Health inspection·November 2, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and understood others. Resident #106's BIMS score was 15 indicating her cognition was intact. The section of Resident Mood Interview indicated Resident #106 had not felt down, depressed or hopeless, had not had little interest or pleasure in doing things. The section of Resident #106's MDS indicated she had no physical, verbal, or other behaviors. The section of the MDS of Preferences for Customary Routine and Activities Resident #106 indicated it was very important for her family or a close friend to be involved in discussions about her care. The section of the MDS Medications indicated Resident #106 received an anti-depressant during the last 7 days. Record review of a psychotropic medication consent dated 11/01/2023 at 1:24 p.m., indicated a consent for the use of Wellbutrin (Bupropion) was obtained from Resident #106. This consent was obtained 15 days after admission and after administration of Wellbutrin to Resident #106. Record review of a psychotropic medication consent dated 11/01/2023 at 1:27 p.m., indicated a consent for the use of sertraline was obtained from Resident #106. This consent was obtained 15 days after admission and after administration of sertraline to Resident #106. During an interview on 11/02/2023 at 4:30 p.m., LVN R said all psychotropic medications require a consent prior to administration. LVN R said she would ask the resident or call the responsible party for the consent. LVN R said Resident #106's medications should not be provided until consent was obtained. LVN R said the nurse taking the order for the psychotropic medication was responsible for obtaining consent to administer. During an interview on 11/02/2023 at 5:51 p.m., the ADON said the admitting nurse was responsible for obtaining the psychotropic medication consent. The ADON said the facility was responsible for obtaining consent for liability issues (administering medications) without a consent . During an interview on 11/02/2023 at 7:31 p.m., the Administrator said psychotropic medication consents should be obtained on admission. The Administrator said the resident and responsible party need to understand and agree to the medication administration. The Administrator said the admitting nurse was responsible for ensuring the consent was obtained. The Administrator said nurse managers should be pulling up the new admission records to follow up on psychotropic medication use and need for consent. During an interview on 11/02/2023 at 8:26 p.m., the Corporate Regional Compliance nurse said nursing was required to have consents for psychotropic medications to administer the psychotropic. The Corporate Regional Compliance nurse said when the consent was obtained the side effects were discussed, and then the resident or the responsible party could agree or not agree. The Corporate Regional Compliance nurse said the DON, and ADON were responsible for monitoring the psychotropic consents. 2. Record review of Resident #24 face sheet dated 09/11/23, indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24's diagnoses included Alzheimer's disease (memory loss), diabetes (too much sugar in the blood), high blood pressure, and depression (persistent feeling of sadness). Record review of Resident #24's order summary report dated 11/02/23, indicated she had an order for risperidone 1mg give one tablet by mouth one time a day for Alzheimer's with an order start date of 10/18/23. Record review of Resident #24's admission MDS assessment dated [DATE], indicated she was able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 2 of 56 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 11/02/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few make herself understood and understood others. The MDS assessment indicated Resident #24 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS did not indicate Resident #24 had any behaviors, delusions, hallucinations or wandered. Resident #24 required limited assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of Resident #24's comprehensive care plan dated 09/15/23, indicated Resident #24 required anti-psychotropic medications. The care plan interventions included to administer medications as ordered, monitor/document for side effects and effectiveness and consult with physician to consider dose reduction when clinically appropriate. Record review of Resident #24's EMR on 11/02/23, did not reveal a psychotropic consent was obtained for the use of risperidone. During an interview on 11/02/23 at 06:11 PM the ADON said the charges nurses were responsible for getting a consent for medication upon admission or when they received the order. The ADON said the risk to Resident #24 was for her to have received medications without wanting to take the medication. The ADON said Resident #24 also could have had a reaction to the medication and she may not have wanted the medication or not known what the medication was. During an interview on 11/02/23 at 07:38 PM the Administrator said all psychotropic medications were expected to have had the consents to be completed on admission or when medication was ordered. The Administrator said the risk to Resident #24 was for her not knowing what medication she was taking and not knowing the risks of the medications. She said the resident may be unaware of what are they were being given or they may not agree with the medication being given. The Administrator said the charge nurse was responsible for ensuring the consents were completed, and the nurse management should be monitoring to ensure consents were in place. During an interview on 11/02/23 at 08:28 PM the RCN said psychotropic medications should have had consents to have permission for the resident to have it, and for the resident and responsible party to be aware of the side effects of the medication. The RCN said charge nurse was responsible and ADON and DON should have been monitoring the consents. She said the risk to resident was the resident may not want the medication or their responsible party may not have been ok with them taking the medication. Record review of the Nursing Facility Residents' Rights policy dated November 2021 indicated the resident had the right to participate in their care Receive information about prescribed psychoactive medication from the person who prescribes the medication or that person's designee. Have the right to have any psychoactive medication prescribed and administered in a responsible manner as mandated by the Texas health and Safety Code, and to refuse to consent to the prescription of psychoactive medications. Record review of the facility's policy titled Psychotropic Drugs revised on 10/25/17, indicated . The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . Consent . A psychotropic consent form explains the risk and benefits of psychotropic medication. The resident or their representative must provide documented consent prior to administration of a newly ordered psychotropic medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 3 of 56 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 11/02/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide all necessary information and any other documentation to ensure a safe and effective discharge for 1 of 2 residents reviewed for discharge. (Resident #54) The facility failed to document Resident #54's reason for being discharged from the facility. These failures could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Record review of Resident #54's face sheet dated 11/02/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54's diagnoses included dementia with behavioral disturbance (memory loss with behaviors), psychotic disorder with delusions (mental disorder characterized by disconnection of reality often accompanied by disturbances of thought and perception), depression (persistent feeling of sadness), and anxiety. Record review of Resident #54's comprehensive care plan dated 09/25/23, indicated Resident #54 had potential to demonstrate physical behaviors with a goal she would not harm herself or others. The care plan interventions included to notify the charge nurse of any physical abusive behaviors and intervene before agitation escalates. The care plan also indicated Resident #54 had a potential to demonstrate verbally abusive behaviors and indicated a resident-to-resident altercation on 09/07/23. The care plan interventions initiated on 10/4/23, included for medication adjustment, Resident #54 was placed on one-on-one monitoring with staff and psychiatric services referral ordered for behavior management. Record review of Resident #54's discharge MDS assessment dated [DATE], indicated it was an unplanned discharge. The MDS assessment indicated Resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #54 had verbal behavioral symptoms directed toward others which occurred 1 to 3 days within the lookback period. The MDS indicated Resident #54 wandered daily. The MDS indicated Resident #54 required substantial/maximal assistance with toileting, showering and lower body dressing. Record review of Resident #54's progress note dated 10/05/23 at 09:45 AM and signed by RN F, indicated Resident enroute with staff member to [receiving facility] with all meds and personal belonging. No behaviors this am (morning). The progress note did not indicate the reason for discharge. Record review of Resident #54's discharge summary report dated 10/05/23, under section 3, brief history, indicated . Resident responding well to staff this am. No behaviors this am. signed by RN F. The discharge summary report was not signed by Resident #54's physician and it did not contain the information about the basis for the discharge which included the specific resident needs the facility could not meet, the efforts to meet those needs, and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility. Record review of Resident #54's order summary report dated 11/02/23, indicated she had an order to refer to psychiatric services due to increase behavior with a start date of 10/5/23. The order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 4 of 56 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 11/02/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm summary report also indicated Resident #54 had an order for one-on-one monitoring with an order date of 10/03/23. The order summary report did not reveal a physician's order for discharge. During an interview on 11/02/23 at 11:55 AM, the ADON said RN F was hospitalized and unable to be interviewed. Residents Affected - Few During an interview on 11/02/23 at 1:48 PM, the SW said the state had come recently for a complaint regarding behaviors on the secure unit. The SW said Resident #54 was being racist towards the other residents. The SW said due to the behaviors they looked for alternate placement and sent Resident #54 to another facility. The SW said the lady from the state advised Resident #54 to be moved to another facility and that was not something they had wanted to do and felt they had no choice. The SW said they called Resident #54's family member and the ombudsman was notified. During an interview on 11/02/23 at 2:01 PM, Resident #54's family member said the facility notified her that Resident #54 was being transferred to another facility the day before she discharged on 10/4/23. Resident #54's family member said she understood what happened but did not like how quickly the discharge happened. Resident #54 said she was informed from the facility that it was an emergency transfer because of her aggressive behavior towards other people. Resident #54's family member said they had to get her out of the facility as soon as possible. Resident #54's family member said she had no choice of which facility to send her to and would have liked to have Resident #54 sent to a facility closer to her as Resident #54 was now 2 hours away. During an interview on 11/02/23 at 2:30 PM, the Ombudsman said she was notified of Resident #54's discharge regarding her behaviors. During an interview on 11/02/23 at 03:13 PM, the Administrator said Resident #54 was the aggressor and was identified as being a threat to the other residents at the facility. The Administrator said she called Resident #54's family member, and she agreed with the discharge and informed her they had found a safe placement for Resident #54. The Administrator said she notified the ombudsman of the transfer, and the transfer was done regarding the plan of correction for the previous IJ (immediate jeopardy) situation at the facility. During an interview on 11/02/23 at 6:34 PM, the Administrator said the discharge summary was completed by the nurse and should summarize the reason for discharge. The Administrator said Resident #54 should have had an order for discharge. The Administrator said the nurse discharging the resident was responsible for obtaining the order for discharge. The Administrator said Medical Records sent the discharge summary to the physician for it to be signed. The Administrator said Resident #54 discharge summary did not reflect the reason she was being discharged from the facility. During an interview on 11/02/23 at 7:55 PM, the Regional Compliance Nurse said the discharge summaries were completed by the nurse and the ADON and DON oversee that it was completed. The Regional Compliance Nurse said the discharge summary should include the summary of their care, what they needed, and the plan once they discharge. The Regional Compliance Nurse said Resident #54's discharge summary should have been more detailed and should include the reason for discharge. The Regional Compliance Nurse said they had verbally talked with the regional managers but unsure of where it was documented. The Regional Compliance Nurse said Resident #54 should have had a physician's order for discharge and since she did not have one Resident #54 should have not been discharged as it did not show release from the facility. The Regional Compliance Nurse said the physician should have had signed the discharge summary indicating he approved of the discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 5 of 56 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 11/02/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's undated policy titled Discharge Planning Process Policy indicated . Nursing facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility Discharge summary must include: A) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent labs, radiology and consultant results .C) A final summary of the resident's status medical and functional status at the time of discharge . Event ID: Facility ID: 675801 If continuation sheet Page 6 of 56 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 11/02/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents reviewed for baseline care plans. (Resident #106) The facility failed to develop a baseline care plan that addressed Resident #106's risk to fall, use of psychotropic medications, use of an assistive devices, abnormal gait, history of falls, unsteadiness of feet, and muscle weakness. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #106'd#106's face sheet dated 11/02/2023 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of history of falls, abnormal gait, muscle weakness and unsteadiness on feet. Record review of a fall risk assessment dated [DATE] indicated Resident #106 had a history of falls in the last 1-2 months, she was chair bound and required assistance with elimination, balance problem with standing, and walking, decreased muscular coordination, and required assistive devices. The fall risk assessment indicated Resident #106 had taken medications in the last 7 days that could contribute to the fall risk. The Fall-Risk assessment indicated Resident #106 was at High Risk to fall. Record review of an admission MDS assessment dated [DATE] indicated Resident #106 understood others and was understood. Resident #106's BIMS score was 15 indicating her cognition was intact. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #106 used a walker and a wheelchair. The MDS indicated Resident #106 had cataracts. The MDS indicated in Section J170D Fall History Resident #106 had a fall in the last month prior to admission. During an interview on 10/31/2023 at 10:00 a.m., the MDS nurse said the baseline care plan was not initiated or completed. The MDS nurse said the admission assessment areas triggers the problem areas to be included on the baseline care plan. The MDS nurse said she had been off work with Covid 19 and had not followed up on Resident #106's baseline care plan. The MDS nurse said the base line care plan indicated the care Resident #106 required. During an interview on 10/31/2023 at 11:20 a.m., the admitting nurse LVN E said she had completed the baseline care plan for Resident #106 but was unsure why the care plan was not visible to anyone. LVN E said the baseline care plan directed Resident #106's care needs. During an interview on 11/2/2023 at 5:37 p.m., the ADON said the baseline care plan should be completed on admission by the admitting nurse. The ADON said by not completing the baseline care plan care needs could be missed. The ADON said the baseline care plan directs Resident #106's care. The ADON was unsure who monitors the completion of the baseline care plans. During an interview on 11/2/2023 at 6:50 p.m., the Administrator said the first line nurse should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 7 of 56 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 11/02/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have completed the baseline care plan. The Administrator said the baseline care plan was a tool used to provide care to the residents. The Administrator said the baseline care plan ensured the best care was provided. During an interview on 11/2/2023 at 8:17 p.m., the Corporate Compliance nurse said nurses could care plan the items triggered from the assessment. The Corporate Compliance nurse said the nurse managers should monitor and open a baseline care plan if the admitting nurse had not done so. Record review of an undated Base Line Care Plan policy and procedure indicated completion and implementation of the baseline care plan within 48 hours of a resident's admission was intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that were most likely to occur right after admission; and to ensure ethethe resident and representative, if applicable were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan .The facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary. The medical record will contain evidence that the summary was given to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 8 of 56 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 11/02/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 19 residents (Resident #'s 207, 50, 19, 20, 34, and 33) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #207's comprehensive care plan addressed that she received olanzapine (antipsychotic medication). The facility failed to ensure Resident #50's siderails, and risk of dehydration were care planned. The facility failed to ensure Resident #19's siderail was care planned. The facility failed to ensure Resident #20's siderails were care planned. The facility failed to ensure Resident #33's Covid 19 infection was care planned. The facility failed to ensure Resident #34's risk of Covid 19 infection was care planned. These failures could place residents at risk of not receiving necessary medications and services, and decreased quality of life. Findings included: 1. Record review of Resident #207's face sheet dated 11/02/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #207 diagnoses included dementia (memory loss), delirium (type of confusion), high blood pressure, and atrial fibrillation (irregular heart rate). Record review of Resident #207's comprehensive care plan dated 09/28/23 did not indicate Resident #207 was receiving olanzapine. Record review of Resident #207's admission MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #207 had a BIMS score of 7 which indicated her cognition was moderatelyseverely impaired. The MDS indicated Resident #207 was taking antipsychotic medication during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #207's order summary report dated 11/02/23, indicated she had the following orders: *Olanzapine 2.5mg give one tablet by mouth at bedtime for depression with an order start date of 09/24/23. *Olanzapine 5mg give one tablet by mouth at bedtime for depression with an order start date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 9 of 56 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 11/02/2023 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 0656 10/23/23. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #207's MAR for October 2023, indicated she had been receiving olanzapine 2.5mg at bedtime and olanzapine 5mg at bedtime since 10/24/23 after her most recent readmission to the facility. Residents Affected - Some During an interview on 11/02/23 at 4:28 PM, LVN R said Resident #207's antipsychotic medications should have been care planned. LVN R said all medications should be care planned as it was part of the resident's care. LVN R said the MDS nurse was responsible for care planning the medications. During an interview on 11/02/23 at 5:43 PM, the ADON said Resident #207's antipsychotic medications should have been care planned as it was part of the resident's care. The ADON said the MDS nurse was responsible for care planning the medications. During an interview on 11/02/23 at 6:34 PM, the Administrator said Resident #207's antipsychotic medications should have been care planned. She said the comprehensive care plan was a personalized instruction book. The Administrator said Resident #207 receiving antipsychotic medication should have been reflected on her care plan. The Administrator said she was not clinical so she was unsure of the risks of why Resident #207 should have had her antipsychotic medication on her plan of care. The Administrator said the charge nurse and the DON were responsible for the acute care plans and the MDS nurse was responsible for updating the care plans quarterly and annually. During an interview on 11/02/23 at 7:48 PM, the MDS nurse said she was responsible for the comprehensive care plans and quarterly updates. The MDS nurse said nursing was responsible for the acute care plans and baseline care plans. The MDS nurse said Resident #207 should have had her antipsychotic medication care planned to monitor for side effects and behaviors. The MDS nurse said failure to care plan Resident #207's antipsychotic medication placed Resident #207 at risk for not having psychotropic monitoring. The MDS nurse said she would not have known Resident #207 was receiving antipsychotic medication until the next MDS assessment was completed. During an interview at 07:55 PM, the Regional Compliance Nurse said she expected Resident #207's antipsychotic medications to be care planned so anyone can be aware of why Resident #207 was taking the medication and the need to monitor for side effect and behaviors. The Regional Compliance Nurse said the nursing team was responsible for the acute care plans and the MDS nurse was responsible for the comprehensive care plan when she completed a significant change or quarterly MDS. The Regional Compliance Nurse said by not having Resident #207's antipsychotic medication care planned the person taking care of her would not know what to monitor for. 2. Record review of a face sheet dated 11/02/2023 indicated Resident #34 originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of memory deficit, anxiety, and high blood pressure. Record review of the Annual MDS dated [DATE] indicated Resident #34 was usually understood and usually understands others. Resident #34's MDS indicated her BIMS was a 15 indicating she was cognitively intact. The MDS indicated Resident #34 required supervision of one staff to walk in the room and corridor. Record review of the consolidated physician orders dated 11/02/2023 failed to reveal Resident #34 was on droplet isolation precautions due to her exposure to Resident #33. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 10 of 56 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 11/02/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #34's comprehensive care plan dated 1/10/2022 failed to reveal Resident #34 was on isolation precautions for exposure to Covid 19 and was at risk of contracting the virus herself. 3. Record review of a face sheet dated 11/02/2023 indicated Resident #33 admitted on [DATE] with the diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, or posture. Cerebral palsy is due to abnormal brain development often before birth). The list of diagnosis failed to reveal Resident #33 was diagnosed with Covid 19. Record review of an Annual MDS dated [DATE] indicated Resident #33 was understood and understood others. The MDS indicated Resident #33's BIMS score was a 14 indicating her cognition was intact. Record review of the comprehensive care plan dated 1/10/2022 failed to reveal Resident #33 had the Covid 19 virus and was on droplet isolation precautions. Record review of the physician's orders dated October 2023, indicated Resident #33 was ordered Vitamin C 500 milligram give 6 tablets one time a day for 10 days for the diagnosis of Covid. Record review of the consolidated physician's orders dated November 2, 2023, failed to reveal Resident #33 was placed on Covid 19 droplet isolation precautions. Record review of the progress notes dated 10/22/2023 indicated Resident #33 tested positive for Covid 19. The progress note indicated Resident #33 and Resident #34 who were family also shared a room were notified of the positive test. The progress note indicated Resident #33 chose to continue to reside with her family member regardless of the risks involved. 4. Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the left side. Record review of a Quarterly MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19's BIMS score was 15 indicating her cognition was intact. The MDS indicated Resident #19 required extensive assistance of two staff for bed mobility, transfers, and personal hygiene. The MDS indicated Resident #19 required limited assistance of two staff for dressing and one staff for toileting. In section P Restraints and Alarms revealed Resident #19 was not coded as having a bed rail in use. Record review of the comprehensive care plan dated 1/09/2023 indicated Resident #19 used hypnotic therapy and was at risk to have falls. The comprehensive care plan failed to address Resident #19's side rail. Record review of the physician's orders dated November 2, 2023, failed to reveal any ordered siderails/bedrails. Record review of Resident #19's electronic medical record failed to provide a siderail/bedrail assessment or a consent for use. During an observation on 10/30/2023 at 10:05 a.m., Resident #19 was lying in her bed. Resident #19 had a ½ sized bed rail to the right side of her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 11 of 56 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 11/02/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Record review of a face sheet dated 11/02/2023 indicated Resident #20 was an [AGE] year-old female who admitted originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of stroke, Alzheimer's disease (dementia), abnormal gait and mobility, falls, head laceration, and muscle weakness. Record review of a Quarterly MDS dated [DATE] indicated Resident #20 was usually understood, and usually understands others. The MDS indicated Resident #20 had a BIMS score of 00 indicating she had severe cognitive deficit. The MDS also indicated Resident #20 was not oriented and was not able to demonstrate any recall. The MDS indicated Resident #20 required extensive assistance of two staff with bed mobility, transfers, dressing. The MDS indicated Resident #20 required extensive assistance of one staff with eating, and personal hygiene. Section P Restraints and Alarms indicated bed rails were not used. Record review of Resident #20's consolidated physician orders dated 11/02/2023 did not reveal physician's ordered bedrail/siderails. Record review of Resident #20's electronic medical record failed to reveal a bedrail/siderail assessment or a consent for use. During an observation on 10/30/2023 at 2:29 p.m., Resident #20 was transferred to her bed. Resident #20's bed was against the wall on the left-hand side, and she had a half rail on the right side of her bed. 6. Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. Record review of the Quarterly MDS dated [DATE] indicated Resident #50 was understood, and usually understood others. The MDS indicated Resident #50's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #50 required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS indicated Resident #50 required extensive assistance of one staff member for walking, dressing and personal hygiene. In section P Restraints and Alarms indicated Resident #50 had not used bed rails. Record review of Resident #50's comprehensive care plan dated 3/23/2023 revealed she was at risk to fall. The care plans interventions were to keep the environment safe. The ADLs care plan indicated Resident #50 had a self-care deficit and required assistance with be mobility to turn and reposition in bed. The comprehensive care plan failed to indicate Resident #50 was at risk for dehydration or had siderails. Record review of Resident #50's dehydration risk screen conducted on 2/27/2023 indicated she was at risk for dehydration. Record review of Resident #50's consolidated physician orders dated 11/02/2023 revealed there was no ordered siderails or bedrails. Record review of Resident #50's electronic medical record revealed there was not a bedrail/siderail assessment completed or a consent for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 12 of 56 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 11/02/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/30/2023 at 3:30 p.m., Resident #50 was in her bed. Resident #50 has her legs elevated in the air and appears to be stretching them. Resident #50 has ½ bedrails up on each side of her bed. During an interview on 11/02/2023 at 4:51 p.m., LVN R said the MDS Coordinator was responsible for the care plan. LVN R said the care plans guided the care of the residents. LVN R said she had not updated the care plan as the charge nurse. During an interview on 11/02/2023 at 5:40 p.m., the ADON said the MDS Coordinator was responsible for creating the care plan. The ADON said she will refer would confer with the MDS Coordinator when she had a problem requiring care planning. The ADON said the care plan directs the residents care and should include all aspects of the resident's care. The ADON said she was unsure if the charge nurses knew how to formulate a care plan. During an interview on 11/02/2023 at 6:50 p.m., the Administrator said the care plan was a personalized instruction book for the resident. The Administrator said the MDS Coordinator was responsible for the care plans. The Administrator said she hoped to have the charge nurses trained on how to care plan care needs. The Administrator said the risk was the resident would not receive their personalized care. During an interview on 11/02/2023 at 8:19 p.m., the Corporate Compliance nurse said without the care plan staff would not know the care needs of the residents. The Corporate Compliance nurse said the MDS Coordinator was responsible for the comprehensive care plan to include the use of siderails for Resident #'s 19 ,20, and 50, risk of dehydration for Resident #50 , and isolation precautions for Resident #33 and 34 Record review the facility's undated policy titled Comprehensive Care Planning indicated . The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 13 of 56 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 11/02/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 4 (Resident #50) residents reviewed for care plan revisions. The facility failed to ensure Resident #50's care plan was updated when she moved from the secured unit to the general community. on 10/19/2023. TThe facility failed to ensure Resident #50's care plan was updated when she was no longer an elopement risk . These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included : Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. The face sheet indicated Resident #50 was residing in room [ROOM NUMBER]. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #50 was understood, and usually understood others. The MDS indicated Resident #50's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #50 required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS indicated Resident #50 required extensive assistance of one staff member for walking, dressing and personal hygiene. Record review of Resident #50's comprehensive care plan dated 3/23/2023 revealed she was at risk for wandering and had exit seeking behaviors, and she resided on the secure unit. The comprehensive care plan was not revised to indicate Resident #50 was no longer at risk to elope from the facility and Resident #50 resided in the general community of the facility. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #50 was bed bound, or unable to propel herself. During an observation on 10/30/2023 at 3:30 p.m., Resident #50 was in her bed in room [ROOM NUMBER] B . Roo 122 B was on the general community side of the nursing facility. Resident #50 was not interviewable. During an interview on 11/02/2023 at 5:54 p.m., the ADON said the MDS Coordinator was responsible for the revision of the care plan. The ADON said the care plan should be updated to not miss care needs of the residents. The ADON was unsure how the care plan was being monitored. During an interview on 11/02/2023 at 6:50 p.m., the Administrator said the MDS Coordinator was responsible for the revision of the care plan. The Administrator said the care plan should be up to date to ensure the best care provided. The Administrator said the care plan should tell staff how to care for Resident #50. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 14 of 56 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 11/02/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/02/23 at 7:48 PM, the MDS nurse said she was responsible for the comprehensive care plans and quarterly updates. The MDS nurse said nursing was responsible for the acute care plans and baseline care plans. During an interview on 11/02/2023 at 8:27 p.m., the Regional Compliance nurse said the care plan should be revised with any changes. The Regional Compliance nurse said the MDS Coordinator was responsible for revision of the care plan. The Regional Compliance nurse said when the care plan was not revised the care plan would not reflect the resident's needs. The l Compliance nurse said Resident #50's care plan should reflect a picture of the resident. A revision of the care plan policy was requested by not provided. Event ID: Facility ID: 675801 If continuation sheet Page 15 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 11/02/2023 indicated Resident #34 originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of memory deficit, anxiety, and high blood pressure. Residents Affected - Some Record review of the Annual MDS assessment dated [DATE] indicated Resident #34 was usually understood and usually understands others. Resident #34's MDS indicated her BIMS was a 15 indicating she was cognitively intact. The MDS indicated Resident #34 required supervision of one staff for ambulation. The MDS indicated she required extensive assistance of one staff with bathing and supervision and setup for personal hygiene. Record review of the MDS in the section Behaviors there were no behaviors documented in the area of refusal of care. Record review of Resident #34's comprehensive care plan dated 1/10/2022 indicated Resident #34 had an ADL self-care deficit and the goal was her needs were met on a daily basis. The interventions in the care plan included Resident #34 required assistance with showering, dressing, person hygiene including oral care, and toileting. Record review of the comprehensive care plan failed to reveal any care planned rejection of care with ADLs. During an interview on 10/30/2023 at 11:06 a.m., Resident #34said she had not been showered in a week. Resident #34 said her shower days were Monday, Wednesday, and Friday. Record review of the electronic medical record for bathing indicated Resident #34 was scheduled to shower on Monday, Wednesday, and Friday after 12:00 p.m. The electronic medical record indicated for the month of October 2023 Resident #34 received one shower. The electronic medical record indicated Resident #34 missed 12 opportunities for a shower. Record review of the shower sheets for Resident #34 indicated she was showered on October 11, 2023, and October 18, 2023. There were no other shower sheets provided indicating further bathing opportunities. 3). Record review of a face sheet dated 11/02/2023 indicated Resident #33 admitted on [DATE] with the diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, or posture. Cerebral palsy is due to abnormal brain development often before birth). Record review of the Annual MDS dated [DATE] indicated Resident #33 understood others and was understood. The MDS indicated Resident #33 BIMS score was 14 indicating her cognition was intact. The MDS indicated in section of Behaviors Resident #33 had not rejected care. In section GG Functional Abilities and Goals was dependent with showers and personal hygiene. Record review of the comprehensive care plan dated 1/10/2022 failed to reveal Resident #33 had an ADL deficit. Record review of the electronic medical record indicated for bathing failed to indicate any baths or showers were documented as provided for the month of October 2023. Record review of the shower sheets provided for Resident #33 indicated Resident #33 was showered on 10/11/2023 and 10/18/2023. The facility failed to provide any other shower sheets for review. Resident #33 missed 11 opportunities for showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 16 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/30/2023 at 11:06 a.m., Resident #33 said she had not been showered in a week. Resident #33 said her shower days were Monday-Wednesday-Friday. 4). Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the left side. Record review of a Quarterly MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19's BIMS score was 15 indicating her cognition was intact. The MDS indicated Resident #19 required extensive assistance of two staff for bed mobility, transfers, and personal hygiene. The MDS indicated Resident #19 required limited assistance of two staff for dressing and one staff for toileting. The MDS indicated Resident #19 required total assistance of one staff for bathing. The MDS in the section of Behaviors failed to indicate Resident #19 had demonstrated in behaviors including rejection of care. Record review of the comprehensive care plan dated 1/09/2023 indicated Resident #19 had an ADL self-care deficit. The goal of the care plan was Resident #19 would have her needs met on a daily basis. The interventions for Resident #19 were she required assistance on the part of bathing by the staff, nail care, and dressing. Record review of the electronic medical record dated October 2023 indicated Resident #19 had been showered on October 4, 9, and 11 of 2023. There were no other days documented for showering or any other type of bathing. During an observation and interview on 10/30/2023 at 10:05 a.m., Resident #19 was lying in her bed. Resident #19 said she had not had a bed bath in 6 days. Resident #19 went on to say she had not been showered in the last two weeks. Resident #19 said I feel so nasty. Resident #19 said she had a doctor's appointment today and was hoping to have a bath provided before leaving for the appointment. Resident #19 said her shower schedule was Tuesday, Thursday, and Saturday. Record review of shower sheets for Resident #19 indicated she was showered on October 2, 19, and 30 of 2023. There were no other shower sheets provided. 5). Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. Record review of the Quarterly MDS dated [DATE] indicated Resident #50 was understood, and usually understood others. The MDS indicated Resident #50's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #50 required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS indicated Resident #50 required extensive assistance of one staff member for walking, dressing and personal hygiene. Record review of the MDS in the section G bathing indicated Resident #50's activity did not occur. Record review of Resident #50's comprehensive care plan dated 3/23/2023 revealed she had an ADL deficit for self-care. The goal indicated Resident #50 would have her daily needs met. Resident #50's care planned interventions included she required assistance with showering, and personal hygiene including oral care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 17 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/30/2023 at 3:30 p.m., Resident #50 was in her bed in room [ROOM NUMBER] B. Resident #50 was not interviewable and appeared disheveled and unkempt. Record review of Resident #50's electronic medical record for bathing indicated there were no baths documented for the entire month of October 2023. Residents Affected - Some Record review of Resident #50's shower sheets provided indicated Resident #50 was bathed on October 11, 16, 18, and 25 of 2023. The facility failed to provide any other bath sheets. 6) Record review of a face sheet dated 11/02/2023 indicated Resident #20 was an [AGE] year-old female who admitted originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of stroke, Alzheimer's disease (dementia), abnormal gait and mobility, falls, head laceration, and muscle weakness. Record review of a Quarterly MDS dated [DATE] indicated Resident #20 was usually understood, and usually understands others. The MDS indicated Resident #20 had a BIMS score of 00 indicating she had severe cognitive deficit. The MDS also indicated Resident #20 was not oriented and was not able to demonstrate any recall. The MDS indicated Resident #20 required extensive assistance of two staff with bed mobility, transfers, dressing. The MDS indicated Resident #20 required extensive assistance of one staff with eating, and personal hygiene. The MDS indicated Resident #20 required extensive assistance of two staff for bathing. In the section Behaviors the MDS indicated Resident #20 had no rejection of care documented. During an observation on 10/30/2023 at 10:40 a.m., Resident #20 was sitting in her Broda chair (reclining chair). Resident #30#20 had brown material underneath her fingernails. Resident #30 had facial hair in the corners of her mouth. Resident #30 was not interviewable. Record review of Resident #20's electronic medical record dated October 2023 indicated a bath on October 7, 2023. The facility failed to provide any shower sheets for Resident #20. During an interview on 11/02/2023 at 3:45 p.m., the shower aide indicated she worked the shift 8:00 a.m. 4:00 p.m. when she was in the role as shower aide. The shower aide said she had been employed one month in her role. The shower aide said she often times has been moved from shower aide to working as the primary CNA and during those times she and the other CNAs would be responsible for their own shower schedule. The shower aide said the residents who have Covid 19 was were supposed to be showered on the evening shift for Resident #'s 33, 34, and 50. The shower aide said she had not removed the any female resident's facial hair unless they asked for it to be removed. The shower aide said her login for documenting was not working and she believed the other nurse aides were charting the showers. The shower aide indicated skin problems could occur without resident's receiving their baths. During an interview on 11/02/2023 at 4:00 p.m., LVN D said the shower schedule was A-bed day shift and B-bed evening shift. LVN D said the nurse aides were responsible for providing the showers and the nurses were responsible for ensuring the showers were provided. LVN D said she had been used of to receiving shower sheets for the residents who received baths. LVN D said residents should receive nail care when their nails were dirty. LVN D said the nurses monitored the nail care. LVN D said the nurse aides were responsible for removing facial hair. LVN D said female residents could feel unlike a lady with facial hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 18 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/02/2023 at 5:31 p.m., the ADON said she expected the residents to receive their baths as scheduled. The ADON said she had redone the shower schedule to ensure showers were provided. The ADON said she expected the nurses to monitor the showers and follow up when not provided. The ADON said the lack of bathing was neglect, could lead to skin issues, emotional issues, and affect their self-esteem. The ADON said she expected nail to be provided on Sundays and with showers. The ADON said she expected women with facial hair to have it removed. The ADON said facial hair on a woman could make them feel less of a woman. During an interview on 11/02/2023 at 6:52 p.m., the Administrator said she expected the CNAs to follow the bath list. The Administrator said she expected if a bath was refused this should be documented in the record. The Administrator said with missed documentation opportunities, no shower sheets provided, and residents saying they have not been bathed concluded not documented nothing happened. The Administrator said residents not receiving their scheduled bathing were at risk for skin breakdown. The Administrator said the CNAs were responsible for providing the showers and the nurses monitoringmonitored. The Administrator said the facility had attempted to ensure a shower aide was available to provide the showers but at times she had been working as the primary CNA. The Administrator said facial hair on a female would elicit individualized responses. During an interview on 11/02/2023 at 7:58 p.m., the Corporate Compliance nurse said she expected the baths to be provided according to the schedule. The Corporate Compliance nurse said she expected refusals to be documented. The Corporate Compliance nurse said not providing residents with bathing was not following their policy. 7. Record review of resident #11's face sheet dated 11/02/23, indicated she was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #11's diagnoses included Alzheimer's disease (memory loss), depression (persistent feeling of sadness), anxiety, high blood pressure, and seizures. Record review of Resident #11's annual MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #11 had a BIMS score of 14, which indicated her cognition was intact. The MDS did not indicate Resident #11 had any behaviors or refused care. Resident #11 required substantial/maximal assistance with showering/bathing. Record review of Resident #11's comprehensive care plan dated 09/22/23, did not indicate she needed assistance with showering/bathing. During an interview and observation on 10/30/23 at 11:06 AM Resident #11 said she only received one shower last week. Resident #11 said she was scheduled to receive a shower 3 days a week. Resident #11 said she liked to receive her showers routinely because she liked her hair washed and to be clean. Resident #11 said she felt good after receiving a hot shower and felt unclean by not receiving them. Resident #11 had upper lip hair that she said did not bother her and had not asked staff to remove. During an interview on 11/01/23 at 10:44 AM, Resident #11 said she was scheduled to receive a shower yesterday, 10/31/23, and had not received one. She said not receiving a shower made her feel like they (staff) don't care. Record review of Resident #11's point of care response history for bathing self-performance dated 11/1/23, indicated Resident refused showers on 10/3/23 and 10/7/23. The point of care response did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 19 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not indicate Resident #11 received or refused a shower for the following dates for the month of October 2023: 10/5/23, 10/10/23, 10/12/23, 10/14/23, 10/17/23, 10/19/23, 10/21/23, 10/24/23, 10/26/23, 10/28/23, and 10/31/23. Record review of Resident #11's showers sheets provided from the facility from 10/01/23-11/01/23, indicated Resident #11 had refused a shower on 10/3/23, 10/7/23, and 10/10/23. No further shower sheets for the month of October 2023 had been provided by the facility. Record review of Resident #11's progress note dated 10/07/23- 11/02/23, indicated on 10/7/23 resident refused her bed bath/shower 3 times stating she did not feel like it and signed the refusal. There were no further refusals documented since 10/07/23. During an interview on 11/02/23 at 3:52 PM, CNA G said she had been a shower aide for a month and worked from 8:00 AM to 4:00 PM. CNA G said she provided the morning showers and Resident #11 was scheduled for the night shift. CNA G said Resident #11 had refused her showers before but was unsure if she had been refusing her showers recently since she had not provided a shower to her. On 11/02/23 at 4:09 PM call was placed to CNA CC, who worked the night shift, with no response. Record review of the facility's shower scheduled on 11/01/23, indicated Bed A received their showers on the day shift and Bed B received their showers on the night shift. Even room numbers received their bath/shower on Monday, Wednesday, Friday, and odd room numbers received their showers on Tuesday, Thursday, Saturday. The shower schedule also indicated . any refusals should be documented by the charge nurse and all shower sheets required a signature. Resident #11 was scheduled to receive her showers on Tuesday, Thursday, Saturday on the night shift per the shower schedule. During an interview on 11/02/23 at 4:28 PM, LVN R said Resident #11 refused her showers a lot of the times and said she had discussed it with the family member the day before on 11/01/23. LVN R said Resident #11 tended to say she wanted the shower in the morning and then when they would go get her, she would refuse. LVN R said the CNA who was scheduled for that hall was responsible for providing the showers. LVN R said the charge nurse was responsible for overseeing the showers were being provided. LVN R said they usually received a shower sheet indicating the number of times the resident refused. LVN R said since Resident #11 did not have shower sheets to show shower was refused, did not have documentation on the point of care system the shower was provided or refused, and did not have documentation in the progress notes that the showers were refused, then she would take Resident #11's shower had not been provided or offered. LVN R said not providing showers as scheduled placed the residents at risk for skin issues. During an interview on 11/02/23 at 5:34 PM, the ADON said she had redone the shower schedule to know who was responsible for providing the showers. The ADON said if she had to work the floor, she did not fill out a shower sheet all the time as she just provided the showers. The ADON said she was responsible for ensuring the showers were being provided. The ADON said by not providing the showers as scheduled the residents were at risk for skin issues and neglect. During an interview on 11/02/23 at 6:34 PM, the Administrator said she expected the showers/baths to be given per the shower schedule and to accommodate personal preference and needs. The Administrator said if a resident refused her shower/bath she expected the staff to reattempt. The Administrator said if it was not documented it did not happen. The Administrator said not providing showers as scheduled placed the resident at risk for skin breakdown. The Administrator said the CNA assigned to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 20 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that hall was responsible for ensuring the showers were being provided as per the shower schedule. The Administrator said the charge nurse was responsible for ensuring the CNAs were providing the showers as scheduled or charting the resident refusals. During an interview on 11/02/23 at 7:43 PM, the CNA O said she worked 6:00 PM- 6:00 AM shift and sometimes took care of Resident #11. CNA O said Resident #11 tended to refuse her showers most of the time. CNA O said she would notify the charge nurse of any refusals and fill out a shower sheet. CNA O said if it was not documented that the resident refused or that she received a shower then that indicated Resident #11 was not offered a shower. CNA O said it was their responsibility to ensure the showers or baths were being provided as scheduled. CNA O said the charge nurse was responsible for ensuring the CNAs were providing the showers/baths as scheduled. CNA O said by not providing the showers as scheduled the resident was at risk for skin breakdown. During an interview on 11/02/23 at 07:55 PM, the Regional Compliance Nurse said she expected the showers/baths to be provided as per the bathing schedule. The Regional Compliance Nurse said showers were provided 3 times a week and as needed. The Regional Compliance Nurse said the nurse was responsible for ensuring the showers/baths are provided and documenting refusals. The Regional Compliance Nurse said by not providing showers/ baths as scheduled the CNA was not following the facility's policy. The Regional Compliance Nurse said since there was no documentation of refusals or showers given then there was no way of knowing ADLS were being provided. Record review of the facility's policy titled Bath, Tub/Shower dated 2003 indicated . Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation . Goals . 1. The resident will experience improved comfort and cleanliness by bathing. 2. The resident will maintain intact skin integrity. 3. The resident will be free from soil, odor, dryness, and pruritus following bathing . Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 7 of 12 residents reviewed for quality of life. (Resident #'s 7, 11, 19, 20, 33, 34, and 50) The facility failed to provide facial hair removal/shaving for dependent female Resident #7. The facility failed to ensure Resident #'s 50, 33, 34, and 19 received their scheduled baths. The facility failed to ensure Resident #20's nails were clean and free of a brown colored material. The facility failed to ensure Resident #20 was free of facial hair. These failures could place residents who were dependent on staff to perform personal hygiene at risk of embarrassment, decreased self-esteem, or decreased quality of life. The findings included: 1. Record review of Resident #7's face sheet, dated 11/1/2023, revealed Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hyperlipidemia (blood has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 21 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some too much fat), type 2 diabetes mellitus without complications ( characterized by high levels of sugar in the blood),hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (symptom that involves one-sided paralysis), unspecified lack of coordination ( Uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Record review of Resident # 7's MDS assessment, dated 9/15/2023, indicated Resident #7 had a BIMS score of 15, indicating Resident #7 was cognitively intact, indicating she understood others as well as being understood. The MDS revealed Resident #7 had no behaviors or rejection of care during the look-back period. The MDS revealed Resident #7 required supervision with a one-person assistance for dressing, toilet use, and personal hygiene. Record review of Resident #7's comprehensive care plan, last revised on 8/29/2023, revealed Resident #7 has an ADL self-care performance deficit. Care plan goals included maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The care plan interventions include, Resident # 7 requires extensive assist of one staff toileting, dressing, transfers, mobility, and personal hygiene. During an observation on 10/30/2023 at 9:50 AM, Resident # 7 was observed with facial hair on the corners of her mouth and on her chin. During an observation on 10/31/2023 at 8:40 AM, Resident # 7 was observed with facial hair on the corners of her mouth and on her chin. During an observation and interview on 11/1/2023 at 11:20 AM, Resident # 7 was observed with facial hair on the corners of her mouth and on her chin after a shower. Resident # 7 stated she would like the facial hair removed however the staff has never offered to remove it and she didn't know they would remove facial hair. During an interview on 11/02/2023 at 3:52 PM, with CNA G stated she didn't notice Resident #7 had facial hair. CNA G stated she had been working at the facility for one month. CNA G stated she shaves the residents that want to be shaved. CNA G stated she was really scared of cutting the residents. CNA G stated she has given Resident #7 one shower and didn't notice her having facial hair. CNA G stated some people like to be shaved and some don't because it will grow back faster. CNA G stated she wouldn't want facial hair left on her. During an interview on 11/02/2023 at 4:29 PM, LVN R stated she was responsible for monitoring the CNA's. LVN R stated she expect the shower aides to shave and pluck the ladies if needed. LVN R stated it was important to remove facial hair because it was part of the grooming, if the residents want it removed. LVN R stated it could make the residents feel not very ladylike. During an interview on 11/02/2023 at 5:31 PM, the ADON stated CNAs are expected to do the task of facial hair removal and this should be offered during showers. The ADON stated it was her responsibility to monitor the CNAs. The ADON stated the importance of removing facial hair was because it could make them feel less of a woman. During an interview on 11/2/2023 at 6:35 PM, the ADM stated she expects CNAs to ensure female residents don't have hair on their chin. The ADM stated it was the responsibility of the nurse to monitor the CNAs. The ADM stated she monitors by observation. The ADM stated the importance of removing facial hair was for their dignity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 22 of 56 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 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gilmer Nursing and Rehabilitation 703 Titus Street Gilmer, TX 75644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/2/2023 at 7:58 PM, the Corporate Compliance nurse stated she expect the CNAs to offer facial hair removal as part of ADL's and should be offered during showers. The Corporate Compliance nurse stated the charge nurses were responsible for monitoring. The Corporate Compliance nurse stated this could make female residents feel self-conscious. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 23 of 56 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 11/02/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 9 residents (Resident #'s 19, and 106) reviewed for accidents and supervision. The facility failed to ensure Resident #19 was free from 2 bottles of wound cleanser, and one plastic medication cup with a white cream at her bedside. The facility failed to implement any interventions to prevent Resident #106's fall on 10/25/2023. These failures places residents at risk for injury and serious injuries. The findings included: 1). Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the left side. Record review of a Quarterly MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19's BIMS score was 15 indicating her cognition was intact. The MDS indicated Resident #19 received an application of ointments in Section M1200. Record review of the comprehensive care plan dated 1/09/2023 indicated Resident #19 had a traumatic injury to her left calf and required wound care until 10/21/2023 when the wound was resolved. Record review of the physician's orders dated November 2, 2023, revealed Resident #19 had an order for barrier cream as needed, and an order to cleanse a wound to the left lower extremity with normal saline, daily. During an observation and interview on 10/30/2023 at 10:05 a.m., Resident #19 was lying in her bed. Resident #19 had a medicine cup with a white colored cream in the cup and she had two bottles of wound cleanser on her bedside table. Resident #19 said she had a wound to her left leg and the nurses treated the wound daily. Resident #19 was unsure how long the white cream or the wound cleanser spray had been on her bedside table. 2). Record review of Resident #106's face sheet dated 11/02/2023 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of history of falls, abnormal gait, muscle weakness and unsteadiness on feet. Record review of a fall risk assessment dated [DATE] indicated Resident #106 had a history of falls in the last 1-2 months, she was chair bound and required assistance with elimination, balance problem with standing, and walking, decreased muscular coordination, and required assistive devices. The fall risk assessment indicated Resident #106 had taken medications in the last 7 days that could contribute to the fall risk. The Fall-Risk assessment indicated Resident #106 was at High Risk to fall. The fall risk assessment failed to indicate interventions placed to prevent Resident #106 from falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 24 of 56 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 11/02/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Record review of an admission MDS dated [DATE] indicated Resident #106 understood others and was understood. Resident #106's BIMS score was 15 indicating her cognition was intact. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #106 used a walker and a wheelchair. The MDS indicated Resident #106 had cataracts. The MDS indicated in Section J170D Fall History Resident #106 had a fall in the last month prior to admission. Residents Affected - Few Record review of an Event Nurses note dated 10/25/2023 at 4:57 p.m. indicated Resident #106 was found by the medical records staff sitting on the floor counting her money and eating. The note indicated Resident #106 said she was ambulating with her walker and fell onto the floor. The note indicated Resident #106 said she always had falls. The event note indicated in the area of interventions: check all interventions that were in place prior to this fall and the answer marked was none of the above. The note indicated Resident #106 was reminded to use the call light when needing assistance. The event note indicated the intervention put in place for this fall was bed low . The event note indicated Resident #106 had previous falls, unsteady gait, leans forward, balance problem, and lack of mobility strength. The environmental factor indicated Resident #106 was a new admission, and the cognition area indicated she had cognitive impairment. During an observation and interview on 10/30/2023 at 4:00 p.m., Resident #106 was sitting in her wheelchair in her room. Resident #106 said she had not had to use her call light for any needs. Resident #106 said she showered herself. When asked about falls Resident #106 said she had fallen prior to admission and since admission. Resident #106 was unable to recall what she was doing when she fell since admitted to the facility. During an interview on 10/31/2023 at 10:00 a.m., the MDS nurse said the Resident #106's baseline care plan was not initiated or completed. The MDS nurse said the admission assessment areas triggers the problem areas to be included on the baseline care plan. The MDS nurse said she had been off work with Covid 19 and had not followed up on Resident #106's baseline care plan. The MDS nurse said the base line care plan would have indicated the care Resident #106 required and should have indicated her risk of falls. During an interview on 11/02/2023 at 5:40 p.m., the ADON said the care plan should be updated immediately to prevent falls and further future falls. The ADON said when the baseline care plan had not been completed there were no interventions to prevent Resident #106 from falling initially. The ADON said the white colored cream, and the wound cleanser should not be stored in the resident's room. The ADON said any resident who roamed could get these medications and use inappropriately. The ADON said all staff should monitor the resident's rooms to ensure medications were not stored at bedside. The ADON said the facility completed champion rounds (rounds by department heads to monitor rooms, patients, and patient care) to help monitor for inappropriate items at bedside. During an interview on 11/02/2023 at 7:19 p.m., the Administrator said the fall risk care plans should be in place to prevent initial falls, and then care plan should be revised with other falls. The Administrator said champion rounds were used for monitoring of items at bedside or other opportunities to correct in a resident's environment. The Administrator said nothing should be stored at the bedside that was not safe to be with children therefore should not be with the elderly. The Administrator said she expected these items to be stored properly by the person who used those items. During an interview on 11/02/2023 at 8:22 p.m., the Corporate Compliance nurse said the white cream in the medication cup and the wound cleanser should not be stored in a resident's room. The Corporate Compliance nurse said keeping these medications stored properly ensures a resident would not use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 25 of 56 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 11/02/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm the medication inappropriately. The Corporate Compliance nurse said the nurses and nurse aides were responsible for monitoring the rooms for the stored medications. The Corporate Compliance nurse also said the champion rounds should have caught these stored medications in the resident's room. The Corporate Compliance nurse said the baseline care plans should be completed on admission and reflect a resident being at risk to have an initial fall and interventions to prevent a fall. Residents Affected - Few Record review of an Items Not Allowed In Resident Rooms dated 4/13/2022 indicated Medications (includes all prescription and over the counter drugs except nitroglycerin, which must be ordered by the doctor through the Health Care Center). Note: a good rule of thumb has been established by the Food and Drug Administration whereby any products labeled Keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our resident, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. Record review of the undated Baseline Care plans policy indicated the baseline care plan will reflect the resident's stated goals and objectives and include interventions and address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting rom from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 26 of 56 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 11/02/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 2 residents (Resident #'s 21 and 50) reviewed for hydration. Residents Affected - Few The facility failed to ensure Resident #21, and Resident #50 received adequate hydration. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings included: 1). Record review of a face sheet dated 11/01/2023 indicated Resident #21 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (dementia), and diabetes. Record review of the Quarterly MDS dated [DATE] indicated Resident #21 was understood and understood others. Resident #21's BIMS score was 10 indicating moderately impaired cognition. The MDS indicated Resident #21 required extensive assistance of one staff with eating. Record review of the comprehensive care plan dated 7/06/2023 indicated Resident #21 had a self-care deficit and required assistance with ADLs. The interventions included the resident required assistance with meals to eat. Record review of Resident #21's physician orders indicated do not order labs notify the hospice provider. 2). Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. Record review of the Quarterly MDS dated [DATE] indicated Resident #50 was understood, and usually understood others. The MDS indicated Resident #50's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #50 required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS indicated Resident #50 required supervision of one staff for eating. Record review of Resident #50's comprehensive care plan dated 3/23/2023 revealed she was at risk to fall. The care plans interventions were to keep the environment safe. The ADLs care plan indicated Resident #50 had a self-care deficit and required assistance by staff to eat. Record review of Resident #20's#50's physician orders indicated on 3/20/2023 she was order to encourage fluids. Record review of a Dehydration Risk Screener dated 2/27/2023 indicated Resident #50 was at risk for dehydration. During an observation and interview on 10/30/2023 at 10:46 a.m., Resident #21 was lying in her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 27 of 56 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 11/02/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #21 had no fluids available in her room for consumption. Resident #21 said she was thirsty and requested a cup of coffee. Resident #21 was in droplet isolation for Covid 19. The surveyor activated Resident #21's call light. During an observation and interview on 10/30/2023 at 10:46 a.m., Resident #50 was lying in her bed. There were no fluids available in her room for consumption. Resident #21#50 said she was thirsty. Resident #'s 21 and 50 share a room and both residents had the Covid 19 virus and was were on isolation precautions. During an observation and interview on 10/30/2023 at 11:05 a.m., CNA N indicated prior to entering the resident's room she said I bet they want their coffee now. During the observation CNA N entered the room and asked Resident #21 and Resident #50 if they were ready for their coffee and both residents answered yes. CNA N returned with two 8-ounce Styrofoam cups with coffee. During an observation and interview on 10/31/2023 at 9:30 a.m., Resident #21 and Resident #50 neither had water available in their room. CNA N said Resident #'s 21 and 50 should have had water available in their room. CNA N obtained two 8-ounce Styrofoam cups with water for both Resident #'s 21 and 50. During an observation on 11/02/2023 at 10:30 a.m., Resident #21 was lying in her bed, she had warm water on her over the bed table. The over the bed table was against the wall not within reach of Resident #21. Resident #50 had a water pitcher with warm water on her over the bed table. The over the bed table for Resident #50 was across the room near the television. Resident #50 could not access her water. During an interview on 11/02/2023 at 4:57 p.m., LVN R said the hydration assessment was completed by the dietician. LVN R said water was to be always within reach for the residents. LVN R said Resident #'s 21 and 50 were at risk of dehydration and electrolyte imbalance when water was not available or within reach. During an interview on 11/02/2023 at 5:50 p.m., the ADON said she expected the CNAs to round and provide the residents with water. The ADON said Resident #'s 21 and 50 would need more water during this time since they both were ill with Covid 19. The ADON said dehydration was a risk when water was not available for each resident. During an interview on 11/02/2023 at 7:29 p.m., the Administrator said the CNAs were responsible for hydration rounds and was were responsible for ensuring water was within reach for each resident. The Administrator said without water the residents could become dehydrated. During an interview on 11/02/2023 at 8:23 p.m., the Corporate Compliance nurse stated each resident should have fluids available for consumption. The Corporate Compliance nurse said the CNAs were responsible for hydration pass and the nurses were responsible for monitoring. The Corporate Compliance nurse said residents were at risk for dehydration when water was not available for hydration. Record review of a Hydration Policy dated 2003 indicated the facility provides each resident with sufficient fluid intake to maintain proper hydration and health. The resident will receive sufficient amounts of fluids based on assessed need to prevent dehydration and promote optimum physiological functions daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 28 of 56 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 11/02/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 2 of 4 resident reviewed for quality of care. (Resident #6 and Resident #18) Residents Affected - Few The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #6. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #18. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: 1. Record review of Resident #6's face sheet dated 11/02/23, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), depression (persistent feeling of sadness), high blood pressure, congestive heart failure (heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (causes obstructive airflow from the lungs). Record review of Resident #6's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #6 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #6 required extensive assistance with bed mobility, locomotion, toileting, and personal hygiene. Resident #6 was totally dependent on staff for bathing. The MDS assessment had oxygen therapy checked as being received within the last 14 days of the lookback period. Record review of Resident #6's comprehensive care plan dated 09/13/23, did not indicate Resident #6 was receiving oxygen. Record review of Resident #6's order summary report dated 11/02/23, indicated she had an order for may use oxygen at 3 liters per minute via nasal cannula with a start date of 10/26/23. Record review of Resident #6's MAR for the month of October 2023, indicated she had been receiving oxygen at 3 liters per minute via nasal cannula since 10/26/23. During an observation on 10/30/23 at 11:02 AM, Resident #6 was lying in bed and receiving oxygen at 2 liters per minute via nasal cannula. During an observation on 10/30/23 at 2:28 PM, Resident #6 was lying in bed and receiving oxygen at 2 liters per minute via nasal cannula. During an observation on 10/31/23 at 8:36 AM, Resident #6 was lying in bed and receiving oxygen at 2 liters per minute via nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 29 of 56 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 11/02/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/01/23 at 08:40 AM, Resident #6 was sitting up in bed eating her breakfast and receiving oxygen at 2 liters per minute via nasal cannula. During an observation and interview on 11/01/23 at 3:33 PM, LVN R said oxygen was administered as per physician orders. LVN R said the TAR was completed every shift where it indicated the oxygen was checked and was set at the prescribed rate. LVN R went to Resident #6's room where she checked Resident #6's oxygen concentrator and indicated it was set at 2 liters per minute. LVN R reviewed Resident #6's orders and said Resident #6 had an order for oxygen at 3 liters per minute via nasal cannula and the oxygen should have been set at 3 liters per minute as ordered. LVN R said Resident #6 had not had complications to receiving less than the ordered amount of oxygen as her oxygen saturation was at 94%. LVN R said the nurse was responsible for ensuring the oxygen was set at the prescribed rate. LVN R said not setting the oxygen at the ordered amount could cause problems as Resident #6 could be not be receiving enough oxygen. During an interview on 11/02/23 at 5:57 PM, the ADON said oxygen should be administered as per the physician's orders. The ADON said the nurse was responsible for ensuring the resident was receiving the prescribed amount of oxygen. The ADON said Resident #6 should have been receiving oxygen at 3 liters per minute via nasal cannula. The ADON said Resident #6 not receiving oxygen as ordered could cause her to not receive enough oxygen and could cause her to have confusion. During an interview on 11/02/23 at 6:34 PM, the Administrator said she expected oxygen to be administered as ordered. The Administrator said the nurse was responsible for ensuring the oxygen was set at the ordered rate when doing their morning rounds and checking the TAR. The Administrator said she was unsure of the risks of the oxygen not being set at the correct rate. During an interview on 11/02/23 at 7:55 PM, the Regional Compliance Nurse said she expected oxygen to be administered as ordered. The Regional Compliance Nurse said the nurses were responsible for ensuring the oxygen was set at the ordered amount during their rounds. The Regional Compliance Nurse said not administering oxygen as ordered the resident was at risk for not receiving enough oxygenation or may be receiving too much oxygen. 2. Record review of Resident #18's face sheet, dated 11/2/2023, revealed Resident #18 was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) ( a disease that cause airflow blockage and breathing-related problems), hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (symptom that involves one-sided paralysis), unspecified lack of coordination (Uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), hyperlipidemia (blood has too much fat. Record review of Resident #18's MDS assessment, dated 9/19/2023, revealed Resident 18's BIM score was 13 indicating Resident #18 was cognitively intact, indicating he understood as well as being understood by others. The MDS assessment revealed Resident #18 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident # 18 was receiving oxygen therapy. Record review of Resident #18's care plan, revision date 8/29/2023, indicated Resident #18 received oxygen therapy at 2-4 liters per minute via nasal canula. Record review of Resident #18's order summary, dated 11/1/2023, indicated Resident #18 received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 30 of 56 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 11/02/2023 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 0695 oxygen therapy at 2liter per minute via nasal canula. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 10/30/2023 at 11:15 AM, Resident #18 was lying in bed wearing oxygen via nasal cannula. Resident #18's oxygen concentrator was set at 4 liters per minute. Resident #18 stated he wore oxygen all the time because he has COPD. Residents Affected - Few During observation on 10/31/2023 at 11:00 AM, Resident #18 was lying in bed, watching TV, wearing oxygen via nasal cannula. Resident #18's oxygen concentrator was set at 4 liters per minute. During observation on 10/31/2023 at 1:14 PM, Resident #18 was lying in bed, singing, wearing oxygen via nasal cannula. Resident #18's oxygen concentrator was set at 4 liters per minute. During an interview on 10/31/2023 at 1:14 PM, LVN L confirmed Resident #18's orders for O2 to be at 2 liter per minute and Resident #18 O2 was set on 4 liters per minute. LVN L stated it was her responsibility for ensuring the O2 was on the correct settings. LVN L stated it was important for Resident #18 to be on the correct O2 setting because he had COPD and could retain CO2 (carbon dioxide). LVN L stated the risk associated with not setting the O2 at prescribed rate could potentially put residents at risk for COPD exacerbation. During an interview on 11/02/2023 at 5:31 PM, the ADON stated it was the nurse's responsibility to follow the order for O2 in the facilities computerized documentation. The ADON stated it was important for the nurses to ensure O2 was on the correct settings per the orders every shift. The ADON stated the risk to the resident was too much O2 can cause hyperoxygenation. During an interview on 11/2/2023 at 6:35 PM, the ADM stated she expects the nurses to follow the doctor's orders. The ADM stated it was the responsibility of the nurse to monitor proper O2 setting and should be checked during rounds or medication pass. The ADM stated there was probably a list of risks to the resident if the O2 setting were incorrect, but she was not sure what they were. During an interview on 11/2/2023 at 7:58 PM, the Corporate Compliance nurse stated she expected the nurses to follow the orders. The Corporate Compliance nurse stated the charge nurse was responsible for monitoring when doing rounds. The Corporate Compliance nurse stated the risk to the resident was they may not be oxygenated enough or over oxygenated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 31 of 56 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 11/02/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 3 of 3 residents (Resident #'s 19, 20, and 50) reviewed for bedrails. 1.The facility failed to assess Resident #s 19, 20, and 50 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation for Resident #'s 19, 20, and 50. 3. The facility failed to document the attempt of alternatives to meet Resident #'s 19, 20, and 50 needs. These failures could place residents at risk for entrapment with serious injury and even death. Findings included: 1). Record review of a face sheet dated 11/02/2023 indicated Resident #19 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of unsteadiness on her feet, muscle weakness, fainting and collapse, and paralysis to the left side. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19's BIMS score was 15 indicating her cognition was intact. The MDS indicated Resident #19 required extensive assistance of two staff for bed mobility, transfers, and personal hygiene. The MDS indicated Resident #19 required limited assistance of two staff for dressing and one staff for toileting. In section P Restraints and Alarms revealed Resident #19 was not coded as having a bed rail in use. Record review of the comprehensive care plan dated 1/09/2023 indicated Resident #19 used hypnotic therapy and was at risk to have falls. The comprehensive care plan failed to address siderails. Record review of the physician's orders dated November 2, 2023, failed to reveal any ordered siderails/bedrails. Record review of Resident #19's electronic medical record failed to provide a siderail/bedrail assessment or a consent for use. During an observation on 10/30/2023 at 10:05 a.m., Resident #19 was lying in her bed. Resident #19 had a ½ sized bed rail to the right side of her bed. 2) Record review of a face sheet dated 11/02/2023 indicated Resident #20 was an [AGE] year-old female who admitted originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of stroke, Alzheimer's disease (dementia), abnormal gait and mobility, falls, head laceration, and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 32 of 56 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 11/02/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a Quarterly MDS dated [DATE] indicated Resident #20 was usually understood, and usually understands others. The MDS indicated Resident #20 had a BIMS score of 00 indicating she had severe cognitive deficit. The MDS also indicated Resident #20 was not oriented and was not able to demonstrate any recall. The MDS indicated Resident #20 required extensive assistance of two staff with bed mobility, transfers, dressing. The MDS indicated Resident #20 required extensive assistance of one staff with eating, and personal hygiene. Section P Restraints and Alarms indicated bed rails were not used. Record review of Resident #20's comprehensive care plan dated 4/09/2023 failed to reveal any alternatives to siderails trials prior to placing the siderails in place. Record review of Resident #20's consolidated physician orders dated 11/02/2023 did not reveal physician's ordered bedrail/siderails. Record review of Resident #20's electronic medical record failed to reveal a bedrail/siderail assessment or a consent for use. During an observation on 10/30/2023 at 2:29 p.m., Resident #20 was transferred to her bed. Resident #20's bed was against the wall on the left-hand side, and she had a half rail on the right side of her bed. 3). Record review of a face sheet dated 11/02/2023 indicated Resident #50 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (dementia), muscle weakness, and fracture of the sacrum. Record review of the Quarterly MDS dated [DATE] indicated Resident #50 was understood, and usually understood others. The MDS indicated Resident #50's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #50 required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS indicated Resident #50 required extensive assistance of one staff member for walking, dressing and personal hygiene. In section P Restraints and Alarms indicated Resident #50 had not used bed rails. Record review of Resident #50's comprehensive care plan dated 3/23/2023 revealed she was at risk to fall. The care plans interventions were to keep the environment safe. The ADLs care plan indicated Resident #50 had a self-care deficit and required assistance with be mobility to turn and reposition in bed. The comprehensive care plan failed to address the use of siderails or alternatives used prior to the placement of the siderails. Record review of Resident #50's consolidated physician orders dated 11/02/2023 revealed there was no ordered siderails or bedrails. Record review of Resident #50's electronic medical record revealed there was not a bedrail/siderail assessment completed or a consent for use. During an observation on 10/30/2023 at 3:30 p.m., Resident #50 was in her bed. Resident #50 has her legs elevated in the air and appears to be stretching them. Resident #50 has ½ bedrails up on each side of her bed. During an interview on 11/02/2023 at 4:52 p.m., LVN R said they needed a physician's order, and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 33 of 56 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 11/02/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few siderail assessment prior to placing siderails in use for a resident. LVN R said she residents could get injured from use of siderails. During an interview on 11/02/2023 at 5:48 p.m., the ADON said a siderail assessment should be completed prior to implementing a siderail for use. The ADON said siderails could cause injuries such as choking and fractures for Resident #'s 19, 20 and 50. The ADON said the DON and herself was responsible for monitoring the use of siderails. During an interview on 11/02/2023 at 7:23 p.m., the Administrator said all care and treatment requires a physician's order. The Administrator said she expected an assessment for siderail use to be done to ensure appropriateness for Resident #'s 19, 20 and 50. The Administrator said she also expected therapy to be involved to determine the need for siderails. The Administrator said she was unsure how they monitored the use of siderails but thought it was feasible in a weekly assessment. During an interview on 11/02/2023 at 8:22 p.m., the Corporate Regional Compliance nurse said she expected the siderail policy to be followed. The Corporate Regional Compliance nurse said she expected an assessment to be completed, then a physician's order and then a care plan. The Corporate Compliance nurse said siderails were a risk for injury for Resident #'s 19, 20, and 50. Record review of a Bed Rails policy dated November 8, 2016, indicated the facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail was used, the facility must ensure the correct installation, use, and maintenance of bed rails, including but not limited to the following elements: *Assess for the risk of entrapment from bed rails prior to installation. *Review the risks and benefits of bed rails with the resident or resident representative and obtain an informed consent. *Ensure that the bed's dimensions are appropriate for the resident's size and weight . Assessment: *Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the residents needs *The facility will re-evaluate the use of the rail on periodic basis *Based on the resident assessment, the interdisciplinary team will make the determination for the plan of care as it relates to the bed rail. Consent: The resident and/or resident representative will provide consent for the sue of rails prior to installation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 34 of 56 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 11/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #106's face sheet dated 11/02/2023 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). Record review of an admission MDS dated [DATE] indicated Resident #106 understood others and was understood. Resident #106's BIMS score was 15 indicating her cognition was intact. Record review of the consolidated physician orders dated November 2, 2023, indicated Resident #106 had ordered Bupropion ER (Wellbutrin) 300 milligrams daily for depression (Major Depressive Disorder) on 10/17/2023. The physician orders also indicated Resident #106 had ordered Sertraline (Zoloft) 100 milligrams daily for depression on 10/17/2023. The consolidated physician orders did not indicate any physician ordered behavior monitoring or side effect monitoring for the ordered Sertraline and Bupropion. Record review of the medication administration record dated October 2023 indicated on October 18, 2023, Resident #106 began receiving Bupropion ER (Wellbutrin) and Sertraline (Zoloft). The medication administration record did not indicate any behavior monitoring entries or any side effect monitoring entries for the administration of Bupropion and Sertraline. During an interview on 11/02/2023 at 4:30 p.m., LVN R said she had never entered the behavior monitoring or side effect orders for psychotropic medications to have them populate for monitoring. LVN R said psychotropic medications should be monitored to evaluate the need of the medication and whether the medication should be adjusted. During an interview on 11/02/2023 at 5:54 p.m., the ADON stated the nurses should put in the behavior monitoring and/or side effect monitoring when the order was received for a psychotropic medication. The ADON said when the monitoring was not present the nurse could miss a change, or a change be overlooked. The ADON said she and the DON were responsible for ensuring the behavior monitoring and side effect monitoring was implemented with psychotropic medication orders. During an interview on 11/02/2023 at 6:45 p.m., the Administrator said the charge nurse was responsible for entering the behavior and side effect monitoring for medications. The Administrator said without having the medications monitored a nurse would not be able to communicate the fullest information to the physician. During an interview on 11/02/2023 at 8:04 p.m., the Regional Compliance nurse indicated psychotropic medications required monitoring for behaviors and side effects. The Regional Compliance nurse indicated the medication monitoring was to ensure the medications were effective and at the right level to maintain symptoms. The Regional Compliance nurse said the charge nurse was responsible for entry of the behavior monitoring and side effect monitoring. The Regional Compliance nurse indicated the ADON and DON were responsible for monitoring for side effect monitoring and behavior monitoring during chart checks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 35 of 56 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 11/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #24 face sheet dated 09/11/23, indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24's diagnoses included Alzheimer's disease (memory loss), diabetes (too much sugar in the blood), high blood pressure, and depression (persistent feeling of sadness). Record review of Resident #24's order summary report dated 11/02/23, indicated she had an order for risperidone 1mg give one tablet by mouth one time a day for Alzheimer's with an order start date of 10/18/23. Record review of Resident #24's admission MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #24 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS did not indicate Resident #24 had any behaviors, delusions, hallucinations or wandered. Resident #24 required limited assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of Resident #24's comprehensive care plan dated 09/15/23, indicated Resident #24 required anti-psychotropic medications. The care plan interventions included to administer medications as ordered, monitor/document for side effects and effectiveness and consult with physician to consider dose reduction when clinically appropriate. During an interview on 11/02/23 at 06:11 PM the ADON said the diagnosis of Alzheimer's was not a diagnosis that can be used for an antipsychotic medication. She said the charge nurse should have input an accurate diagnosis when inputting the order and the nurse should have noticed the diagnosis not being accurate when she completed the quality measures and the MDS nurse should have followed up to ensure it was correct. The ADON said she was responsible for the pharmacy recommendations. She said pharmacist noted on the recommendations and she said she called the doctor, but the Medical Director did not give a new diagnosis for the medication, so she left Alzheimer's diagnosis. The ADON said the risk to the resident was getting a medication that she did not need, and it could have caused declines, hallucinations, or possible memory loss. During an interview on 11/02/23 at 07:38 PM the Administrator said psychotic medication cannot be given for diagnosis of Alzheimer's. She said the charge nurse should have noted the incorrect diagnosis and the MDS nurse and the Management nurses should have caught that the diagnosis was not accurate. The Administrator said the risk to the resident was increased sleepiness, problems with movement, increased side effects of the medication but she is unaware of anything else. During an interview on 11/02/23 at 08:28 PM the RCN said Alzheimer's was not an appropriate diagnosis for antipsychotic medication. She said the charge nurse was responsible for entering reason for use when the medication was ordered. The ADON and DON were responsible for following up on the pharmacy recommendations to ensure they are completed. The risk to the resident was taking a medication without needing it. Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 4 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #'s 207, 106, 24, and 1). The facility failed to adequately monitor Resident #207's side effects and behaviors regarding her antipsychotic medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 36 of 56 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 11/02/2023 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 0758 The facility failed to follow Resident #207's hospital discharge orders for her antipsychotic medication. Level of Harm - Minimal harm or potential for actual harm The facility failed to monitor Resident #106's side effects for the use of Sertraline (Zoloft) and Bupropion (Wellbutrin). Residents Affected - Some The facility failed to obtain appropriate diagnosis for Resident #24's antipsychotic medication. Resident #1 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident #207's face sheet dated 11/02/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #207 diagnoses included dementia (memory loss), delirium (confusion), high blood pressure, and atrial fibrillation (irregular heart rate). Record review of Resident #207's hospital after visit summary dated 10/19/23- 10/23/23, indicated under instructions . change how you take: Olanzapine (Zyprexa). The hospital after visit summary indicated under medication list . change olanzapine 2.5mg take 2 tablets (5mg total) by mouth nightly. Record review of Resident #207's order summary report dated 11/02/23, indicated the following orders: *Olanzapine 2.5mg give one tablet by mouth at bedtime for depression with an order start date of 09/24/23. *Olanzapine 5mg give one tablet by mouth at bedtime for depression with an order start date of 10/23/23. The order summary report did not indicate an order for side effect or behavior monitoring for Resident #207's antipsychotic medication. Record review of Resident #207's MAR for October 2023, indicated she had been receiving Olanzapine 2.5mg at bedtime and Olanzapine 5mg at bedtime since 10/24/23 after her most recent readmission to the facility. Record review of Resident #207's TAR for October 2023, did not indicate Resident #207 was being monitored for behaviors or side effects for the use of her antipsychotic medication. Record review of Resident #207's comprehensive care plan dated 09/28/23 did not indicate Resident #207 was receiving an antipsychotic medication. Record review of Resident #207's admission MDS assessment dated [DATE], indicated she was able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 37 of 56 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 11/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some make herself understood and understood others. The MDS assessment indicated Resident #207 had a BIMS score of 7 which indicated her cognition was severely impaired. The MDS indicated Resident #207 was taking an antipsychotic medication during the last 7 days or since admission/entry or reentry if less than 7 days. During an interview and observation on 11/02/23 at 11:25 AM, the ADON said she was the charge nurse taking care of Resident #207. The ADON said residents who received antipsychotic medications required a consent with a proper diagnosis and should be monitored for side effects or behaviors. The ADON said the nurse who admitted the resident or who obtained the order for antipsychotic medication should have placed the orders for side effect and behavior monitoring with the appropriate diagnosis. The ADON reviewed Resident #207's physician orders and she said Resident #207 was receiving olanzapine 2.5mg and olanzapine 5mg at bedtime and were being given for depression. The ADON said Resident #207 was not being monitored for side effects or behaviors regarding her antipsychotic medication. The ADON then reviewed Resident #207's hospital after care summary where she said Resident #207 should have been only receiving Olanzapine 5mg at bedtime. The ADON said the order for Olanzapine 2.5mg should have been discontinued on 10/23/23. The ADON said depression was not an appropriate diagnosis for olanzapine. The ADON said the admitting nurse was responsible for ensuring the orders were correct and placing the order for the side effect and behavior monitoring. The ADON said RN F, the admitting nurse, was currently hospitalized . The ADON said not discontinuing the medication as ordered was considered a medication error. The ADON said the process for physician orders was as follows: the nurse obtained the order, the order or hospital discharge paperwork went to medical records, and then medical records uploaded it to the resident's chart. The ADON said she was unaware of Resident #207 being sent to the hospital or had readmitted back to the facility, so her discharge orders were not checked. The ADON said not monitoring for side effects or behaviors the nurse could miss a change. During an interview on 11/02/23 at 4:28 PM, LVN R said when a resident was receiving antipsychotic medications the order for side effect and behavior monitoring was automatically placed in the computer. LVN R said she had never placed an order for psychotropic medication side effects or behaviors as she knew they were always there. LVN R said not monitoring for psychotropic side effects or behaviors could place the resident at risk for not knowing if the medications were being effective or causing side effects such as oversedation or tardive dyskinesia (a neurological syndrome that results in involuntary and repetitive body movements). During an interview on 11/02/23 at 6:34 PM, the Administrator said residents receiving antipsychotic medications should be monitored for side effects and behaviors. The Administrator said by not monitoring for side effects and behaviors they were not going to be able to relay all information to the physician so it could be reviewed. The Administrator stated it would be poor communication with the physician. The Administrator said nursing was responsible for ensuring Resident #207 was being monitored for antipsychotic side effect and behavior monitoring. During an interview on 11/02/23 at 07:55 PM, the Regional Compliance Nurse said she expected residents receiving antipsychotic medications to be monitored for side effects and behaviors. The Regional Compliance nurse said by not monitoring the resident's behaviors or side effects for their antipsychotic mediations then they may not be managing Resident #207's effectively. The Regional Compliance Nurse said the charge nurse was responsible for inputting the order for the side effect and behavior monitoring on admission or when they obtain an order for a psychotropic medication. The Regional compliance nurse said the ADON and DON were responsible for following up on orders when they did the chart audits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 38 of 56 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 11/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Record review of Resident #1's face sheet, dated 11/2/2023, revealed Resident # 1 was a [AGE] year-old female with diagnoses of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements), unspecified intellectual disabilities (disorders characterized by an impairment to the intelligence an individual possesses) unspecified lack of coordination ( Uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Record review of Resident # 1's MDS assessment, dated 9/4/2023, reveals Resident #1 had a BIMS score of 12, indicating Resident #1 had moderate cognitive impairment. Record review of Resident #1's order summary, dated 11/1/2023, revealed an order start date of 10/10/23 for Lorazepam intensol oral concentrate 2mg/ml. as needed. Record review of Resident # 1's EMAR didn't indicate a physician review. Resident #1 hadn't been given Lorazepam. Record review of Resident #1's care plan, revised on 6/2/2023, reveals Resident #1 used anti-anxiety medication. During an interview on 11/02/2023 at 4:29 PM, LVN R stated Resident #1 was on hospice. LVN R stated prn medication orders are good for fourteen-days. LVN R stated prn medication orders usually fall off the MAR after fourteen days. LVN R stated she would assume the bosses keep an eye on monitoring the prn medication orders. LVN R stated the failure was the resident could get a medication she didn't need. During an interview on 11/02/2023 at 5:31 PM, the ADON stated prn medication orders should be reviewed every fourteen days. The ADON stated she didn't know how they were monitoring prn medication orders before she came to work at the facility, but she would have a calendar with a stop date and have hospice to send an order every two weeks. The ADON stated the failure was someone could give the resident a medication that has been discontinued. During an interview on 11/2/2023 at 6:35 PM, the ADM stated she expects prn medication orders to be discontinued after fourteen days and reevaluated for new orders. The ADM stated it was the nurse responsibility to monitor prn medication orders. The ADM stated the failure was it could be a risk for side effects if given unnecessary medication. During an interview on 11/2/2023 at 7:58 PM, the Corporate Compliance nurse stated prn medication should be revaluated every fourteen days and reordered if needed. The Corporate Compliance nurse stated the charge nurses were responsible for monitoring. The Corporate Compliance nurse stated the failure was the resident could receive medication they didn't need. Record review of the facility's policy titled Psychotropic Drugs revised on 10/25/17, indicated . The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i)Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic . Monitoring . Nurses will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 39 of 56 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 11/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete continually monitor for behaviors, adverse consequences and/or side effects and utilizing the Psychotropic Medication Behavior/Side Effect Monitoring' forms generated by PCC, the nurse will document the behavior and/or side effect using charting by exception (only charting when the occurrence is observed or assessed.) Target Behaviors or behaviors that are being treated should be included on the Behavior Monitoring Form . If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-planned, non- Event ID: Facility ID: 675801 If continuation sheet Page 40 of 56 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 11/02/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure a fan blowing toward the stove was free from dust like material. The facility failed to ensure the microwave was free from a light beige colored material dried to the number pad of the microwave. The facility failed to ensure the can opener blade was free from a rust-colored material. The facility failed to ensure 7 dozen boiled eggs with an expiration date of 10/25/2023 were not available for use. The facility failed to ensure the dishwasher aide was wearing a hair net. The facility failed to ensure a red cleaning bucket had sufficient sanitizing chemical for cleaning. The facility failed to ensure the cereal in the dining room dispensers were dated when filled. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During initial tour on 10/30/2023 at 9:15 a.m. - 9:46 a.m. the observations included: *An upright standing fan had gray colored material appearing to be dust blowing toward the stove. *A sanitizer bucket underneath the steam table was tested by the DM Dietary Manager using the chemical strips. The chemical strips read no sanitizer was in the cleaning bucket. *The microwave had a light beige colored material dried on the number panel of the microwave. *There was were 7 dozen, bagged 1 dozen to each bag, of boiled eggs with the expiration date of 10/25/2023 in the refrigerator. *A rust-colored material was on the can opener's blade. *The dishwasher aide was not wearing a hair net while inside the dietary department. *Cereal stored in the self-serve bins in the dining room was not dated. During an interview on 11/02/2023 at 6:03 p.m., the Dietary Manager said she was responsible for ensuring the dietary department was serving foods in a safe manner. The Dietary Manager said she expected the dietary staff monitored the dates on the foods to ensure none were expired. The Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 41 of 56 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 11/02/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Manager said she monitors by making rounds and monitoring the cleaning schedule. The Dietary Manager said by having expired foods for use could make residents sick and by not having a sanitary environment germs could be spread. The Dietary Manager said she expected all staff entering the dietary department to wear hair nets. During an interview on 11/02/2023 at 7:33 p.m., the Administrator said she expected the Dietary Manager to change the can opener blade as often as needed to prevent rusting. The Administrator said she expected expiration dates be monitored, ensure the microwave was wiped down after use, clean the fan, and follow the recommendations for the chemical guidelines for sanitation buckets. The Administrator stated these findings could pass on unsanitary items to the residents and could make them sick. Record review of the 2012 Equipment Sanitation policy and procedure indicated the facility would provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. 1. Equipment must be thoroughly sanitized between use in different food preparation tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 42 of 56 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 11/02/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #10) reviewed for hospice services. The facility failed to obtain Resident #10's physician's order for hospice services and the most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #10's face sheet dated 11/02/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 diagnoses included chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe), diabetes (too much sugar in the blood), Alzheimer's (memory loss), and schizoaffective disorder (mental health condition characterized primarily of symptoms of schizophrenia). Record review of Resident #10's order summary report dated 11/02/23 did not reveal an order for hospice care. Record review of Resident #10's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #10 had a BIMS score of 12 indicating his cognition was moderately impaired. The MDS indicated under section, special treatments, procedures, and programs, had hospice care checked. Record review of Resident #10's comprehensive care plan dated 10/09/23, indicated he had a terminal prognosis and/or was receiving hospice services. The care plan interventions included if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Record review of Resident #10's hospice binder on 11/02/23 at 09:29 AM, indicated the last IDG comprehensive assessment was dated 08/23/23. There was not a recent plan of care update noted in the facility's hospice binder or Resident #10's EMR. Record review of Resident #10's EMR on 11/02/23 at 09:31 AM, revealed an updated hospice medication record dated 10/18/23. The orders for the hospice administration record and the facility's physician orders did not match. The following orders were noted on the hospice medication record and not in Resident #10's facility's order summary report: *Acetaminophen 650mg suppository administer one suppository rectally every 4 hours as needed for fever/temperature with an order date of 12/30/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 43 of 56 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 11/02/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm *Artificial tears 0.1-0.3% instill one drop in both eyes every 8 hours as needed for dry eyes with an order date of 12/30/22. *Atropine 0.01% drops administer 2 drops sublingual (under the tongue) every 2 hours as needed for secretions with an order date of 12/30/22. Residents Affected - Few *Bisacodyl 10mg suppository administer one suppository rectally daily as needed for constipation with an order date of 12/30/22. *Centrum silver administer one tablet by mouth one time a day for protein calorie malnutrition with an order date of 12/30/22. *Cepacol Extra strength 15-2.6mg give one lozenge every 2 hours as needed for sore throat with an order date of 12/30/22. *Cholestyramine 4 gm packet give one packet by mouth 2 times a day for diarrhea with an order date of 10/18/23. *Gabapentin 600mg give one tablet by mouth three times a day for nerve pain with an order date of 12/30/22. *Loperamide 2mg tablet take initial dose of 2 tabs by mouth for diarrhea and then 1 tablet by mouth after each loose stool. Do not exceed 6 tablets in 24 hours. *Lorazepam 2mg/ml give 0.5ml by mouth every 2 hours as needed for agitation with an order date of 12/30/22. *Promethazine 25mg give one tablet every 4 hours as needed for nausea or vomiting with an order date of 12/30/22. During an interview on 11/02/23 at 4:28 PM, LVN R said a resident on hospice should have had an order for hospice services. LVN R said hospice was responsible for providing an updated hospice plan of care and failure to do so was poor communication with hospice. LVN R said Resident #10's hospice MAR and the facility's physician orders should match and was unsure of why they did not. During an interview on 11/02/23 at 5:57 PM, the ADON said she expected hospice to provide updated paperwork for any changes so the facility was aware for coordination of care. The ADON said if Resident #10 had an order change, and they were not aware then they would not be able to properly care for the resident. The ADON said the DON, herself, and the hospice company were responsible for ensuring the updated hospice plan of care was available at the facility for reference. The ADON said Resident #10 should have had an order for hospice services, so staff was aware Resident #10 was receiving hospice services. The ADON said Resident #10's order for hospice should have been completed when he admitted to hospice. During an interview on 11/02/23 at 6:20 PM, the Hospice PCM said the resident hospice care plan should have been updated every couple of weeks when they had their hospice care plan meeting. The Hospice PCM said Resident #10's hospice case manager was responsible for providing the updated hospice care plans to the facility. The Hospice PCM said Resident #10 recently had a change to his primary nurse about a week and a half ago. The Hospice PCM said they were having issues with Resident #10's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 44 of 56 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 11/02/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm previous hospice nurse and was not aware the updated hospice documentation was not being provided to the facility. The Hospice PCM said Resident #10's previous hospice nurse should have been updating Resident #10's hospice binder twice a month. The Hospice PCM said failure to keep Resident #10's hospice chart updated was poor communication with the facility. The Hospice PCM said they would not know of any order changes Resident #10 had unless they were notified by the facility. Residents Affected - Few During an interview on 11/02/23 at 6:34 PM, the Administrator said she expected hospice to follow their policy and ensure updated orders and instructions were provided to the facility. The Administrator said she expected Resident #10 to have had an order for hospice for compliance and so they could follow the physician's orders. The Administrator said there was no risk for the resident for not having an order. The Administrator said by not having the updated hospice paperwork they were not communicating together, and Resident #10 could miss some of his services and not know. The Administrator said hospice was responsible for providing the updated hospice paperwork so Resident #10 could receive the best care. During an interview on 11/02/23 at 07:55 PM, the Regional Compliance Nurse said Resident #10's hospice emailed her and brought his most recent hospice paperwork today, 11/02/23. The Regional Compliance Nurse said not having the most current hospice plan of care could cause the continuum of care to not match. The Regional Compliance Nurse said the Hospice, nursing and medical records were responsible for ensuring the hospice binder were kept updated. The Regional Compliance Nurse said Resident #10 should have had an order for hospice and since he did not, he should not have been admitted to hospice. The Regional Compliance Nurse said a hospice order was needed to indicate Resident #10 was admitted to an extended provider for services. Record review of the facility's policy titled Hospice Services revised on February 13, 2007, indicated . 11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: * The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071) * Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073) * Physician Certification of Terminal Illness (#3074) * Medicare Election Statement (if dual eligible) * Verification that the recipient does not have Medicare Part A * Hospice Plan of Care * Current interdisciplinary notes to include nurses' notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period. 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the recipient, and legal representative to the extent possible. 13. The plan of care must include directives for managing pain and other uncomfortable symptoms. The plan must be revised and updated as necessary to reflect the resident's current status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 45 of 56 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 11/02/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Many Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 13 (Residents #7, #31, #208, #30, #39, #45, #32, #44, #28, #15, #16 , #34, #25 ) of 15 residents and 9 employees ( LVN B, MDS nurse, Dietary staff V, CNA D, Housekeeping Supervisor, Housekeeper Y, Housekeeper EE, CNA N, and CNA H ) out of 135 employees in the facility, 1 (RN DD) of 1 contract employees and 1 (clean cart) of 3 linen carts reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #208 and #31 were separated after Resident #31 tested positive for COVID on 10/23/23, and Resident #208 did not. 2. The facility failed to ensure Residents #39 and #30 were separated after Resident #30 tested positive for COVID on 10/23/23, and Resident #39 did not. 3. The facility failed to ensure Residents #32 and #45 were separated after Resident #45 tested positive for COVID on 10/25/23, and Resident #32 did not. 4. The facility failed to ensure Residents #28 and #44 were separated after Resident #44 tested positive for COVID on 10/25/23, and Resident #28 did not. 5. The facility failed to ensure LVN B, MDS nurse, and Dietary staff V remained off from work for the policy requirement of 10 days while having COVID-19 symptoms. 6. The facility failed to ensure and Housekeeper Y utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. 7. The facility failed to ensure CNA D utilized PPE appropriately to prevent cross contamination between Resident #15, who was positive with COVID-19, and residents who were not positive for the virus. 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 46 of 56 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 11/02/2023 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 0880 The facility failed to ensure Contract RN DD utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. Level of Harm - Immediate jeopardy to resident health or safety 9. Residents Affected - Many The facility failed to ensure the Housekeeping Supervisor was not working with residents when she was covid positive . 10. The facility failed to ensure Resident #16 did not acquire COVID-19 on 11/01/23. 11. The facility failed to ensure housekeeper EE was using the covid cleaner properly in the resident rooms. 12. The facility failed to ensure CNA N performed hand hygiene after she changed her gloves during Resident #25's incontinent care. 13. The facility failed to ensure CNA H Performed hand hygiene and glove change while providing Resident #7's incontinent care. 14. The facility failed to ensure failed to ensure the clean linen cart was covered. An IJ was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 11/01/23, the facility remained out of compliance at a scope of actual harm with a potential for more than minimal harm and a severity level of widespread because all staff had not been trained according to the plan of removal and the corrective systems had not been evaluated. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life including hospitalization or death. The findings included: 1.Record review of Resident #31's face sheet dated 11/1/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), cerebral infarction, high blood pressure, diabetes, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated she had a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 47 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety score of 8 which indicated she had moderate cognitive impairment. The MDS assessment also indicated she required extensive assistance with bed mobility, transfers, and toileting, total assistance with bathing, and supervision with eating. Record review of Resident #31's nursing progress note dated 10/23/23 at 23:28 (11:28 PM) indicated she tested positive for COVID-19. Residents Affected - Many Record review of Resident #31's nursing progress notes dated 10/02-11/02/23 did not indicate that the resident was relocated to isolate. Record review of Resident #31's order summary report as of 11/01/23 indicated she did not have an order for isolation related to COVID-19. Record review of Resident #31's care plan initiated 11/01/23 indicated she had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with her. During an observation on 10/30/23 at 10:24 AM Resident #31, who was positive for COVID-19, was in her bed asleep and Resident #208, who shared the room with Resident #31, was in the main dining area at a table sitting alone. 2. Record review of Resident #208's face sheet dated 11/01/23 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of senile degeneration of the brain, depression, and anxiety. Record review of Resident # 208's admission MDS assessment dated [DATE] indicated she had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated she required maximal assistance with toileting, bathing, and transfers. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #208 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 3.Record review of Resident #30's face sheet dated 11/1/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), major depression, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated she had BIMS score of 7 which indicated severely impaired cognition. The MDS assessment also indicated she required extensive assistance from staff for bed mobility, transfers, toileting, dressing and bathing. Record review of Resident #30's nursing progress note dated 10/23/23 at 23:29 (11:29 PM) indicated she was positive for COVID-19. Record review of Resident #30's summary report as of 11/01/23 indicated she did not have an order for isolation related COVID-19. Record review of Resident #30's care plan initiated 11/01/23 indicated she had COVID-19 infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 48 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many with interventions to ensure good infection control measures and personal protective equipment is used when working with her. During an observation on 10/30/23 at 10:29 AM Resident #30, who was positive for COVID-19, was in bed asleep and Resident #39, who shared a room with Resident #30, was wandering the secure unit. 4. Record review of Resident #39's face sheet indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), high blood pressure, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #39's quarterly MDS assessment dated [DATE] indicated that she had a BIMS score of 0 which indicated severely impaired cognition. The MDS assessment also indicated that she required extensive assistance with bed mobility, transfers, dressing, and toileting, and total assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #39 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 5.Record review of Resident #45's face sheet dated 11/01/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), heart disease, high blood pressure, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #45's quarterly MDS assessment date 09/13/23 indicated he had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated that he required extensive assistance with bed mobility and limited assistance with transfers, dressing, toileting, and bathing. Record review of Resident #45's nursing progress note dated 10/25/23 at 17:45 (5:45 PM) indicated he tested positive for COVID-19 and he would be placed in droplet isolation. Record review of Resident #45's nursing progress note dated 10/31/23 at 15:34 (3:34 PM), after surveyor intervention, indicated he was moved from his room to another room. Record review of Resident #45's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #45's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. During an observation on 10/30/23 at 10:30 AM Resident #45, who was positive for COVID-19, was in his room lying in bed and Resident #32, who shared a room with Resident #45), was sitting in the dining area alone at a table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 49 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety 6. Record review of #32's face sheet dated 11/01/23 indicated he was a [AGE] year-old male who re-admitted to the facility 04/27/22 with the diagnoses of Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage), and history of pulmonary embolism. Residents Affected - Many Record review of Resident #32's significant change MDS assessment date 08/10/23 indicated he had a BIMS score of 4 which indicated severely impaired cognition. The MDS assessment also indicated he required supervision for transfers, bed mobility, dressing, and toileting, and extensive assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #32 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 7.Record review of Resident #44's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), Parkinson's disease, high blood pressure, anxiety, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #44's quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated he required limited assistance from staff for bed mobility, toileting, dressing, and eating, and extensive assistance with transfers. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #44 was negative for COVID on 10/23/23 but was positive for COVID on 10/25/23. Record review of Resident #44's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #44's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. Record review of Resident #44's nursing progress notes dated 10/02/23-11/02/23 did not indicate he was COVID positive nor that he was relocated after being positive with COVID-19. During an observation on 10/30/23 at 09:55 AM Resident #44 who was COVID positive was lying in bed asleep and Resident #28, who shared the room with Resident #44, had left the room wandering the secure unit. 8. Record review of Resident #28's face sheet dated 11/02/23 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), psychotic disorder with hallucinations, high blood pressure, cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage), and cerebrovascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 50 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Record review of Resident #28's admission MDS assessment dated [DATE] indicated he had a BIMS assessment of 4 which indicate severely impaired cognition. The MDS assessment also indicated he required limited assistance with transfers, bed mobility, toileting, and dressing, and total assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #28 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 9.Record review of Resident #16's face sheet dated 11/01/23 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses of dementia, chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated he had BIMS score of 10 which indicated moderately impaired cognition. Record review of Resident #16's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #16's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. 10.Record review of Resident #15's face sheet dated 11/07/23 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of schizoaffective disorder, depression, mild intellectual disabilities, and liver disease. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 8 which indicated she had moderately impaired cognition. The MDS assessment also indicated she required limited assistance from staff for transfers, bed mobility, and toileting, total assistance for bathing, and supervision for eating. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #15 was positive for COVID on 10/24/23. Record review of Resident #15's care plan initiated on 11/01/23 indicated she had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with her. Record review of Resident #15's summary report as of 11/07/23 indicated she did not have an order for isolation related COVID-19. During an observation and interview on 10/31/23 at 09:40 AM CNA D walked into the secure unit and did not DON PPE and continued down the hall and went into Resident #15's room, turned the call light off, attempted to assist her in bed and Resident #15 told her something inside was hurting her. CNA D moved Resident #15's bed side table and offered her water and did not have on PPE for COVID isolation which included an N95 mask, a gown, gloves, and a face shield. CNA D had on a pink KN95 mask. CNA D walked out of Resident #15's room and notified LVN B of Resident #15 needing her. CNA D said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 51 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many did not realize she went into the unit and the COVID room with no PPE on. She said she should have used the PPE in the box outside of the room because it could have caused the risk of spreading COVID to other residents. During an interview on 10/31/23 at 09:42 AM LVN B she said CNA D knew better ( she had been verbally informed about using PPE in COVID isolation rooms). She said she instructed her on which residents were in isolation on the morning of 10/31/23 and that if the residents are positive, she should have placed all PPE on to go in the room and change when she exited the room. 11.Record review of a face sheet dated 11/02/2023 indicated Resident #34 originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of memory deficit, anxiety, and high blood pressure. Record review of the face sheet indicated Resident #34 and #33 were in a shared room. Record review of the Annual MDS dated [DATE] indicated Resident #34 was usually understood and usually understands others. Resident #34's MDS indicated her BIMS was a 15 indicating she was cognitively intact. The MDS indicated Resident #34 required supervision of one staff to walk in the room and corridor. Record review of the consolidated physician orders dated 11/02/2023 failed to reveal Resident #34 was on droplet isolation precautions due to her exposure to Resident #33. Record review of Resident #34's comprehensive care plan dated 1/10/2022 failed to review Resident #34 was on isolation precautions for exposure to Covid 19. During an observation and interview on 10/30/2023 at 11:00 a.m., Resident #33 and Resident #34 were rooming together and on droplet precautions. Resident #33 said she tested positive for Covid 19. Resident #34 said she was Resident #33's family member and they wanted to stay together. Resident #34 was not wearing a mask while sitting beside Resident #33. Resident #34 said they hoped to be off droplet isolation soon. During an observation and interview on 10/30/23 at 11:17 AM Housekeeper EE said she had just started on 10/29/23. There was K-Quat in her cart that she said she cleaned the restroom with. She said she was unsure what the COVID cleaner was and said the only place she sprayed the K-Quat was in the restrooms. During an interview on 10/30/23 at 03:35 PM the ADON which is also the Infection Preventionist said she expected all staff in the building to wear surgical masks. She said since the increase in covid positive residents in the secured unit the facility had put in place for the staff to be donning PPE prior to going into the unit, and when they enter the covid positive rooms the staff should be changing PPE going in and exiting. She said it could have caused residents to contract covid if the staff were not wearing or changing PPE correctly. She said she was new to the facility and was continuing to learn her role. During an observation on 10/31/23 at 09:49 AM Contract RN DD presented to go in the room to see Resident #21, she had PPE on, and she did not put a shield on to the enter the room. RN DD had applied the lidoderm patch to the upper back/neck area. During an interview on 10/31/23 at 10:03 AM Contract RN DD she said she was not aware that a shield was required, but she would wear a shield next time. She said the risk to the resident was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 52 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many spread of infection. Contract RN DD said she had not been in-serviced on PPE at the facility, but she had been in-serviced at her employment facility. During an observation and interview on 10/31/23 at 11:01 AM the Housekeeper Supervisor of 2 years was cleaning the hall railings. The Housekeeping Supervisor said the Covid 19 cleaner in the facility was K-Quat. The Housekeeping Supervisor said the K-Quat was to be used on high touch surfaces in the resident rooms and the kill time was 10 minutes (time lapse needed to kill the Covid 19 virus). The Housekeeping Supervisor said she was scheduled to come and in-service and train the new housekeeper on the facility's cleaning procedures, but the Housekeeping Supervisor said after she arrived at the facility, she felt so bad she left and went home. The Housekeeping Supervisor said she had bad allergies and slept with her mouth open which had caused her to feel bad. The Housekeeping Supervisor denied the notification of the nurse managers of her symptoms on 10/29/2023, 10/30/2023 and 10/31/2023 again she stated she had only bad allergies. During an interview on 10/31/2023 at 11:07 AM the RCN said she expected a sick employee to notify the nursing administration, then the facility would test the employee, and if positive determine whom they had contact with. She denied the housekeeping supervisor making her aware of her illness or about needing to go home on Sunday. During an interview on 10/31/2023 at 11:40 AM the RCN informed the surveyor that she sent the housekeeping supervisor home because she tested positive for covid-19 on 10/31/2023. During an observation on 10/31/2023 at 11:50 AM Dietary Staff V has her mask down below her nose assisting with preparing the lunch trays and dessert prep. During an interview with the Administrator on 10/31/23 at 03:56 PM she said she did not complete the IP training. The Administrator said she expected the staff to best of their ability to keep residents separated and re-direct as much as possible. She said she expected the staff to have the residents in the unit to be separated by positive and negative COVID status. The Administrator said she was made aware 10/31/23 that the facility had residents that were co-horted. She said the residents being co-horted was not their policy. She said the staff try to keep residents apart. The Administrator said the staff attempt to stop the visitors and reminded the staff and visitors to wear mask correctly per the facility policy and CDC guidelines for wearing the surgical mask and keeping distance. The Administrator said she expected all staff to DON and DOFF PPE as they were supposed to when they were entering and exiting COVID positive rooms. The Administrator said when the facility had positive staff who tested positive at home, the facility would question how long the staff had been had been having symptoms and the last time the staff had been in the facility working. She said if the staff member tests positive while in building it was considered an outbreak. The Administrator said the facility would have begun the known exposure contact testing and further testing. She said the MDS nurse was working in the secured unit, and she tested positive for COVID-19 on 10/22/23, and the residents were tested, and some were positive. The Administrator said LVN A wasn't feeling well and was tested and positive on 10/22/23 but left her shift after testing positive. LVN B just recovered but she thought there should have been 5 days from symptoms for her to return. LVN B tested positive on 10/24/23. The Administrator said Resident #34 and roommate, Resident #33, were thinking their symptoms were allergies and ended up with COVID as well. She said all staff are responsible for infection control and she expected all the staff to wear their mask the correct way. She said they needed to be stopped and reminded. The Administrator said all the failures placed the residents and staff at risk for spreading infection to other staff or other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 53 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 10/31/23 at 05:30 PM Surveyor requested from RCN the isolation time required by the facility when a staff member tested positive for COVID-19. The RCN could not find the date in the policy stating the length of time for isolation of employee with COVID-19. 12. Record review of Resident #25 face sheet dated 11/02/23 indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's diagnoses included myotonic muscular dystrophy (genetic condition that causes progressive muscle weakness and wasting), intellectual disabilities (person with certain limitations in cognitive functioning and other skills), depression (persistent feeling of sadness), and heart failure (heart does not pump blood as well as it should). Record review of Resident #25's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS indicated Resident #25 required extensive assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, and personal hygiene. The MDS indicated Resident #25 was always incontinent of urine and bowel. Record review of Resident #25's comprehensive care plan dated 10/17/22 indicated she had bladder incontinence with interventions to monitor/document for signs and symptoms of UTI : pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During an observation and interview on 10/31/23 at 09:11 AM, CNA N entered Resident #25's room to provide incontinent care. During the incontinent care process, CNA N failed to perform hand hygiene when she removed her dirty gloves and applied clean gloves. CNA N said she should have hand sanitized in between glove changes and knew that when she finished. CNA N said she forgot because she was nervous. CNA N said by not performing hand hygiene in between glove changes placed Resident #25 at risk for infections. CNA N said she was responsible for performing proper incontinent care and hand hygiene. CNA N said she had been checked off with the previous ADON on her second day of hire. Record review of CNA N's nurse aide incontinence care proficiency assessment dated [DATE], indicated she had passed her skill check off. During an interview on 11/02/23 at 5:57 PM, the ADON said she expected CNA N to have washed her hands or used hand sanitizer in between gloves changes. The ADON said failure to perform hand hygiene in between glove changes placed the resident at risk for cross contamination and infection. The ADON said the aides were responsible for ensuring proper incontinent care and hand hygiene was being performed. During an interview on 11/02/23 at 6:43 PM, the Administrator said he expected the CNA N to maintain proper infection control and perform hand hygiene when incontinent care was provided. The Administrator said she expected CNA N to have hand sanitized in between glove changes and by not doing so placed Resident #25 at risk for infection. During an interview on 11/02/23 at 7:55 PM, the Regional Compliance Nurse said she expected CNA N to have performed hand hygiene prior to applying clean gloves and failure to do so placed Resident #25 at risk for infection. The Regional Compliance Nurse said the Infection Preventionist, and the DON were responsible for checking off the staff on their skills. The Regional Compliance Nurse said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 54 of 56 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 11/02/2023 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 0880 they did monthly random hand hygiene check offs. Level of Harm - Immediate jeopardy to resident health or safety 13. Record review of Resident #7's face sheet, dated 11/1/2023, revealed Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hyperlipidemia (blood has too much fat), type 2 diabetes mellitus without complications ( characterized by high levels of sugar in the blood),hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (symptom that involves one-sided paralysis), unspecified lack of coordination ( Uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Residents Affected - Many Record review of Resident # 7's MDS assessment, dated 9/15/2023, indicated Resident #7 had a BIMS score of 15, indicating Resident #7 was cognitively intact and understood others as well as being understood. The MDS revealed Resident #7 had no behaviors or rejection of care during the look-back period. The MDS revealed Resident #7 required supervision with a one-person assistance for dressing, toilet use, and personal hygiene. Record review of Resident #7's comprehensive care plan, last revised on 8/29/2023, revealed Resident #7 has an ADL self-care performance deficit. Care plan goals included maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The care plan interventions include, Resident # 7 requires extensive assist of one staff. During an observation on 10/31/2023 at 9:08 AM, CNA H provided incontinent care for Resident #7. During the incontinent care CNA H put on gloves and wiped Residents # 7's buttock. CNA H gloves were soiled with feces, and she picked up barrier cream and applied it to Resident # 7 buttock and replaced the cream on the bedside nightstand. CNA H then placed a fresh brief under Resident#7 and had her roll onto her back and proceeded to clean vaginal area without changing gloves. CNA H Performed hand hygiene when finished with incontinent care. During an interview on 10/31/2023 at 9:20 AM, CNA H stated she should have removed her gloves and performed hand hygiene after removing the dirty brief, she was nervous and forgot. CNA H stated it was important to do hand hygiene to prevent cross-contamination. CNA H stated the harm in not changing gloves would be cross-contamination that caused an infection. During an interview on 11/2/2023 at 4:29 PM, LVN R stated hand hygiene should be performed before starting care, after removing gloves, and when they are finished. LVN R stated they're individually responsible, but their direct supervisor was responsible for monitoring. LVN R stated the failure was it could contaminate the cream and it was not good infection control. During an interview on 11/2/2023 at 5:31 PM, the ADON stated hand hygiene should be performed before the start of care, while providing care, and after providing care. The ADON stated hand hygiene should be performed after glove removal to prevent infection. ADON stated nurse management was responsible for making sure the CNAs performed hand hygiene. The ADON stated in-services needed to be done to ensure staff were performing hand hygiene properly. The ADON stated the failure could be cross-contamination and infection. During an interview on 11/2/2023 at 6:35 PM, the administrator stated she expected the CNAs to perform hand hygiene while providing incontinent care to ensure proper infection control. The administrator stated the staff are expected to follow the hand hygiene protocol. The administrator stated it was important to perform hand hygiene to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 55 of 56 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 11/02/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 11/2/2023 at 7:58 PM, the Corporate Compliance nurse stated she expect hand hygiene to be done. The Corporate Compliance nurse stated the charge nurse or infection preventionist was responsible for monitoring. The Corporate Compliance nurse stated hand hygiene was important for maintaining infection control. The Corporate Compliance nurse stated the failure was risk for infection. 2. During an observation on 10/30/23 at 09:45 AM, PVC plastic linen cart sitting on the short hall with cover was open. During an observation on 10/31/23 at 12:00 PM, PVC plastic linen cart sitting on the short hall with cover was open. During an observation on 11/1/23 at 10:01 AM, PVC plastic linen cart sitting on the short h FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675801 If continuation sheet Page 56 of 56