Health inspection·September 20, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Worker visited with resident concerning reports of abuse. BIMS completed with a score of 5. Resident requested to see his new doctor. SW informed nursing staff and next time his doctor comes in the facility he will be seen. Resident complains of pain especially at night. He does have pain medications. He also states he cannot sleep. He will speak to the doctor about these issues also. Resident reports that he requested money from his trust fund and that he gave the money to his 'girlfriend' which is another resident (Resident #10) within the facility. Social Services will continue to visit with resident. He was not in distress during the meeting. Social Services will continue to visit and assess for needs. During an observation on 09/19/23 at 09:30 AM of Resident #26's skin with MA C revealed a head to toe assessment was completed with no red marks, no bruising noted and no open areas on the buttocks, upper body and head as Resident #10 reported in her interview. Resident #26 testicles were pink in color with no rash or abrasions not black as Resident #10 reported in her interview. During an interview on 09/19/2023 at 10:30 AM, Resident #26 denied any incident of abuse. Resident #26 said he had never been abused or mistreated by anyone at the facility. Resident #26 said the staff was sometimes bossy but did not recall any event happening to him as reported by Resident #10. 2. Record review of Resident #10's facility face sheet, dated 09/18/2023, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included encephalopathy (disease of the brain), senile degeneration of the brain, (brain decreasing in size related to age), nontraumatic subdural hemorrhage, (bleeding on the brain), dementia (disorganized thinking related to aging), psychotic disturbance (not in touch with reality), mood disturbance and anxiety (nervousness). Record review of Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 had a BIMS of 13, which indicated Resident #10 had mild cognitive impairment. Record review of the comprehensive care plan, dated 8/08/2023, indicated Resident #10 had impaired cognitive function/dementia or impaired thought processes related to brain hemorrhage and senile degeneration of the brain. During an interview on 09/19/23 at 10:10 AM, Resident #10 said Resident #26 was her man. She said Resident #26 told her a guy who looked like a football player came into Resident #26's room last Friday (9/16/23) night and beat him all around his head and back, they left bruises on his face and upper back, and he was in a lot of pain. Resident #10 said Resident #26 did not recognize the man. Resident #10 said it could have been a medication aide, because Resident #26 didn't like those girls. Resident #10 said Resident #26 reported to her that his testicles had turned black in color, and it was hurting him terribly. Resident #10 did not recall telling anyone about the incident. During an interview on 09/19/2023 at 10:00 AM, the Administrator stated she had been at the facility since September 2022 and was aware of each incident reported by Resident #10. She stated she monitored all incidents that occurred in the facility through the morning meeting and incidents reported directly to her. She stated she did not recognize the incidents needed to be reported within 2 hours if there was an allegation of abuse, because there was no evidence of any bruising on Resident #26 as reported by Resident #10. She said she investigated the allegations, and the DON assessed Resident #26 for injuries/bruises, there were none found. She thought she had 24 hours to make the report. The Administrator said Resident #26 denied any abuse during her interview with him. The Administrator said she felt Resident #26 had the right to determine if he was abused. She said at the time she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 2 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not see any risk to the residents but looking back now she could see the risk of continued abuse, if all incidents were not investigated properly and reported timely. She stated going forward she would follow the abuse program and report abuse allegations within two hours. During a phone interview on 09/20/2023 at 10:30 AM, the Ombudsman said Resident #10 had behaviors of false allegations at the assisted living she resided at before going to live at the facility. The Ombudsman said she would visit with Resident #10 and assist the facility in finding a resolution. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of the facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating, dated March 2018 indicated Facility employees must report all allegations of abuse neglect, misappropriation of property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 3 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 - Few 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 interview and record review the facility failed to ensure comprehensive assessments were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 4 residents (Resident #32) reviewed for care plans. The facility failed to ensure Resident #32's care plan was revised to reflected current condition after hospitalization and readmission to the facility. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of Resident #32's facility face sheet, dated 9/19/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and subsequently readmitted on [DATE]. Resident #32 had a primary diagnosis which included urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). Record review of a Medicare 5-day MDS for Resident #32, dated 8/27/23, indicated he had a BIMS score of 6, which indicated he had severely impaired cognition. The assessment reference date was 8/27/23, with a lookback period of 7 days (8/20/23 to 8/27/23). He required extensive assist of one to two persons for most ADL's. He was frequently incontinent of bowel and bladder. Question I2300 indicated he had a diagnosis of urinary tract infection in the last 30 days. He was coded as receiving an antibiotic 7 out of the previous 7 days. Record review of a care plan for Resident #32 for most recent admission date of 8/21/23 indicated that it did not address his current primary diagnosis of urinary tract infection or his current antibiotic therapy. Record review of a physician order summary report for Resident #32 dated 9/19/23 indicated a phsyician order dated 8/21/23 which read .Macrobid Oral Capsule 100mg .Give 1 capsule by mouth two times a day for UTI for 10 days . During an interview on 9/19/23 at 2:39 PM, the MDS nurse said she and the ADON worked together to do the care plans and she was unsure how this was overlooked. During a joint interview with the DON and the ADON on 9/19/23 at 2:53 PM, they both said the care plan must have somehow gotten overlooked. The DON said the ADON would usually update care plans with new antibiotics when they got them or when a resident was out to the hospital. The ADON said it may had happened while he was working nights and it might had just gotten missed. The DON said she may have been out or just busy because if the ADON did not catch an update, she would usually try to catch it but said Resident #32's care plan just got missed. They both said the risk to the resident could include not receiving medications and possible sepsis if the infection got worse. During an interview on 9/19/23 at 3:19 PM, the SW said they normally did care plan reviews as a team every quarter, annually and after a significant change. She said with Resident #32, he was in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 4 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility and went out to the hospital. Upon his return, she understood nursing should update his care plan with any new interventions. She said they did not have a care plan meeting after his hospital re-admission MDS on 8/27/23. Record review of the, undated, facility policy titled Comprehensive Care Planning, indicated .the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions .care planning drives the type of care and services that a resident receives Event ID: Facility ID: 675816 If continuation sheet Page 5 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 - 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 establish and 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 1 of 4 (CNA A) staff reviewed for infection control. Residents Affected - Few 1. CNA A failed to perform hand hygiene after incontinent care. 2. CNA A failed to properly handle soiled linens and the brief for Resident #39 after performing incontinent care. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: Record review of Resident #39's admission Record, dated 9/20/2023, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included pneumonia (infection with inflammation in the lungs), senile degeneration of brain (a decrease in thinking ability and mental decline), and anemia (low red blood cells in the body). Record review of Resident #39's, Quarterly MDS Assessment, dated 9/4/2023, indicated he had severe impairment in thinking with a BIMS score of 3. He required extensive assistance with 1-2 person assist with bed mobility, dressing, eating, toilet use and personal hygiene. He was always incontinent of bowel and bladder. Record review of Resident #39's care plan, dated 9/1/2022 , indicated he had bladder/bowel incontinence with interventions to provide peri care after each incontinent episode and incontinent care frequently. During an observation on 9/19/2023 at 9:25 AM in Resident #39's room revealed CNA A and MA B were present to perform incontinent care. MA B entered the room and washed her hands in the bathroom. CNA A entered the room and applied gloves to both hands without washing or sanitizing her hands. CNA A removed Resident #39's pants and pulled down his brief. CNA A removed a wipe from a plastic bag and cleaned Resident #39's penis wiping in a circular motion and pulled back the foreskin and cleaned. CNA A placed the wipe on the floor and removed another wipe from the plastic bag and wiped Resident #39's inner thighs and placed it on the floor. MA B assisted and rolled Resident #39 onto his right side. CNA A removed a wipe from the plastic bag and wiped Resident #39's rectal area from front to back using multiple wipes. MA B rolled the linens up to be removed from the bed and CNA A removed a draw sheet and brief from the plastic bag and placed them underneath Resident #39's buttocks. The dirty linens and brief were rolled underneath Resident #39 and removed by CNA A and placed on the floor. MA B secured the linens on the bed and CNA A secured the brief on Resident #39 and both repositioned him in bed. MA B removed her gloves and placed them in the trash and washed her hands in the bathroom. CNA A picked up the dirty linens, wipes and brief off of the floor and placed them in a plastic bag. CNA A removed her gloves and placed them in the trash and placed the bags of linens and trash in the barrels outside in the hallway. CNA A then sanitized her hands in the hallway. During an interview on 9/19/2023 at 9:35 AM, CNA A said she had been employed at the facility on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 6 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 - Minimal harm or potential for actual harm Residents Affected - Few PRN basis for two months. She said during the incontinent care provided to Resident #39 she should have changed her gloves throughout the care provided, after she changed him and before she touched anything when she was done. She said she should have changed her gloves when she went from dirty to clean. She said she should have washed her hands after the glove changes. She said she should have placed the linens in a plastic bag along with the soiled brief instead of placing them on the floor. She said she had not received any check offs with incontinent care since she started working at the facility. She said residents could be at risk for infection if staff did not change gloves or wash/sanitize their hands when providing care along with contamination of items touched with dirty gloves . During an interview on 9/19/2023 at 3:25 PM, the ADON said he had been employed at the facility since April 2023. He said he and the DON were responsible for conducting the competency check offs with the nursing staff. He said the aides in the facility had a competency check off on hire and annually along with PRN staff. He said if there was a rise in infections at the facility such was UTI's with residents who did not have a catheter, then they would begin in-servicing staff on infection control measures, proper wiping of the residents from front to back, gloving and hand hygiene. He said CNA A had been checked off on hand hygiene and incontinent care after being hired. He said staff should perform hand hygiene before providing care to the residents, between glove changes and when care was completed. He said dirty linens should be placed in a plastic bag and not on the floor and wipes in the trash. He said the risk to residents could be UTI's, sepsis and infections . During an interview on 9/20/2023 at 9:14 AM, the DON said she had been employed at the facility since April 2022. She said she and the ADON were responsible for conducting competency check offs with the nursing staff. She said the nurse aides were checked off on hire and annually. She said the check off included observing skills to determine competency. She said staff should change gloves at least 3 times during care, sanitize or wash hands between glove changes and change gloves when going from dirty to clean . She said linens and trash should be placed in a bag and not on the floor to prevent contamination. She said going forward she would in-service staff on infection control and would conduct incontinent check off with all of the nurse aides. She said the risk to the residents would be infection. Record review of a CNA Proficiency Audit, dated 7/21/2023, for CNA A indicated she was satisfactorily checked off for hand washing, perineal care of a female/male resident and handling of clean/dirty linens. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 2019, indicated, .1. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty; Before and after assisting a resident with personal care; After handing soiled or used linens . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 7 of 8 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition for 1 of 1 stove in the kitchen reviewed for food service. Residents Affected - Many 1. The facility failed to ensure the gas stove, in the kitchen, was in proper working order. 2. The facility failed to ensure three of six gas burners, on the stove, lit automatically, when the knob was turned (front on left, middle back, and right back). 3. The facility failed to ensure the pilot lights on the burners would stay lit and the Director of Food and Nutrition Service, had to use a striker, (a lighter with a long barrel), to light the burners. These failures could place residents at risk for injury and under cooked food. Findings include: During an observation and interview on 09/18/23 at 9:20 a.m., the front left, middle back, and right back burners of the stove would not light from the pilot when the knob was turned. The Director of Food and Nutrition Service said the pilot lights would not stay lit. She said she worked at the facility since 02/11/21 and when she came, they were using a striker to light the burners She said she thought the vent a hood was the reason the pilot lights would not stay lit. She said she told the Maintenance Supervisor the pilot light would not stay lit, but he was very new, and he was working on other things in the building. She said the pilot lights not working and having to use a striker could cause a possible fire or someone could get hurt. During an interview on 09/19/23 at 2:15 PM, the Maintenance Director said he worked at the facility since 08/07/23, and he was not aware the burners would not light from the pilot when the knob was turned until yesterday, (09/18/23). He said someone would be at the facility on Friday, (09/22/23) to work on the stove. During an interview on 09/18/23 at 9:55 AM, with the Administrator she said her expectation for the kitchen the Administrator said she expected all appliances in the kitchen to be in proper working order. She said the pilot lights and the burners not lighting when the knob was turned could cause a possible explosion and fire. Record review of a facility policy, (Dietary Services Policy & Procedure Manual), did not address maintenance of the stove. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 8 of 8