Health inspection·June 10, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/9/25 at 10:10 a.m., LVN A said she was a charge nurse at the facility and was assigned to hall for Resident #1 . She said it was her responsibility to supervise CNA staff at the facility to ensure resident care needs were met. She said she monitored staff compliance with resident care plans by regularly rounding, observing staff interactions with residents, and talking to the residents. She said CNA staff were expected to round on residents at least every 2 hours and assist them as needed with incontinent care . During an observation on 6/9/25 at 10:15 a.m., revealed LVN A and CNA B performed incontinent care for Resident #1. Resident #1 was observed to be wearing two incontinent briefs at the same time, and they were saturated with a yellow liquid. LVN A and CNA B provided incontinent care in accordance with Resident #1's comprehensive care plan and used only one incontinent brief. During an interview on 6/9/25 at 10:40 a.m., LVN A said she had never seen a resident double briefed before in the facility. She said double briefing was not an acceptable practice and put residents at risk for skin break down and infection. During an interview on 6/9/25 at 1:30 p.m., CNA B said she was assigned Resident #1's hall and frequently cared for Resident #1. CNA B said she checked on Resident #1 five or more times per shift because she was a heavy wetter. She said she rounded on Resident #1 around 6:00 a.m. that morning and assisted Resident #1 with incontinent care. CNA B said she did not double brief Resident #1 and had never seen any resident at the facility double briefed before. She said it was not acceptable to ever brief a resident double. 2. Record review of Resident #2's admission Record, dated 6/10/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (altered cognition), morbid obesity, and muscle weakness. Record review of Resident #2's admission MDS, dated [DATE], indicated she had moderately impaired thinking with a BIMS of 2. She required total assistance for putting on/taking off footwear and lower body dressing. She required substantial assistance with upper body dressing, showering/bathing, and toileting hygiene, and personal hygiene. She required setup or clean-up assistance with eating and oral hygiene. She was always incontinent of bowel and bladder. Record review of Resident #2's care plan, dated 2/28/25, revealed she was incontinent of bowel and bladder. Interventions were in place which included checking resident every two hours, assist with toileting as needed, and provide incontinent care after every incontinent episode. During an observation and interview on 6/9/25 at 1:40 p.m. revealed Resident #2 was observed in her room, lying in bed. She was under a blanket with only her head and face visible. There was an odor of ammonia emitting from her. Resident #2 said she had not been changed since this morning and she was wet currently. She said a CNA checked on her around 1:00 p.m., when they were picking up lunch trays, and told her she would be back to help her change. She said the CNA had not returned to help her. She could not recall the CNA's name. She said she did not think she was double briefed and could not remember if staff had ever put two incontinent briefs on her at the same time. During an interview on 6/9/25 at 2:00 p.m., CNA C said she was assigned Resident #2's hall. She said she rounded on all residents more frequently than every 2 hours to make sure their needs were met. She said she had not seen Resident #2, or any other resident double briefed. She said she had never double briefed a resident because it could cause a UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 2 of 4 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 06/10/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/9/25 at 2:30 p.m., CNA D and CNA E performed incontinent care for Resident #2. Resident #2 was observed to be wearing two incontinent briefs at the same time, and they were saturated with a yellow liquid. CNA D and CNA E provided incontinent care in accordance with Resident #2's comprehensive care plan and used only one incontinent brief. During an interview on 6/9/25 at 5:22 p.m., the DON said she was responsible for overseeing supervision of all nursing staff, which included CNAs. She said CNAs were expected to round on each resident every 2 hours at a minimum and to change residents' briefs and provide incontinence care as needed. She said no staff should ever double brief a resident because it created a risk of skin break down and UTI. She said she had already begun in-servicing all direct care staff on not double briefing residents and had 1 on 1 coaching with CNA B and CNA C. She said going forward the facility planned to implement random sweeps on all shifts to identify any incidents of double briefing. During an interview on 6/10/25 at 12:10 p.m., the ADM said the DON was responsible for supervising nursing staff . She said nurses who worked on the floor were expected to supervise CNAs to ensure appropriate care was being provided to residents, which included rounding on residents every 2 hours and providing incontinent care as needed. She said she was not aware of any other incidents of a resident being double briefed in the facility. She said risks to a resident from double briefing could be skin breakdown. She said the DON had already begun training staff on double briefing and incontinent care. She said going forward the facility administration planned to begin randomly checking residents for double briefing on all shifts. During additional staff interviews on 6/9/25 and 6/10/25 at various times on multiple shifts all staff members interviewed (CNA D, CNA E, CNA F, LVN G, LVN H) said residents were rounded on every 2 hours and incontinent care was provided as needed. All staff interviewed said they had never seen a resident double briefed in the facility and risks to residents from double briefing would include skin breakdown and infections. Record review of a CNA Proficiency Audit, dated 1/28/25, revealed CNA B had successfully demonstrated all required skills competencies. Record review of a CNA Proficiency Audit, dated 2/27/2025, revealed CNA C had successfully demonstrated all required skills competencies. Record review of a Coaching Form dated 6/9/25, for CNA B revealed the following coaching instruction .Always open and check briefs on all residents. There should never be two briefs or double pads of any kind under or around residents Record review of a Coaching Form dated 6/9/25 for CNA C revealed the following coaching education .absolutely no 2 briefs, pads, or any padding agents can be used at one time Record review of an In-Service Training Record, dated 6/9/25, covering training topic Double Briefing Not Allowed indicated .Nursing staff must not apply double briefs or any type of double padding to residents that are not care planned to be Attendance sign in sheet revealed the training was attended by CNAs (10), LVNs (5), RNs (1). Record review of the facility's policy titled Perineal Care, dated 5/11/22, revealed the following .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services . Skin problems associated with moisture can range from irritation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 3 of 4 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 06/10/2025 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 0690 to increased risk of skin breakdown Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675816 If continuation sheet Page 4 of 4