Health inspection·February 7, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/07/24 at 08:59 a.m., the Administrator said that they had been having intermittent issues with the water heater and they were working on trying to figure out a solution; but then they had the ice storm and issues from that. She said that she was uncomfortable with the water temperatures in the laundry room and was concerned and that's why she had them taking them to the laundromat, but there should never be a time when there are no linens here for resident baths and showers. Requested policies related to water temps and laundry sanitation policies. She said that she signed for linen orders for housekeeping supervisor every month. During an interview on 02/07/24 at 09:29 AM, Resident # 33 said that missing his bath made him feel dirty and gross and really irked him because he only got one on Mondays, Wednesdays, and Fridays. He said since he had not had one since Friday and then had to wait an extra day to get a shower, it made him feel dirty. During an observation on 2/7/24 at 9:35 a.m., the linen cart at the end of the 100 hall had no towels or washcloths, only gowns, briefs, and gloves. During an observation on 2/7/24 at 9:40 a.m., the linen closet for the 100 & 200 halls had no towels or washcloths, only blankets, gowns, and flat and fitted bed sheets. During an interview on 2/7/24 at 10:00 a.m., CNA F said that they often run out of towels and washcloths and if there are none on the other halls to use, then they must wait to give residents baths or showers. She said that she does let her charge nurse know when they have to wait for showers. During an interview on 2/7/24 at 10:10 a.m., the HSK supervisor said that the water heater in the laundry had been broken for maybe a month or two, or since sometime in December. He said that administration was aware, and he said that he thought they had ordered a part and it had not come in. He said that he did not order the part, that would have been done by the administrator. He said that he was responsible for ensuring that the facility had enough linens on the halls and sometimes the halls must borrow from other halls. He said that the laundry aides were having to wash linens at the facility in cold water and detergents to wash them out somewhat before taking them to the laundromat, then bring them back to the facility to dry them and get them back out to the halls. He also said that the laundromat was only open during certain hours, and they were really having a hard time getting the linens back and forth to the laundromat because they must wait for the administrator to be here so they can get the money to do the laundry. Sometimes they use the facility van and sometimes they use their personal vehicles. He said that they did follow infection control procedures and all laundry was appropriately bagged and handled during transportation. He said that he was hoping the facility was planning to buy a new water heater for the laundry. He said the water heater in the laundry was only for the laundry facilities, and it did not supply anything else other than laundry. He said if residents did not have clean linens to bathe or shower, it could make them feel bad, or it could possibly lead to infection if the residents had poor hygiene. During an interview on 2/7/24 at 10:51 a.m., Maintenance Director said that the water heater was completely broken. He said that he did not have documentation of routine maintenance checks for the water heater in the laundry facilities. He said that they had tried ordering a part to repair it, but it was going to be 2 - 3 weeks before it would be in and now they are thinking of replacing it and he was waiting on a bid from a couple of plumbers but did not have them yet, hopefully he will get them this afternoon. During an interview on 2/7/24 at 11:03 a.m., the Administrator said that during the first part of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 2 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few January, the maintenance director and housekeeping supervisor had notified her that the water in the laundry was not hot enough and that temperatures were not where they needed to be to properly wash the linens. She said that she started having them wash linens offsite due to the issue. She said that a local plumbing company had told them that since the water heater was older, it would need a part to fix it, but the part would take 2-3 weeks to come in. She said that they are now requesting bids to replace the water heater and have also talked to another local plumbing company. She said that they currently have no residents on any type of isolation precautions. She said that risks to residents include improper sanitation, illness, skin breakdown and dignity issues if they are unable to take a shower or bathe. During an interview on 2/7/24 at 11:56 a.m., laundry aide said that she had just gotten back from the laundromat and now would have to dry the linens before taking them out to the halls in the facility. She said that she had left the facility around 10:30 am this morning, and she had spent a little over an hour washing them out here before taking them to laundromat. She said that she would estimate that it was taking them approximately 3 ½ - 4 hours to do a load of linens. She said that they are having trouble keeping up with the laundry right now because of how long it was taking to get the laundry done. She said that right now they did not have any residents on isolation precautions. During an interview on 2/7/24 at 12:00 pm HSK supervisor said that the water heater was not on right now because it was not working, and the washing machines are just used to wash linens with cold water before taking them out to the laundromat. He said that there was no one currently on isolation precautions. Record review of a text message conversation on January 8, 2024 between Maintenance Director and local plumbing company indicated that facility had already discussed getting a bid for a new water heater for the laundry facilities. Record review of a facility policy titled Laundry Standards May 2003 read .The facility will provide a quality laundry operation. The program will address itself to upgrading the professionalism of laundry personnel and the prevention of the spread of disease and infection through proper and effective laundry procedures . and .E. Distribution - schedule for the finished product to ensure a timely return of all items within a prescribed period of time . Record review of a facility policy titled Resident Rights dated 2/23/16 and revised on 2/20/21 read .8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 3 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 that residents who need respiratory care are provided such care, consistent with professional standards of practice for 2 of 9 residents (Residents #9 and #15) reviewed for oxygen usage. Residents Affected - Few The facility failed to ensure Resident #9's oxygen tubing was changed weekly. The facility failed to ensure Resident #15's oxygen concentrator filter was clean and free of dust, oxygen tubing was changed weekly, and humidifier bottle was connected to the oxygen concentrator. These deficient practices could place residents at risk of breathing in dust and allergens, decreased effectiveness of oxygen concentrators and respiratory infections. Findings include: 1. Record review of a facility face sheet dated 2/6/24 for Resident #9 indicated that she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). Record review of a Quarterly MDS assessment dated [DATE] for Resident #9 indicated that she had a BIMS score of 00 indicating that she had severe cognitive impairment. Section O indicated that resident had received oxygen therapy in the last 14 days while a resident of the facility. Record review of a physician order report dated 2/6/24 for Resident #9 indicated to change O2 tubing weekly when O2 in use every night shift, every Sunday, with a start date of 7/12/20 and continuous O2 @ 2L/min via N/C every shift with a start date of 1/9/24. Record review of a comprehensive care plan for Resident #9 revised on 4/19/23 indicated that she required oxygen therapy continuously via nasal cannula with an intervention to provide oxygen as ordered. During an observation on 2/5/24 at 12:00 p.m., Resident #9 was observed in the dining room using oxygen via nasal cannula and a portable tank. The nasal cannula tubing was dated 1/21/24. During an interview on 2/6/24 at 1:50 p.m., LVN G said that she only worked at the facility 2 to 3 times per month and charge nurses were responsible to change the oxygen tubing every Sunday. She said that residents could be at risk for infections such as pneumonia if tubing was not changed. 2. Record review of a facility face sheet indicated Resident #15 was a [AGE] year-old male and readmitted to the facility on [DATE] with the diagnosis of COPD (chronic obstructive pulmonary disease). Record review of a comprehensive care plan dated 11/16/2023 indicated Resident #15 used oxygen routinely for COPD and to administer oxygen per physician orders. Record review of a significant change MDS assessment dated [DATE] indicated Resident #15 required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 4 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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. Level of Harm - Minimal harm or potential for actual harm Record review of a physician order dated 11/20/2023 indicated Resident #15 had an order for oxygen at 2 liters per nasal cannula. There was no order for changing the oxygen tubing, humidifier water use and cleaning the filters. Residents Affected - Few During an observation and interview on 02/05/24 at 9:39 AM, Resident # 15 was ambulating in the hallway with portable oxygen tank and nasal cannula tubing was dated 01/28/24. Oxygen concentrator in room and humidifier bottle was not connected to the concentrator and there was not a connector on the concentrator to attach the humidifier bottle to the concentrator. The filter on one side of the concentrator was clean but there was no filter on the other side and area had dust buildup in the holes. During an observation and interview on 02/06/24 at 7:55 AM, Resident # 15 was dressed and ambulating in the hall with portable oxygen tank. Oxygen tubing dated 01/28/2024. Resident #15 stated the nurse usually changed all his oxygen tubing weekly but not sure why the tubing on his portable tank was not changed. He stated his concentrator was not working right and was not setup for the water. He said his nose gets dry and bleeds at times because he used oxygen all the time. He said the nurse brought the bottle of water to his room but had not been putting it on the concentrator because there was no connector. Oxygen concentrator in the room had a prefilled humidifier bottle unopened and no connector present to connect bottle to the concentrator. The internal filter was inspected and observed with large amounts of black residue. Resident #15 stated he had not had anyone change the internal filter before that he could remember. During an interview on 02/06/24 at 8:00 AM, LVN E stated she worked at the facility for 1 year as needed through an agency staffing company. She stated that all oxygen tubing was changed weekly as well as the filters being cleaned weekly by the nurse. She stated she was not sure about the internal filter and had not been told she needed to change those and if not changed could lead to infections or affect oxygen delivery. She stated that the oxygen tubing should be connected to a humidifier bottle to prevent the residents from getting a dry nose and was not aware Resident #15's concentrator did not have a connector and the humidifier bottle was not being used. During an interview on 02/06/24 at 8:05 AM, the regional nurse stated she was the acting DON since January 2024. She stated that the nurses were responsible for changing out the oxygen supplies weekly, and prn and supplies should be dated when changed. She stated each concentrator should have a humidifier bottle attached as well. She stated she was not sure on who was responsible for the internal filters and there was no system in place for replacing the internal filters on the oxygen concentrators. She stated if the oxygen tubing was not changed weekly, humidifier bottles not attached to the concentrator and the filters not cleaned and changed it could cause infections, oxygen delivery issues and adversely affect the resident. During an interview on 02/06/24 at 9:47 AM, the Maintenance Director stated that the facility owns their own oxygen concentrators but also rents them when needed. He stated Resident #15's concentrator was the facilities. He stated he was not aware of need to replace an internal filter and thought the nursing department handled everything related to the concentrators. He stated he would meet with the regional nurse to discuss a new plan for the concentrators. He stated if filters were not changed it could lead to infections or oxygen delivery issues. During an interview on 02/07/24 at 1:50 PM, the Administrator stated the nurses were responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 5 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 FORM CMS-2567 (02/99) Previous Versions Obsolete for oxygen therapy and the DON and ADON were responsible for overseeing that oxygen therapy was correct. She stated all oxygen supplies and tubing should be changed and cleaned weekly but did not have a process for the internal filters. She stated she expected the nurses to follow the policy to prevent respiratory issues with the residents. Record review of a facility policy dated 9/12/2014 titled Oxygen Administration indicated, .humidification; screw bottle to adapter and attach to flow meter, attach cannula tubing to humidifier port, change disposable parts once a week and label with date, clean filter weekly . Event ID: Facility ID: 675835 If continuation sheet Page 6 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 3 (Residents #50 and #28) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #50 and Resident #28. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: Observations of the noon meal on 2/5/24 and 2/6/24 at 00:00, the pureed meats and vegetables were not pureed to a smooth pudding like consistency and were too thick. Record review of face sheet dated 2/07/24 for Resident #50 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with Dx. of dementia unspecified (decline in cognitive abilities), protein calorie malnutrition and nausea with vomiting. Record review of quarterly MDS dated [DATE] indicated Resident #50 had severe cognitive impairment. Section GG indicated dependent for ADL's including feeding. Record Review of a physician's order summary indicated an order for pureed diet thin liquids consistency dated 9/18/23. Record Review of face sheet dated 2/07/24 for Resident #28 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with Dx. of dysphagia (difficulty swallowing), Dementia (decline in cognitive abilities), protein calorie malnutrition, and nausea with vomiting. Record review of a quarterly MDS dated [DATE] indicated Resident #50 had severe cognitive impairment. Section GG indicated dependent for ADL's including feeding . Record review of a physician's order summary dated 2/06/24 indicated an order for pureed diet thin liquids consistency dated 9/18/23. During an observation of dining on 2/05/24 at 12:15 p.m., Resident #50 and Resident #28 were served pureed diets, as indicated on diet marker on meal trays. Pureed Mexican Lasagna and pureed corn with beans observed to have a course thick texture with chunks, not pudding consistency. On 02/06/24/4/23 at 8:00 a.m., the surveyor requested to sample the puréed foods being served for lunch. During an observation and interview on 02/06/24 p.m. at 10:30 a.m., the Dietary Aide said she had worked at the facility for about 3 months and received training from the DM on how to puree foods. She said she was told the consistency should be like pudding and a spoon should stand up in it. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 7 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dietary aide said she did not puree the foods yesterday. The Dietary Aide completed the puree of baked onion chicken and placed in a container, the chicken contained visible chunks not smooth in texture and the spinach pasta had visible strings and bits of bacon not pudding like texture. The lunch puree was placed in the oven to reheat. During an observation and interview on 02/06/24 at 11:50 a.m., the puree tray was provided by the dietary manager. The tray was sampled by the survey team and dietary manager. The test tray of spinach pasta had strings of spinach and chunks of bacon not pudding consistency. The onion chicken breast was coarse in texture not smooth like pudding consistency. The DM said the texture did not meet requirements. The DM said she would correct the texture and plate the meals for the three residents being served pureed meals. The DM said she would provide additional training to her staff. During an interview on 02/07/24 at 2:00 p.m., the Administrator said she expected the puree food to be of appropriate consistency. She said not pureeing to pudding consistency could cause the resident to choke. Review of Dining Service Menu Guide-Health Technologies, Inc. dated 2020, page 9 .Process hot or cold items until they are homogenous in texture. Add measured amounts of hot liquid or cooked foods and cold liquid for cold foods (if required) and process until there is a smooth, pudding-like, or smooth mashed potato consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 8 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 6 residents (Resident #24) reviewed for therapeutic diets. The facility failed to serve 4oz of yogurt with lunch meal as prescribed by physician to Resident #24. This failure could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. Findings include: Record review of a face sheet dated 2/6/24 for Resident #24 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic peripheral venous insufficiency (when your leg veins don't allow blood to flow back up to your heart) and chronic kidney disease (occurs when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years). Record review of a Quarterly MDS assessment dated [DATE] for Resident #24 indicated that she had a BIMS score of 15 indicating that she had no cognitive impairment. Record review of a physician order report dated 2/6/23 for Resident #24 indicated that she had the following physician order: 4oz of yogurt with lunch meal dated 8/26/23. During an observation and interview on 2/5/24 at 9:58 a.m., Resident #24 was observed lying in bed and she said that she was supposed to be getting yogurt with her meals but had not been getting it. She said that it was on her meal tray paper to get yogurt with each meal. During an observation and interview on 2/5/24 at 00:00, Resident #24 was observed in bed with her lunch, which consisted of 2 grilled sandwiches, a bag of chips and a piece of cake. Meal tray ticket was observed and indicated yogurt with each meal, no yogurt was with the meal. She said she needs it to help her digestion. During an interview on 2/6/24 at 3:00 p.m., [NAME] said that they were out of yogurt. He said that if there was something needed for a resident meal that they did not have, they could go pick it up at a local store if they needed to. During an interview on 2/6/24 at 3:05 p.m., the Dietary Manager said that Resident #24 hoards the yogurt and had a bunch in her refrigerator in her room. She said that she had not been worrying about sending it out because the resident always has some. During an observation on 2/6/24 at 3:16 p.m., Resident #24's personal refrigerator was observed to have no yogurt inside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 9 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0808 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 2/6/24 at 3:40 p.m., the Dietary Manager said that she had now gotten yogurt for Resident #24 and would ensure that she had it on her trays with her meals. Record review of a facility policy titled Supplement and Snack Distribution dated 1/8/2011 read .There will be adequate supplements or snacks for those residents who require a supplement or wish to have a snack . and .supplements will be provided to all residents who have an order for a supplement . Event ID: Facility ID: 675835 If continuation sheet Page 10 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 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 ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: Residents Affected - Many The facility failed to label and date items in the dry storage and freezer. The facility failed to ensure the dish machine reached recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle. This failure could place the residents at risk of foodborne illnesses. Findings included: During an observation and interview 02/05/24 beginning at 9:20 a.m., initial kitchen tour with the Dietary Manager the following was observed: Dry storage: -Unlabeled dry cereal in bins x 3 no opened dates (Frosted Flakes, Cheerios, and Raisin Bran). 2- plastic packages of open, unsealed, unlabeled cereal in plastic packages. Unlabeled sugar and flour stored in bins with no use by date. Freezer: - - pancakes, burritos and chicken breasts with no labels, no dates when opened or expired dates. The Dietary Manager said she had worked at the facility for 10 years. She said that all food items stored in the dry storage area and freezer should be secured in airtight packages and labeled with use by date or date opened. She said foods stored incorrectly could be contaminated by pests or cause illness due to spoilage. During an observation and interview on 2/05/24 at 9:30 a.m., the Dish aide was standing at the dish machine, he said he had worked at the facility for two weeks. He said he was trained to test the machine by the Dietary Manager. Upon request the Dish Aide tested the dish machine, and it tested at 100 parts-per-million, (PPM), of hypochlorite (chlorine), and the water temperature read 80 degrees Fahrenheit, (F). The Dish Aide ran the machine two times to try to get the water temperature up to required 120 degrees Fahrenheit, (F). On the third time the machine reached 82 degrees Fahrenheit, (F). the Dish Aide said the dish machine usually reaches 100 to 110 degrees Fahrenheit, (F). The Dish Aide said that is the temp they told him it needs to reach. Dish Aide said he had not reported the problem to maintenance. During an observation and interview on 2/5/24 at 9:40 a.m., the Dietary Manager said they had been having problems with the machine temping after they do morning meal and wash dishes. She ran machine again, and the water temperature read 82 degrees Fahrenheit, (F). She said disposable dishware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 11 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 would be used until the problem was corrected. She said the dish machine not sanitizing the dishes could make the residents sick. During an interview on 02/05/24 at 11:30 a.m., the Maintenance Director said the Dietary Manager notified him this morning there was an issue with the dish machine not temping after this surveyor entered the kitchen and discovered a problem. He said that there is some play in the thermostat for the hot water in the kitchen and he adjusted it. They will recheck before they wash dishes after lunch . He said not sanitizing the dishes could make the residents sick. During an observation and interview on 02/05/24 at 12:30 p.m., the Dish Aide ran the dish machine and hit 82. Stated they will continue to use disposable dishware as directed by the Dietary Manager until the problem is resolved . During an observation and interview on 02/06/24 at 8:00 a.m., the Dish Aide ran the dish machine the temperature reached 122 degrees Fahrenheit, (F). During an observation and interview on 02/06/34 at 10:45 a.m., the Dietary Manager and Dietary Aide A checked the dish machine while washing the Robo coupe with the low temp machine, machine only reached 114 degrees Fahrenheit, (F). during three attempts on the temperature dial. The Robo coupe was then washed in the three-compartment sink. The machine was checked with a digital thermometer and only reached 114 degrees Fahrenheit, (F). The Dietary Manager said she would contact the representative for the dish machine for service and continue to use disposable dishware. During an interview on 02/07/24 at 2:00 p.m., the Administrator said the Dietary Manager would be responsible for in servicing the staff, and she expected the staff to test the dish machine before use as required. She said if the dish machine was not working, disposable dishware would be used, and she needs them to call out the service technician to test the machine. She said the dishes not being sanitized could make the residents sick. Record review of Infection control surveillance logs for January 2024 and February 2024 had no indication of gastro-illness or outbreak related to sanitation in the kitchen. Requested a policy for dish machine use and none provided to survey team. Review of Food and Nutrition Services Policy and procedure Manual review date 7/22/22, procedures . 9. Items stored in the refrigerator must be dated upon receipt, unless they contain manufacturers use by date, sell by or a date delivered. 10. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled for continued storage. This includes individual bags of frozen vegetables removed from the original storage box, unless they have a common name of product and dated as noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 12 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 4 resident's (Resident #2) personal refrigerators reviewed for food and nutrition services. Residents Affected - Few The facility failed to ensure the refrigerator for Resident #2 did not contain a cup of peach yogurt dated 1/18/24. This failure could place residents at risk for food borne illnesses. Findings include: Record review of a facility policy with a revised date of 8/28/2023 titled Resident Refrigerators indicated, .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. 3. Staff shall inspect the refrigerator weekly, clean as needed, and discard any foods that are out of compliance . Record review of an admission Record dated 2/6/2024 for Resident # 2 indicated she admitted to the facility on [DATE] and was 69 years with diagnoses of atherosclerotic heart disease (buildup of plaque in the blood vessels), ataxia (poor muscle control that causes clumsy movements), hypertension and osteoporosis (brittle bones). Record review of a care plan dated 12/27/2023 for Resident #2 indicated she required a mechanical diet with nectar thickened liquids and she required assistance with meals. Record review of a Quarterly MDS Assessment for Resident #2 dated 11/20/2023 indicated she had severe impairment in thinking with a BIMS score of 6 and w (as dependent with activities of daily living. During an observation and interview on 2/5/2024 at 9:57 AM, in the room of Resident #2 who was up in a specialized wheelchair, alert to person and place was dressed, said she had been at the facility for a long time. A personal refrigerator was in the room that had a cup of peach yogurt dated 1/18/24. During an observation on 2/6/2024 at 9:11 AM, f Resident #2 was not in the room still had a cup of peach yogurt dated 1/18/24 in her personal refrigerator. During an interview on 2/6/2024 at 9:12 AM, HSK C said she had been employed at the facility for a year and was assigned hall three hundred where Resident #2 resided. She said each day housekeeping was responsible for checking the personal refrigerators for temperatures and expired foods. She said some residents would not allow staff to remove items from the refrigerators. She said she checked the refrigerators on hall three hundred yesterday 2/5/2024 and again this morning. She said she was not aware Resident # 2 had foods that were expired. She said she would go back and check her refrigerator and throw the foods away. She said residents could get sick if they ate foods that were expired. She said Resident #2 does not refuse to allow staff to check her refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 13 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/6/2024 at 9:20 AM, the HSK Supervisor said housekeeping were responsible for checking the personal refrigerators daily for temperatures and expired foods. He said residents could get sick if they ate foods that were expired. During an interview on 2/7/2024 at 9:48 AM, the Regional Nurses said residents have the right to put foods in the refrigerators and facility staff were to check the temperatures. She said staff would ask the residents about items in the refrigerators and hopefully the residents would allow staff to dispose of items that were expired. She said residents could get sick if they ate foods that were expired. She said going forward, staff would review the items in the refrigerators to make sure they were in date and if the residents allowed them to. During an interview on 2/7/2024 at 10:11 AM, the Administrator said the housekeeping staff were responsible for checking the personal refrigerators daily for temperatures and expired foods. She said residents could get sick form eating expired foods. She said going forward she would have the housekeeping staff to provide documentation to her with temperatures and expired foods daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 14 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the fourth quarter July 1, 2023 to September 30, 2023) reviewed for administration. The facility failed to submit data for the fourth quarter of the fiscal year from July 1, 2023, to September 30, 2023, to CMS This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review of the facility's Civil Rights form (3761) dated 2/5/2024 provided by the Administrator indicated a total of 49 residents and 70 staff that included: 3-Registered Nurses 8-Licensed Vocational Nurses 19-Direct Care Staff 10-Dietary Staff 11-Housekeeping and Laundry 19-All others Record review of the CMS PBJ (payroll-based journal) Staffing Data Report dated 2/1/2024 for the FY Quarter 4 2023 (July 1-September 30) indicated the facility failed to submit data for the quarter. During an interview on 2/5/2024 at 2:46 PM, HR said she had been employed since August 1, 2023, at the facility. She said she was not responsible for submitting information to PBJ but would gather the payroll numbers and send them to corporate. She said corporate would send the information to be submitted to CMS. During an interview on 2/5/2024 at 2:49 PM, the Regional Director of Operations said corporate was responsible for the submission of PBJ information and was not aware that the fourth quarter of 2023 was not submitted to PBJ. He said the facility only completed the daily payroll numbers and corporate staff pulled the data and that was submitted to CMS for PBJ. During a phone conversation on 2/5/2024 at 3:22 PM, the Director of Finance said he worked for a third-party vendor that submitted the information of PBJ. He said they received the information out of the facility's payroll system and then submitted the information to CMS. He said they send the information back to the facility for verification to make sure information was correct before it was submitted to CMS. He said he had some facilities that had an error with submissions recently but was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 15 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not sure if the facility was one of them or not. He said he was not aware if it was submitted and not sure if it was late and if it was past the time and did not go back to submit it for the fourth quarter. During an interview on 2/7/2024 at 10:01 AM, the Administrator and Regional Director of Operations said they submitted the RN hours to the Regional Director of Operations and everything thing else the third-party vendors had access to the facility payroll system. They both said going forward they would make sure the third-party vendors sent a copy of the submissions for approval prior to the deadline and they do not see any risk to the residents. Record review of a facility policy dated 4/10/2022 titled Nursing Services and Sufficient Staff indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. 7. The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 16 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 observations, interviews, and record reviews, 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 2 of 5 residents (Resident #5 and #14) and 3 of 6 staff (MA H, wound care doctor, and Treatment nurse) reviewed for infection control. Residents Affected - Some MA H failed to properly clean reusable equipment in between each resident during medication administration on 02/06/2024. The wound care doctor failed to properly bag soiled wound bandages removed from Resident #5 on 02/05/2024. The Treatment nurse failed to perform proper hand hygiene while providing wound care to Resident #14 on 2/6/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: 1. During medication pass observation on 2/6/24 between 7:47 a.m. and 8:02 a.m., MA H was observed to not sanitize the reusable blood pressure cuff between Resident #42 and Resident #33. She was observed checking the blood pressure of Resident #42, then preparing and administering his medication. She then checked the blood pressure of Resident #33 without sanitizing the cuff. During an interview on 2/6/24 at 8:49 a.m., MA H said that the nurse had already sanitized the cuff before she got it this morning. She said that she did not know to sanitize it between residents and that she had never been told that. She said that she could see that it could be an infection control issue. 2. Record review of a facility face sheet indicated Resident #5 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of cerebrovascular disease. Record review of comprehensive care plan dated 11/08/2023 indicated Resident #5 had a lymphademic (swelling caused by fluid) wound to right calf, was at risk for infection and to provide wound care as ordered. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #5 had open lesions. Record review of a physician order dated 01/29/2024 for Resident #5 indicated to cleanse right calf with wound cleanser, pat dry, apply hydrofera blue foam dressing and wrap with super absorbent gelling fiber bandage and cover with kerlix daily. During an observation on 02/05/24 at 2:20 PM, soiled bandages were on the floor with treatment nurse present providing care to Resident #5. During an interview on 02/05/24 at 2:24 PM, the treatment nurse stated the wound doctor had removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 17 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 - Some the soiled bandages and placed them on the floor before she could properly bag the soiled bandages. She stated she knew the proper disposal of soiled wound supplies, but the doctor doesn't always follow the proper steps. She stated if soiled bandages were not disposed of properly it could cause spread of infection. During an interview on 02/05/24 at 2:27 PM, the wound care doctor stated he placed the soiled bandages on the floor when he removed the bandage from Resident #5's leg because he forgot the trash bag and was in a hurry. He stated he was aware of the risk, and it could cause spread of infection if soiled bandages were not disposed of properly. During an interview on 02/07/24 at 10:55 AM, the ADON stated she had been the infection prevention nurse for 2 years and was responsible for training all staff on infection control measures. She stated the wound care doctor should have known how to properly dispose of soiled wound care supplies and by not doing so could lead to infections. During an interview on 02/07/24 at 10:59 AM, the regional nurse stated that all staff in the building were responsible for following infection control measures including the physicians that make rounds. She stated she expected everyone to follow infection control measures. She stated there was no policy for infection control related to wound care but followed the wound care checklist. 3. Record review of an admission Record dated 2/6/2024 for Resident #14 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia (memory loss), non-pressure chronic ulcer of other part of left foot (wound on other part of the foot), bipolar disorder (extreme mood swings) and PVD (narrowed blood vessels in the legs that causes poor circulation). Record review of active physician orders dated 2/6/2024 for Resident #14 indicated to cleanse stage 3 (wound has gone through all layers of skin into the fat tissue) to the left ankle with wound cleanser, pat dry, apply collagen sheet and cover with a silicone dressing for 23 days everyday shift for wound care. Record review of a Quarterly MDS for Resident #14 dated 1/9/2024 indicated he had severe impairment in thinking with a BIMS score of 00. He had a pressure ulcer/injury with one or more unhealed pressure ulcers/injuries with one stage 3 pressure ulcers that was present upon admission/entry or reentry. Record review of a care plan revised on 12/14/2023 for Resident #14 indicated he had a pressure ulcer and was at risk for infection with interventions to provide wound care per physician's order. During an observation on 2/6/2024 at 9:30 AM, the Treatment Nurse was in the room of Resident #14 to provide wound care to his left and right ankles. The Treatment Nurse placed wound care supplies on waxed paper in the room on an over bed table. She placed gloves on both hands without washing or sanitizing them, removed the dressing from Resident #14's left ankle and placed it in the trash along with her gloves. She placed gloves on both hands without washing or sanitizing them and sprayed wound cleanser to Resident #14's left ankle and cleaned with a gauze and placed in the trash along with her gloves. She placed gloves on her hands, applied collagen to the wound bed and a foam dressing. She removed her gloves and placed them in the trash. She exited the room to get more gloves and reentered the room and went into the restroom and washed her hands. She applied gloves and sprayed skin prep to both of Resident #14's heels and placed his heel protectors back on. She removed her gloves and placed them in the trash. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 18 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 - Some During an interview on 2/6/2024 at 9:30 AM, the Treatment Nurse said she had been employed at the facility for 3 years. She said she had only been the treatment nurse in the facility for about 3 months. She said during the wound care provided to Resident #14, she should have changed her gloves and washed her hands before applying the collagen and washed her hands between glove changes. She said she had been trained by a treatment nurse from a sister facility but had not been checked off by anyone in the facility with a competency evaluation. She said if staff did not wash or sanitize their hands between glove changes, residents could be at risk for infections. During an interview on 2/07/2024 a 9:52 AM, the Regional Nurse said hand washing should be done before care was provided, during care from dirty to clean, after care, between glove changes, and anytime gloves were changed staff should be washing or sanitizing their hands. She said the ADON did the trainings on hire with the nurses on infection control. She said the Treatment Nurse has had a competency evaluation but was not able to say what date that occurred. She said going forward she would conduct an inservice with staff and had an inservice with the Treatment Nurse on yesterday 2/6/2024 on hand washing with wound care treatments. She said residents could be at risk of infections. During an interview on 2/07/2024 at 10:06 AM, the Administrator said the ADON was the IP in the facility and was responsible for completing check offs with staff and with wound care on infection control. She said she was aware of the incident with the Treatment Nurse on yesterday 2/6/2024. She said going forward they would complete an inservice with the Treatment Nurse with a return demonstration and follow-up training to make sure she was washing her hands appropriately. She said residents could be at risk for infections. Record review of a wound care validation checklist dated 11/2/2023 indicated the Treatment nurse performed satisfactory with wound care and hand hygiene by the DON. Record review of a wound care validation checklist dated 2/6/2024 indicated the Treatment nurse performed satisfactory with wound care and hand hygiene by the DON. Record review of a facility policy dated 2/13/2020 indicated, .The purpose for this policy is to reduce and prevent the spread of infection by the use of evidence-based techniques established infection control policies and procedures. 4. Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact . Record review of facility document titled Validation Checklist Wound Care indicated, .13. follow infection control protocol (dispose of soiled items in appropriate receptacle) . A facility policy for checking blood pressures with reusable cuffs was requested multiple times, but never provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 19 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program so that the facility was free of pests for 1 of 12 (room [ROOM NUMBER]) rooms reviewed for pest control. Residents Affected - Many The facility failed to ensure room [ROOM NUMBER] did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. Findings include: During an observation on 02/05/24 at 9:34 AM, room [ROOM NUMBER] had a small refrigerator in the room. Inside the refrigerator was two dead roaches and one live roach. The refrigerator was unplugged and empty. During an interview on 02/05/24 at 9:35 AM, HSK D stated housekeeping staff cleaned the refrigerators weekly. He stated the refrigerator in 411 had not been working, had been unplugged and they had not been checking it. He stated the facility maintenance director was over the pest control program. He stated there had been roaches in the facility but had not seen any recently. He stated he did not know the risk to the residents if there was pest present. During an interview on 02/04/24 at 10:30 AM, the Maintenance Director stated he had been in the position since August 2023. He stated he was not aware of any roach issues on 400 hall particularly room [ROOM NUMBER] but he would have pest control make an additional visit to assess. He stated the pest control company came monthly and the facility had issues with roaches on and off since his starting as maintenance director. He stated the pest control company changed their treatment plan in October and December for increased issues with roaches. He stated he did not know the risk of having roaches other than it being unsanitary. During an interview on 02/07/24 at 1:42 PM, the administrator stated she had been at the facility one year. She stated the maintenance director was responsible for the pest control program. She stated the pest control company came monthly and as needed for issues. She stated she was not aware of the roach issues in the facility. She stated it pest were not controlled or eradicated it could cause disease. She stated she expected the facility to have an effective program and to contain or eliminate all pest. Record review of pest control monthly visit summary reports dated from July 2023 to February 2024 indicated facility has had issues with roaches at monthly visits and different areas had been treated. Record review of a facility policy dated 1/20/2020 titled Pest Control Program indicated, .it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pest and rodents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 20 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 2 of 3 smoking areas reviewed. Residents Affected - Some The facility failed to keep trash out of the red metal trash cans designated for cigarette butts in the smoking area and failed to implement their smoking safety policy. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The Findings Included: During an observation on 2/5/2024 at 11:07 AM, 5 residents were outside of the dining room smoking with staff present and a red smoking can had cigarette butts and multiple empty cigarette boxes that was about ¾ full. There was a fire blanket and fire extinguisher present. During an observation and interview on 2/6/2024 at 9:20 AM, the HSK Supervisor said housekeeping was responsible for emptying the red smoking cans and should be checking them daily. The red smoking cans outside of the secured unit and outside of the dining room had trash inside that included plastic wrapping from cigarette boxes and cigarette boxes. He said the red cans should not have any trash inside, only ashes and butts. He said if the cans had paper in them and a butt was still lit, then the paper inside could catch fire. During an interview on 2/7/2024 at 10:08 AM, the Administrator said maintenance and housekeeping were responsible for checking the red smoking cans and should look at them daily. She said only ashes and cigarette butts were supposed to be in the red smoking cans. She said there was a risk for fires and going forward they would be checking the cans twice daily. Record review of a facility policy with a revision date of 7/14/2023 indicated, .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking. 3. Safety measures for the designated smoking area will include, but not limited to: c. Accessible metal container(s) with self-closing covers into which ashtrays can be emptied . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 21 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 10 of 15 employees (ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA A, CNA B, CNA K, MA L, and CNA M) new and existing staff reviewed for training. Residents Affected - Some The facility failed to ensure ADON, SW, DM was trained on HIV, dementia, restraint reduction and completed 2-hour quarterly trainings annually. The facility failed to ensure the Treatment nurse was trained on HIV, restraint reduction and completed 2-hour quarterly trainings annually. The facility failed to ensure LVN J was trained on HIV, restraint reduction, fall prevention, and completed 2-hour quarterly trainings annually. The facility failed to ensure CNA A and CNA B was trained on HIV on hire. The facility failed to ensure CNA K was trained on HIV, and restraint reduction annually. The facility failed to ensure MA L was trained on HIV, restraint reduction, and dementia annually. The facility failed to ensure CNA M was trained on HIV, dementia, and restraint reduction on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of the personnel file for the ADON indicated she hired at the facility on 4/16/2020 and did not have annual training on HIV, dementia, restraint reduction and had not completed the 2-hour quarterly trainings. Record review of the personnel file for the Treatment Nurse indicated she hired at the facility on 4/22/2022 and did not have annual training on HIV, restraint reduction and had not completed the 2-hour quarterly trainings. Record review of the personnel file for LVN J indicated she was hired at the facility on 7/1/2021 and did not have annual training on HIV, restraint reduction, fall prevention, and had not completed the 2-hour quarterly trainings. Record review of the personnel file for the SW indicated she was hired at the facility on 11/2/2021 and did not have annual training on HIV, restraint reduction, dementia and had not completed the 2-hour quarterly trainings. Record review of the personnel file for the Dietary Manager indicated she was hired at the facility on 12/16/2015 and did not have annual training on HIV, restraint reduction, dementia and had not completed the 2-hour quarterly trainings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 22 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0940 Level of Harm - Minimal harm or potential for actual harm Record review of the personnel file for CNA A indicated she was hired at the facility on 5/23/2023 and did not receive training on HIV. Record review of the personnel file for CNA B indicated he was hired at the facility on 8/24/2023 and did not received training on HIV. Residents Affected - Some Record review of the personnel file for CNA K indicated she was hired at the facility on 10/20/2021 and did not have annual training on HIV, and restraint reduction. Record review of the personnel file for MA L indicated she was hired at the facility on 7/1/2012 and did not have annual training on HIV, restraint reduction, and dementia. Record review of the personnel file for CNA M indicated she was hired at the facility on 11/6/2023 and did not have training on HIV, dementia, and restraint reduction. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: g. Restraints, h. HIV, i. Dementia management and care of the cognitively impaired . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 23 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 5 of 15 employees (ADON, Treatment Nurse, SW, CNA K and MA L) reviewed for training, in that: The facility failed to ensure effective communication training was provided to the ADON, Treatment Nurse, SW, CNA K and MA L annually. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings include: Record review of the personnel file for the ADON indicated she hired at the facility on 4/16/2020 and did not have annual training on effective communication. Record review of the personnel file for the Treatment Nurse indicated she hired at the facility on 4/22/2022 and did not have annual training on effective communication. Record review of the personnel file for the SW indicated she was hired at the facility on 11/2/2021 and did not have annual training on effective communication. Record review of the personnel file for the Dietary Manager indicated she was hired at the facility on 12/16/2015 and did not have annual training on HIV, restraint reduction, dementia and had not completed the 2-hour quarterly trainings. Record review of the personnel file for CNA K indicated she was hired at the facility on 10/20/2021 and did not have annual training on effective communication. Record review of the personnel file for MA L indicated she was hired at the facility on 7/1/2012 and did not have annual training on effective communication. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 24 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: a. Effective communication for direct care staff . Event ID: Facility ID: 675835 If continuation sheet Page 25 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 4 of 15 employees (ADON, LVN J, SW, and Dietary Manager) reviewed for training in that: The facility failed to ensure required training was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted annually to the ADON, LVN J, SW, and Dietary Manager. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel file for the ADON indicated she hired on 4/16/2020 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for LVN J indicated she hired on 7/1/2021 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the SW indicated she hired on 11/1/2021 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the Dietary Manager indicated she hired on 12/16/2015 and had not completed training on infection control within the previous 12 months. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: b. Resident rights and facility responsibilities for caring of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 26 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0942 residents . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 27 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and resident abuse prevention for 4 of 15 employees (LVN J, LVN N, SW, and MA L) reviewed for training. The facility failed to ensure abuse training was provided to LVN J, LVN N, SW, and MA L. This failure could affect residents and place them at risk abuse due to lack of staff training. Findings include: Record review of the personnel file for LVN J indicated she was hired at the facility on 7/1/2021 and did not have annual training on abuse. Record review of the personnel file for LVN N indicated she was hired at the facility on 7/18/2023 and did not have training on abuse on hire. Record review of the personnel file for the SW indicated she was hired at the facility on 11/2/2021 and did not have annual training on abuse. Record review of the personnel file for MA L indicated she was hired at the facility on 7/1/2012 and did not have annual training on abuse. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: j. Abuse, neglect, and exploitation prevention . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 28 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings: Record review of the personnel file for the DON indicated she hired on 5/11/2015 and did not have training on QAPI. Record review of the personnel file for the ADON indicated she hired at the facility on 4/16/2020 and did not have training on effective QAPI. Record review of the personnel file for the Treatment Nurse indicated she hired at the facility on 4/22/2022 and did not have training on QAPI. Record review of the personnel file for LVN J indicated she was hired at the facility on 7/1/2021 and did not have training on QAPI. Record review of the personnel file for the SW indicated she was hired at the facility on 11/2/2021 and did not have training on QAPI. Record review of the personnel file for CNA K indicated she was hired at the facility on 10/20/2021 and did not have training on QAPI. Record review of the personnel file for MA L indicated she was hired at the facility on 7/1/2012 and did not have training on QAPI. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 29 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: c. Elements and goals of the facility's QAPI program . Event ID: Facility ID: 675835 If continuation sheet Page 30 of 37 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 675835 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 8 of 16 staff (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L. This failure could place residents at risk of illness due to lack of staff training. The findings were: Record review of the personnel file for the DON indicated she hired on 5/11/2015 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the ADON indicated she hired on 4/16/2020 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the Treatment Nurse indicated she hired on 4/22/2022 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for LVN J indicated she hired on 7/1/2021 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the SW indicated she hired on 11/1/2021 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for the Dietary Manager indicated she hired on 12/16/2015 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for CNA K indicated she hired on 10/20/2021 and had not completed training on infection control within the previous 12 months. Record review of the personnel file for MA L indicated she hired on 7/1/2013 and had not completed training on infection control within the previous 12 months. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 31 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: d. Written standards, policies, and procedures for the facility's infection prevention and control program . Event ID: Facility ID: 675835 If continuation sheet Page 32 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the required compliance and ethics training for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training in that: Residents Affected - Some The facility failed to ensure compliance and ethics training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of the personnel file for the DON indicated she hired on 5/11/2015 and had not completed training on compliance and ethics. Record review of the personnel file for the ADON indicated she hired on 4/16/2020 and had not completed training on compliance and ethics. Record review of the personnel file for the Treatment Nurse indicated she hired on 4/22/2022 and had not completed training on compliance and ethics. Record review of the personnel file for LVN J indicated she hired on 7/1/2021 and had not completed training on compliance and ethics. Record review of the personnel file for the SW indicated she hired on 11/1/2021 and had not completed training on compliance and ethics. Record review of the personnel file for the Dietary Manager indicated she hired on 12/16/2015 and had not completed training on compliance and ethics. Record review of the personnel file for CNA K indicated she hired on 10/20/2021 and had not completed training on compliance and ethics. Record review of the personnel file for MA L indicated she hired on 7/1/2013 and had not completed training on compliance and ethics. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 33 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0946 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: e. Written standards, policies, and procedures for the facility's compliance and ethics program . Event ID: Facility ID: 675835 If continuation sheet Page 34 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain record of the required annual in-service records and required in-service trainings for nurse aides were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year and included abuse, neglect training for 2 of 5 staff, (CNA K and MA L) records reviewed for staff training. The facility failed to provide CNA K and MA L 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff. The findings included: Record review of the personnel file for CNA K indicated she hired at the facility on 10/20/2021 and it did not include evidence for 12 hours of training each year since date of hire. Record review of the personnel file for MA L indicated she hired at the facility on 7/1/2013 and it did not include evidence for 12 hours of training each year since date of hire. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Record review of the facility assessment dated [DATE] indicated, .Required in-service training for nurse aides that must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management and resident abuse training. Action to be taken/already this year for training competencies included routine staff training will continue . Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 35 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K and MA L. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of the personnel file for the DON indicated she hired on 5/11/2015 and had not completed training on behavioral health. Record review of the personnel file for the ADON indicated she hired on 4/16/2020 and had not completed training on behavioral health. Record review of the personnel file for the Treatment Nurse indicated she hired on 4/22/2022 and had not completed training on behavioral health. Record review of the personnel file for LVN J indicated she hired on 7/1/2021 and had not completed training on behavioral health. Record review of the personnel file for the SW indicated she hired on 11/1/2021 and had not completed training on behavioral health. Record review of the personnel file for the Dietary Manager indicated she hired on 12/16/2015 and had not completed training on behavioral health. Record review of the personnel file for CNA K indicated she hired on 10/20/2021 and had not completed training on behavioral health. Record review of the personnel file for MA L indicated she hired on 7/1/2013 and had not completed training on behavioral health. During an interview on 2/7/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire and annually until the Surveyor requested the trainings for selected employees. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 2/7/2024 at 9:32 AM, the Administrator said prior to the change of ownership the staff were watching videos on trainings and have continued to watch them that included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 36 of 37 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 675835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785 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 0949 Level of Harm - Minimal harm or potential for actual harm abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings. Residents Affected - Some Record review of a facility policy dated 11/29/2022 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training contents includes, at a minimum: f. Behavioral health including informed trauma care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675835 If continuation sheet Page 37 of 37