:17 pm, 3 SNAs from 5:45 pm-6 am, 2 SNAs from 7 pm-6 am; . 9/8/23: 1 CNA from 6 am-6 pm, 1 CNA from 6 am-4 pm, 1 SNA from 6 am-2 pm, 1 SNA from 7 am-8 am, 1 SNA from 6 am-6 pm, 1 CNA from 12:15 pm-12:35 pm, 3 SNAs from 4 pm-6 am, 2 SNAs from 5 pm-6 am; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 28 of 41 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 10/04/2023 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 0725 9/9/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6 am-6 pm, 1 SNA from 8 am-4 pm, 2 SNAs from 6 pm-10 pm, 1 SNA from 6 pm-6 am; Level of Harm - Actual harm 9/10/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6 am-10 pm, 2 SNAs from 6 pm-6 am; Residents Affected - Some 9/11/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6:30 am-10 pm, 1 SNA from 7:50 am-6 pm, 2 SNAs from 6 pm-6 am, 2 SNAs from 7 pm-3 am; 9/12/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am-4 pm, 1 SNA from 6 am-6 pm, 1 SNA from 6 am-5 pm, 2 SNAs from 6 pm-6 am, , 2 SNAs from 6 pm-10:46 pm; 9/13/23: 3 CNAs from 6 am-6 pm, 1 SNA from 6 am-6 pm, 1 SNA from 7 am-1:30 pm, 1 SNA from 6 pm-9:14 pm, 1 CNA from 6 pm-6 am, 1 SNA from 7 pm- 6am, 1 SNA from 10 pm-6 am; 9/14/23: 1 SNA from 4 am-6 pm, 3 CNAs from 6 am-6 pm, 1 SNA from 6 am-7:30 pm, 1 SNA from 8 am-6 pm, 1 CNA from 6 pm-6 am, 2 SNA from 6 pm-6 am; 9/15/23: 2 CNAs from 6 am-6 pm, 1 CNA from 10 am-2 pm, 2 SNA from 6 am-6 pm, 1 SNA from 8 am-3 pm, 2 SNAs from 6 pm-6 am, 1 SNA from 8 pm-10 pm; 9/16/23: 1 CNA from 6 am-6 pm, 2 CNAs from 6 am-7 pm, 1 SNA from 6 am-6 pm, 1 SNA from 6 am-7:30 pm, 1 SNA from 7 pm-9:45 pm, 2 SNAs from 7:30 pm-6:132 am; 9/17/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am- 4 pm, 2 SNAs from 6 am-6 pm, 1 CNA from 6 pm-5 am, 2 SNAs from 5:45 pm-6 am; 9/18/23: 1 CNA from 5:45 am-10 pm, 1 CNA from 6 am-6:30 pm, 1 SNA from 6:16 am-6:46 pm, 1 SNA from 6:25 pm-6:31 am, 1 CNA from 6:48 pm-6 am, 1 CNA from 10 pm-6 am. Observation and record review of the facility on 9/18/23 beginning at 2:30 revealed they had a census on 65 residents. They had three nurses and 2 CNAs. They had one SNA who was acting as a hospitality aide with a shoulder sling on one arm working on the secure unit. During an interview on 9/18/23 at 6:18 p.m. the Administrator said they were supposed to have 3 nurses on days and 4 aides. On nights they had two nurses and 2 to 3 aides but then they have not fully transitioned to 12-hour shifts and some of the staff work form 6p to 2p, 2p to 10 p and 10 p to 6a, and then some staff worked from 6a to 6p and from 6p to 6a. The Administrator said they used the schedule in the book at the nurse's station that the staff sign when they come in as their staffing schedule. The Administrator said they did not have a Nurse Staff Information sheet posted. Record review of the facility Resident Census and Conditions of Residents Report-(Form 672) dated 9/18/23 indicated they had a census of 65 residents. The report indicated independent residents were 4 residents that were capable of bathing independently, 2 residents that were independent for dressing, 11 residents independent for transfers, 10 that were independent for toilet use, and 9 that were independent for eating. The report indicated the residents that required the assistance of one or two staff were 33 for bathing, 60 for dressing, 49 for transfers, 49 for toilet use and 51 for eating. The report indicated resident's dependent for assistance were 28 for bathing, 3 for dressing, 5 for transfers, 6 for toilet use, and 5 for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 29 of 41 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 10/04/2023 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 0725 Record review of the facility Care Plan Item Task Listing Report indicated on Monday 9/18/23 they had 26 residents scheduled for showers and no resident received a shower that day or night. Level of Harm - Actual harm Residents Affected - Some 1. Record review of Resident #1's face sheet dated 9/19/23 indicated she was a [AGE] year-old female initially admitted to the facility 10/4/23. Some of her diagnoses were Spinal Stenosis(narrowing of the spinal column that causes pressure on the spinal cord._ Morbid obesity disease of upper respiratory tract, pain of unspecified joint, unsteadiness on feet, abnormalities of gait and mobility. She had anxiety disorder, and history of heart attack. Record review of Resident #1's quarterly MDS dated [DATE] indicated she was cognitively intact. Resident #1's bed mobility and transfer assistance were listed as extensive assistance with two people physical help. Record review of Resident #1's care plan dated 8/29/23 indicated a potential for pressure ulcer development and one of the interventions was to ensure incontinent care was provided after each episode. One Focus was the resident had the potential for uncontrolled pain. One of the interventions was to monitor the probable cause of each pain episode, remove or limit the cause if possible. Resident #1 had a focus area of desired independence in activities and would attend activities of choice. The resident loved the appetizer program, [NAME] and helping the Activity Director. She also liked therapy. The resident had a Focus are of bladder incontinence and one of the interventions was to apply barrier cream after each incontinent episode, and incontinence care at least every two hours. Resident #1 had a Focus are of self-care performance deficit. She required assisted of one staff for bed mobility, dressing, toileting, encourage the resident to use call light for assistance, and she used a wheelchair for ambulation. Record review of Resident #1's physician order dated 11/15/21 indicated the resident needed to be up in chair for all meals. An order dated 2/523 may use oxygen at 4 liters by nasal cannula, every shift. An order dated 7/23/23 for acetaminophen 500 mg give two tables by mouth as needed for pain. During an observation and interview on 9/18/23 beginning at 2:57 p.m. Resident #1's call light was on. The Activity Director went in the room and turned the call light off. She came out and told CNA A who was at the cart gathering supplies that Resident #1 said she need assistance. The Activity said Resident # 1 was waiting on an aide to come and change her. CNA A said she was going to assist a resident in another room and then she would help Resident #1. When the ADON and the investigator went in the room to check on Resident #1 CNA A came in to see if she could help, the resident at that point. During an observation and interview on 9/18/23 beginning at 3:02 p.m. Resident #1 was observed lying in bed. Resident #1 said she was soaking wet, her bed was wet, the sheets, the gown, and she had been laying in urine since early this morning. She said the last time she was changed was about 8:00 a.m. Resident #1 said she knew they were short staffed and doing the best they could. However, she was told before 11:00 a.m. they were going to try and get her up and then before 2:00 p.m. they were going to get up. Resident #1 said she had been waiting all day. Resident #1 started to cry. The Resident said she knew she was not the easiest person to provide care for. She said CNA A had come in her room only to turn off her call light and say they would be back. She said they had told her she was getting up by 11:00 a.m. to be a part of activities. They have appetizers at 11:00 a.m. and she had missed the appetizers, and she really enjoyed that activity. Resident #1 said she did not like to stay in bed all day and she had been made to miss all activities. Resident #1 said she was out of oxygen on her chair and aide came in and said she would bring some back. Resident #1 stated the aide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 30 of 41 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 10/04/2023 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 0725 Level of Harm - Actual harm Residents Affected - Some brought in a brief, put it on the dresser and said they would be back. She told them to just put her in a gown because the day was mostly gone, the aide took down a gown and put it on the bed side table. Resident #1 said CNA A sit the gown on the bedside table and left and promised her they were coming back. Observation showed the brief on the dresser and the gown on the bedside table. Resident #1 said she was supposed to have a shower today. She said the aide told her she was not giving her a shower on today, because the shower aide was out. Resident #1 said she did not always get her showers like they are scheduled. She should get them on MWF and often only got two a week instead of three. She said most days they get her up and provide care like they are supposed to, but it depended on who was working or not working that day. Resident #1 said they would often come in and turn the call light off and say they would be back in a minute, and it would be a long time before they did. She said she would usually have to put the call light on again to receive assistance. Observation of Resident #1 with the ADON revealed she had on a brief; the brief was wet and soggy. The draw sheet, and sheet had a large wet area, and her gown was wet. Resident #1 said she had to eat her lunch in a wet soiled bed, and she was very uncomfortable. She said because she had laid down so long, she was hurting and asked the ADON for some Tylenol. During an observation and interview on 9/18/23 beginning at 3: 20 p.m., ADON P was seen with a medication cup taking medication to Resident #1's room. ADON P said she had Resident #1's Tylenol. During an interview on 9/18/23 beginning at 3:47 p.m., the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. During an interview on 9/18/23 at 4:12 p.m., CNA A said this was her third day on the job. She started to work at 6 a.m. this morning and it was just her and CNA B today, all day long. She said she had not given any showers and had a hard time trying to answer call lights. She said that Resident #1 had requested to get up all day and changed but she was just trying to keep up as best she could. She said she had apologized to Resident #1 but was doing the best she could. There were a few residents she had not gotten up today. She said she did not have any Hoyer lifts on that hall but Resident #1 should be a Hoyer lift transfer. She said that she had the short hall today and it had 25 residents. During an interview on 9/19/23 at 8:45 am., the Activity Director said Resident #1 liked to come to activities every day. The Activity Director said she had something called appetizers where they offered different foods and all the residents loved that. She said Resident #1 liked to be up by 11 a.m. During an interview and observation on 9/19/23 beginning at 9:00 a.m. Resident #1 was laying in her bed. She said staff had promised her today they would get her up by 10:00 a.m. She said she had to be weighed every day and would like to get a shower today since she missed yesterday. She said that it was painful for her to lay in bed all day and night. Resident #1 said she felt agitated, angry, and hopeless because she was dependent on someone else for help. She said her feelings were hurt that the staff basically lied to her all day. 2. During an observation and interview on 9/18/23 at 3:13 p.m. Resident #2 was sitting on his bed, fully dressed, and said he did not get a shower today. They are short staffed, and he was supposed to get one on Saturday, but Thursday was his last shower. He said he did not know what his regular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 31 of 41 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 10/04/2023 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 0725 Level of Harm - Actual harm scheduled shower days were because, he may or may not get one. Resident #2 said some days they would offer, and it might be any day of the week. Resident #2 said he usually only got about two showers a week and sometimes one. Resident #2 said that was his only problem he goes to the bathroom unassisted and did not really need anything else. Residents Affected - Some 3. During an observation and interview on 9/18/23 at3:24 p.m. Resident #3 was observed in bed. Resident #3 she had not been changed since early this morning, but the pads hold a lot, and they would probably be in in another hour to change her. Observation of her brief with the ADON's assistance revealed it was wet and soggy, but the sheets were not wet. Resident# 3 said she did not receive a shower today and she was supposed to have them on MWF. Resident # 3 said no one asked her if she wanted a shower today, she knew they were short staffed and at least once a week missed a shower. Resident #3 said she did get a shower on Friday. 4. During an observation and interview on 9/18/23 at 3:40 p.m. said Resident #5 said the aides did not get her up today they were short staffed. Resident #5 said she liked to eat breakfast in the dining room. She said a staff was trying to put two briefs on her and she said no. Resident #5 said the CNA had recently changed her. Resident #5 said she required a Hoyer lift and they have not gotten up since Friday. Resident #5 said she stayed in bed all weekend because they did not have staff to get her up or they were too lazy to do so. Resident #5 said she did not take a shower today said there was not anyone here to give a shower. Resident #5 said she liked to go to some of the activities and see some of her friends. Resident #5 said she had pulled her call light and told the aide she needed help to straighten up in bed. She said she was told by the aide she needed some help and did not come back. Resident #5 said the facility needed more help. During an interview and observation on 9/18/23 beginning at 3:47 p.m. the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. 5. During an interview and observation on 9/18/23 at 3: 56 p.m. observation showed Resident #6 had her call light on. Resident said she had been waiting a while. She said the aide had come in at least once and turned the off the light. Resident #6 refused to allow the interim DON and the investigator to see how wet she was. She said she had a BM also. Resident #6 started to cry. During an interview on 9/18/23 at 3:58 p.m. CNA B said she had been in Resident #6's room, but had not changed her since about 11:00 a.m. She said she knew she should have been in the room more frequently to change Resident #6 and she was trying to get to her as quickly as she could. She said it was just her and another aide in the building. CNA B said she came in at 6:00 a.m. this morning and it had just been her and one other aide all day. She was trying as hard as she could to take care of all the residents, but she was overwhelmed. She had the long hall with 20 residents, she also had 17 residents on the unit. She said on the unit they had about 3 residents that went to the bathroom themselves, but all the residents needed to be assisted with toileting. She said there were 3 residents on the hall at the back that were assigned to her. CNA B said she had 9 residents that required Hoyer lift transfers or two people assist and she had gotten up who she could today. She said the administrative staff were aware they were short staffed. She said some of the office staff had helped to pass breakfast and lunch trays and pick up trays. She said all staff were answering call lights but if the residents needed changing the staff usually just turned off the light and informed her what they needed. She said she had not given any showers today. She said she had about 40 residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 32 of 41 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 10/04/2023 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 0725 total. CNA B said some days they have 4 or 5 aides on the halls and some like today they were short staffed. She began to cry and said she was tired and overwhelmed. Level of Harm - Actual harm Residents Affected - Some During an interview on 9/18/23 at 4:12 p.m. CNA A said it took her about 10 minutes a resident to clean them up but if they had had a large or runny BM it could take her longer and in-between, she was trying to keep most of the residents satisfied. She said by the time she got to one end of the hall it was past time to start on the other end of the hall. She said every resident that required assistance had been assisted at least once today. However, there had not been every two-hour care today. The administration was aware they were short staff. Some of the office staff had helped to pass and take up breakfast and lunch trays. If they had not done so it could have been worse. She said the administrative staff had also helped to answer call lights with small things, but if care needed to be provided. She had done the care as best she could manage. During an interview on 9/18/23 at 4:20 p.m. the ADON said short hall had 25 residents and CNA A was working that hall today. She said the long hall had 20 residents and CNA B was working that hall today. She said on the secure unit they had 17 residents and SNA H who was on restricted duty due to having a sling on her arm was on the secured unit. The ADON said when SNA H needed help, she would come and get someone. She said on the unit some were continent, but they all needed supervision. During an interview on 9/18/23 at 4:35 p.m. SNA H she said she had been hurt on the job while trying to assist a resident. She will not see the doctor until 10/14/23 for a release and mean while she was not supposed to lift more than 5 pounds. She had been assigned to the secured unit today. She said she was not familiar with the residents on the unit she usually worked up front. She said the only thing she could do was turn off lights and try to make beds. During an interview on 9/18/23 at 4:45 p.m. LVN C said that all together she had worked at the facility for about 29 years. She said they had 17 residents on the unit. She said that they had about 3 that were continent, but they all required supervision, with toileting. LVN C said she helped when she could. She said they needed more staff. During an interview on 9/18/23 at 5:50 p.m. ADON said they get shower sheet check offs when showers are complete. She said there are no shower sheets for today. 6. During an interview on 9/18/23 at 6:02 p.m. #18 had his call light on. He said he was wet and needed to be changed. He said that he has no idea when his showers are scheduled. There is no rhyme or reason to when he gets a shower. He said on Saturday he got a shower because he had bad diarrhea. He did not know when he had received one before then. Two aides from day shift went to change him. During an interview on 9/19/23 at 4: 57 a.m. CNA K said she was leaving at 5a.m., she had completed her rounds, and SNA D was taking over. During an interview on 9/19/23 at 5:00 a.m. SNA J said she had not done any showers the night before. 7. During an interview and observation on 9/19/23 at 5:05 p.m. SNA D said she was getting residents up on the secured unit. She said CNA K said on the night shad not gotten anyone up. Observation of room Resident #15 room showed him standing beside the bed with the aide trying to direct him. He had his right leg behind him and could not seem to understand he needed to turn to sit in the wheelchair. He sat down on the wet bed several time before he was able to turn around and sit in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 33 of 41 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 10/04/2023 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 0725 Level of Harm - Actual harm Residents Affected - Some wheelchair. SNA D said the night shift staff had left the resident wet. Observation of the sheets on the bed showed they were wet, and the plastic mattress had a pool of liquid in on the mattress. SNA D said the Resident #15 was that wet with urine. Resident #15 would not speak when spoken to him, he would only smile and nod. SNA D said she was mad because the resident should not have been left in that kind of condition. Observation of the bag where Resident #15's brief was showed a wet and soggy brief. SNA D said it took her about 10 to 15 minutes to get each resident cleaned up and dressed. It depended on how soiled they were or like Resident #14 how confused they were. She said she would take the solid brief and sheets and come back later to make the bed. The beds had to be sanitized and let dry and then put the sheets on them. 8. During an observation and interview on 9/19/23 at 8:30 a.m. of Resident #16 showed in in the bed with his bed facing the door. He said that he had told them when the aides he wanted to be turned around and straightened up in the bed. They had come in and tuned off the call light and said they would be back. He said he was uncomfortable, and he could not watch his TV from the way the bed was turned. During an observation and interview on 9/19/23 at 9:21 a.m. Resident #16 said he had pulled his call light again. He said the staff were supposed to be coming to turn him around but had not. At 9:31 a.m. CNA M went in to assist the resident. SNA E and CNA M said that they were aware the resident wanted to be turned but they had to do some else first. During an interview on 9/19/23 at 10:10 a.m. the Corporate RN said residents should have their showers completed according to their shower schedule. She said if the shower showed not applicable it either was not done or it was on the shower sheet tool and did not get transcribed over. She said showers should be completed in the computers under the task, and they could be scheduled or PRN showers. Reviewed bath sheets from the computer system for 9/2023 indicated: Resident #7 should have had a shower/bath on 9/6, 9/11, 9/15, 9/18/23 a shower was done on 9/13/23. PRN bath 9/8/23. Clinical alert showed no showers 3 days prior to 9/7, 9/12, and 9/16/23. Resident #4 did not received bath on 9/8 and 9/13/23. Resident #8 had no showers on 9/12, 9/14, 9/16/23. Last shower was 9/15/23 PRN Resident #9 had no showers noted 9/5-9/19/23. Showers should be TTHS Resident #10 had 1 shower on 9/16/23, no other showers. Showers should be TTHS Resident #11 had shower on 9/7 and 9/12/23, no other showers. Showers should be TTHS Record review of the facility Care Plan Task Listing Report indicated they had 26 residents that were to receive showers on MWF and 39 that were to receive showers on TTHS. . During an interview on 9/19/23 at 1:25 p.m. Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 34 of 41 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 10/04/2023 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 0725 Level of Harm - Actual harm He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said when he pulled the call light staff would come in and turn the light off tell him they will come back but do not always come back to help him. Residents Affected - Some During an interview on 9/19/23 at 1:40 p.m. LVN C said it was hard to get showers for the secured unit due to resident cognition and behaviors, most residents received showers. LVN C said she believed Resident # 8 and Resident # 9, and Resident # 10 refused the showers today. LVN C stated CNAs will report when residents refused showers. During an interview on 9/19/23 at 1:45 p.m. SNA D said Resident # 8 refused his shower today but let her shave him. She said most likely he would take a shower tomorrow. She documented refusals. She said Resident #9 got a shower today but is unsure of the rest of the month. Resident # 10 got a shower today, but she was sure of the rest of the month- she was out over 10 days this month. Sometimes SNA E would shower residents for her when she helped in the secure unit, but she was not sure about her documentation. During an interview on 9/19/23 at 1:50 p.m. SNA E said she worked in the secured unit sometimes. She said she gave showers to Resident #9 and Resident #10 last week she thought she documented them on the computer. SNA E said she worked the unit with SNA D. She struggles to give showers on both units because of lack of staff. During an interview on 9/19/23 at 2:20 p.m. Corporate RN, Interim DON, and Administrator are both trying to cover the schedules. She is unsure what shifts/positions the facility currently has open because she does not normally cover this facility. She said she talked with upper management today on trying to get agency in to help with staffing concerns until the facility gets stabilized. During an interview on 9/20/23 at 9:00 a.m. the Administrator and Area Director of Operations were informed of the concerns with ADL care and residents not receiving showers. They said they had gotten the ADL deficiency on 9/3/23 and had not had a chance to correct the problem. They had just received their deficiencies. They said they were aware of the problem on 9/3/23 and had conducted an in-service. They said the deficiency had already been cited; however, they could not say why the ADL issues had not been fixed. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern is there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. She said the way they treat the residents by making them stay in bed all day was cruel and abusive. Record review of an in-service dated 9/3/23 indicated staff were informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift. It will be reported to the oncoming nurse and aide. During an interview on 9/19/23 at 1:25pm Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 35 of 41 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 10/04/2023 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 0725 when he pulled the call light staff would come in and turn the light off tell him they will come back but don't always come back to help him. Level of Harm - Actual harm Residents Affected - Some During an interview on 9/20/23 at 9:15 a.m. Resident #17 said She said they were always short staffed, and it took long periods of time for them to answer the call light most days. During an interview on 9/20/23 at 11:28 a.m. LVN C said she had never been the only nurse in the building. She said she has occasionally had to split long hall with maybe the ADON or DON but normally she stayed on the secure unit. She said she has seen staffing be shorter here recently, but she had never been the only one here. She is unsure who worked with her on the 14th, but she is sure she wasn't the only one alone in here. She said that the short staffing had not affected her, but she is sure that it could possibly affect others getting tasks done up front. During an interview on 9/20/23 at 11:35 a.m. LVN F said she had a worked several times where she was here with only nurse in the facility. She said normally when that happens its only for a couple of hours until they get another nurse in to assist. She said the facility was frequently short staffed on CNAs and when they are short staffed with CNAs the residents did not get changed as frequently as they need or get turned/repositioned as much. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern is there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. She said the way they treat the residents by making them stay in bed all day was cruel and abusive. Just let them lay there Record review of an in serviced dated 9/18/23 indicated staff were informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurses notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 36 of 41 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 10/04/2023 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 0728 Level of Harm - Minimal harm or potential for actual harm Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review the facility failed to ensure the competency of a certified nurse aide for 6 of 13 CNA's reviewed (SNA D, I, J, L N, and O.) Residents Affected - Many They failed to ensure the nurse aides were certified, and or trained in a state approved training program. They failed to provide evidence the nurse aide had received proficiency training and passed their test for SNA D and SNA J prior to 9/10/23 as required by the waiver program. They failed to ensure SNA I, L, N, and O were certified nurse aides prior to assuming full CNA duties without the oversite of another CNA. This failure placed residents at risk of not receiving proper ADL care. Findings included: Record review of employee files indicated: SNA D had a hire date 3/10/21 had LTCR form 3767 for Nurse Aide Work Training and Work Experience indicated she had training between 5/12/22 and 6/22/22. The form was notarized on 8/24/22. SNA J had a hire date 2/25/22- had LTCR form 3767 for Nurse Aide Work Training and Work Experience indicated she had training between 5/12/22 and 6/8/22. The form was notarized on 8/24/22. SNA O had a hire date 6/30/23SNA L had a hire date 7/20/23- only CNA training such as a proficiency of Nurse Aide Incontinence SNA N had a hire date7/21/23SNA I had a hire date 8/23/23- only CNA training such as a proficiency of Nurse Aide Incontinence Review of Long-Term Care Regulatory Provider Letter 2023-05 dated May 8, 2023, indicated the end of Temporary Waivers during Covid Public Health Emergency. Indicated Nurse aides hired after 5/11/23 had 4 months from the date of hire to be certified. Nurse aides hired before 5/11/23 had until 9/10/23 to become certified. Nurse aides hired before 5/11/23 and worked more than 4 months had until 9/10/23 to be certified. Note this wavier did not suspend requirements for supervision or competencies. During an interview on 9/18/23 at 6:25 p.m. SNA I said she had worked at the facility one month and was not a certified CNA. She said she was working from 6a to 6p. independently. During an interview on 9/18/23 at 6:27 p.m. SNA J said she had worked at the facility for two years. She has tried to get her license two times, but they messed her paperwork up. She said she was working from 6 a to 6 p. independently. During an interview on 9/1823 at 6:55 p.m. HR said she did not keep any files related to the CNA training it was the DON that did all that and kept up with the paperwork. She said that she checked to see if they had a certification when they first started employment and passed that information on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 37 of 41 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 10/04/2023 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 0728 to the DON and that was all she did. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/18/23 at 7:40 p.m. with SNA I and SNA J said they work independently and helped each other if they need assistant with a resident. They had not been told they needed any one to watch over them when they provide care to residents. They said they did the same job as a regular CNA. Residents Affected - Many During an interview on 9/19/23 at 5:00 a.m. SNA J said she was a SNA for two years. She had taken phase I, II, and III however the former DON had put her information into the system wrong on two occasions and she had not been able to test. She said they had not done any showers the night before. During an interview on 9/19/23 at 6:12 a.m. SNA L said she worked at the facility since 7/19/23 she had not scheduled to take her test. She said she had taken her the CNA training about 10 years ago but never tested. She said when she first started, she did some training on the computer and she worked with another CNA for a few days to know how to care for residents. She said she did a peri care check off with the ADON. She said she now worked independently when providing care to a resident unless she needed another aide to assist her with a resident that required two people. During an interview on 9/19/23 11:10 a.m. Corporate RN said they should not have hired the SNA I and SNA L after the waver had ended. She said according to the provider letter the waiver period had ended. They had gone back to CNAs in training prior to the pandemic. She said even if they had paperwork, it did not mean anything if they do have records they are still training. She said the SNA were not qualified to work as CNAs unsupervised. She said at least half of the facility aides were SNAs. During an interview on 9/19/23 at 1:20 p.m. HR manager said that none of the SNA had CNA certification SNA D, SNA I, SNA J, SNA L, SNA N, or SNA O. Record review of Temporary Non-Certified Nurse Aide Transition to Certification Guide for Nurse Aide Training and Working Under Waiver (113.) dated 2/3/22 Indicated once an employee's paperwork was completed. On days two and day three phase one and two competencies and the Texas curriculum for nurse aides in long term facility Section 1 introduction for long term care was completed. There should be 16 hours completed before a TNA works with a resident. On days four- phase one and two competency feeding training check off as competency in skills are mastered. Record review Phase 1 competencies for aides indicated supervisor will initial each part of the procedure if performed correctly. The competencies were hand hygiene, putting on and removing personal protective equipment, assisting with meals, feeding the dependent resident, choking, bathing, shower, incontinent care. oral care, hygiene care, dressing and undressing a resident, bedpan assistance urinal assistance, emptying Foley catheter bag, postmortem care bed mobility, assisting residents to sit on the side of the bed in pushing a resident in a wheelchair. There was no documentation SNA I, L, N, and O had taken these trainings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 38 of 41 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 10/04/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to have a Nurse Staff Information sheet posted. Residents Affected - Many The facility staff were unable to determine how many staff were supposed to be in the building for one of one facility. This negative finding did not allow staff or visitor to determine the number of staff needed to provide care to the facility residents. Findings included: During an observation of the facility on 9/18/23 at 6:17 p.m. reflected they did not have a Nurse Staff Information sheet posted. During an interview on 9/18/23 at 6:18 p.m. the Administrator said they were supposed to have 3 nurses on days and 4 aides. On nights they had two nurses and 2 to 3 aides but then they have not fully transitioned to 12 hour shifts and some of the staff work form 6p to 2p , 2p to 10 p and 10 p to 6a. and then some of her staff worked from 6a to 6p and from 6p to 6a. The Administrator said they used the schedule in the book at the nurse's station that the staff signed when they come in and they not have a Nurse Staff Information sheet posted. During an interview on 9/18/23 at 6:20 p.m. when asked for the facility Nurse Staff Information sheet that was supposed to be posted, the ADON, Interim DON, and Administrator appeared to know what the Facility Nurse Staff Information sheet was or why they needed to have one posted. The ADON said it may be one of her duties to post the staffing daily, but no one instructed her to do so, and she had not had time to complete ADON duties because of being on the floor working as a nurse. The Interim DON called cooperate to determine what needed to be on the sheet and getting it posted. During an interview and record review on 9/18/23 at 6:35 p.m. Interim DON printed out a form and tried to explain to the ADON and the administrator what went on the form but neither one knew how to fill it out. The Administrator said her former DON was the one that posted the form and she had been gone for two weeks. The Interim DON said she put the documentation on the Nurse Staff Information sheet from the daily staff sign in sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 39 of 41 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 10/04/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a resident with a diet that met his daily nutritional and special dietary needs for 1 of 5 residents reviewed for diet (Resident # 4.) The facility did not ensure Resident #4's physician ordered diet of no bread and no pasta was followed. This negative finding could cause residents discomfort and digestive issues. Findings Included: Record review a Resident #4 face sheet dated 9/20/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were depression, Alzheimer's, disease, constipation, and muscle weakness. Record review of an admission MDS dated [DATE] indicated Resident #4 did not have any cognitive impairment. Resident #4 required supervision with eating with set up help only. Record review of Resident #4 care plan dated 6/8/23 indicated he had a focus area of ADL self-care performance deficit. One of the interventions were the resident required assistance by staff to turn in reposition in bed as necessary. Resident required assistance by staff with showering, the resident required assistance with a dressing and personal hygiene and toilet use. Resident #4 had a diet order for a regular diet dated 6/21/23. Record Review of Resident #4's computerized physician orders indicated he had an order dated 6/3/23 for a regular diet, regular texture, regular consistency with no bread and no pasta. Record review of a Nutritional Risk assessment dated [DATE] indicated Resident #4 had a regular diet served as orders. Resident #4 stated he tried to stick to a gluten free diet when possible. He stated he was not real strict. Note for no bread or pasta to be served with meals. The assessment indicated Dietary Staff aware of food preferences. During an interview on 9/20/23 at 11:45a.m. Resident #4's family member said Resident #4 was supposed to be on Gluten Free Diet and they bring him things he cannot eat like pasta and bread. During an observation and record review on 9/20/23 beginning at 12:00 p.m. observation of Resident #4's lunch tray contained some meat over rice, veggies, and egg roll. Review of the meal slip for 9/20/23 did not show any special notes restrictions, likes or dislikes During an interview on 9/2/23 at 12:20 p.m. Dietary manager was shown Resident #4's lunch slip for 9/20/23. She said that the Residents family member complained about Residenrt#4 not eat this or that, but the resident did not complain. The Dietary Manager said she did not have any information about him not getting bread or pasta. She said the dietician recommendations had not been sent to her yet. After the Dietary Manager reviewed the dietician recommendations, for July 2023. The Dietary Manager noted Resident #4 had a physician order that said no bread or pasta. The Dietary Manager said she was not aware of the diet restrictions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 40 of 41 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 10/04/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #4's Nursing -Dietary Communication Form provided by the Dietary Manager dated 6/3/23 indicated the resident was on a regular diet. During an interview on 9/20/23 at 12:44 p.m. CNA G said that Resident #4 ate most of his food. He was served bead at times. Sometimes he got biscuits, rolls, and cornbread. She said he had never complained to her about his meals. She said sometimes he ate good and sometimes not so good. Record review of Resident #4's Nursing -Dietary Communication Form dated 9/20/23 indicated the resident was on a regular diet. With no bread and no pasta. During an interview on 9/20/23 at 12:57 p.m. the Interim DON said she had the Dietary Communication Form was fixed to include the physician order for no breads and no pasta on with Resident #4's meal. During an interview on 9/20/23 at 1:04 p.m. Resident #4 said he was having bowel issues. He said they had not been giving him the gluten free food, he hated having the diet but understood why he needed it. He was not sure if the bowel issues were because of not following his diet or because of him taking a lot of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 41 of 41