Inspection·April 12, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to make sure the diagnosis was correct on Resident #35's MDS. The MDS coordinator stated it had been correct on the MDS for the previous 3 years and she just missed it this time because she was in a rush. The MDS coordinator stated regional did not double check the MDS assessments unless they were flagged or had an increase in payment. Regional nurses only checked the MDS assessments quarterly and at random. The MDS coordinator stated the importance of making sure the MDS assessments were correct was to ensure adequate payment, make sure it was a true picture of the resident and their needs, and quality measures. The MDS coordinator stated if the MDS assessment was not correct it could result in quality measure impairment, or the payment could be wrong. During an interview on 04/12/23 at 9:22 AM, the DON stated the MDS coordinator was responsible for making sure the MDS assessments were correct. The DON stated she reviewed the MDS assessments at random and signed them when they are completed. The DON stated if the MDS was not correct, it could impact payment and Resident #35 could have looked like he was not getting the correct medications or treatment. During an interview on 04/12/23 at 12:11 PM, the Administrator stated the MDS coordinator was responsible for completing the MDS assessments and he expected them to be done correctly. The Administrator stated if the MDS assessments were not correct, it could impact resident care, but it should not take them long to figure out it was marked incorrectly. Record review of the facility's policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy dated 2/2021 indicated . the RN signs the assessment certifying that each section was completed by the appropriate person and the individual is qualified to determine the accuracy of the portion of the resident's assessment completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 2 of 7 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident # 9 and Resident #15) reviewed for dialysis. Residents Affected - Some The facility failed to have a physician's order for dialysis for Resident #9. The facility failed to ensure nursing staff monitored Resident #15's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection and for the dressing to be intact. The facility failed to ensure the dialysis clinic was notified that Resident #15's central venous catheter dressing was loose and needed to be changed. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: 1. Record review of Resident #9's, undated, face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9 had a history of schizophrenia (affects a person's ability to think, feel and behave clearly), type 2 diabetes (the way the body processes blood sugar) and stage 3 kidney disease (mild to moderate kidney damage and kidneys are less able to filter waste and fluid out of your blood). Record review of Resident #9's quarterly MDS dated [DATE] indicated he had a BIMS score of 13 which indicated the resident was cognitively intact. Resident #9 had not rejected care and had a diagnosis of renal insufficiency. The MDS had not indicated dialysis was received. Record review of Resident #9's order summary report dated 04/11/2023 indicated to assess dialysis device location in left arm for positive bruit and thrill every shift for hemodialysis. The physician orders did not indicate Resident #9 received dialysis, the name of the dialysis facility or the days Resident #9 was scheduled to attend dialysis. Record review of Resident #9's care plan dated 04/20/2022 indicated Resident #9 had a history of needing dialysis and had a dialysis port. Resident #9 refused dialysis frequently despite education. The goal indicated Resident #9 would have no complications related to the dialysis port. The interventions included to monitor for dry skin and apply lotion as needed, not to draw blood or take blood pressure in arm with graft, monitor labs and report to the doctor as needed and monitor/document/report to MD PRN any signs or symptoms of infection to access site. Record review of Resident #9's progress notes dated 3/14/23 to 4/6/23 indicated the resident refused dialysis and the primary physician and family member were notified. During an interview on 04/12/23 at 09:59 AM, the Facility Administrator at the Kidney Care facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 3 of 7 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0698 Level of Harm - Minimal harm or potential for actual harm indicated Resident #9 had refused dialysis on several occasions and he attempted to contact the Administrator at the SNF on optioning a withdraw. The facility Administrator stated Resident #9's dialysis seat days were Tuesday, Thursday, and Saturday at 12:15 PM. The facility Administrator stated if residents refused dialysis more than 30 days, they would look at other options and he had tried to set up a meeting with the nephrologist and Resident #9 on 03/09/2023 and Resident #9 refused to attend. Residents Affected - Some During an interview on 04/12/23 at 8:56 AM, LVN A stated any of the nursing staff could write an order for dialysis and the days the resident attendant should be specified on the order. LVN A stated the importance of having an order for dialysis was to make sure staff were aware of the resident's needs and because an order was needed for resident to be able to attend dialysis. LVN A stated it was the responsibility of the DON to check over all the resident orders. During an interview on 04/12/23 at 12:36 PM, the ADON stated Resident #9 should of had an order for dialysis and the charge nurse that took the order was responsible for completing the order. The ADON stated orders are checked at random by herself and the DON, but not all of them are checked. The ADON stated the dialysis order was important because that was where staff communicated the dialysis days for the resident and if they did not have an order they might have overlooked or missed an appointment. During an interview on 04/12/23 at 9:22 AM, the DON stated the process for dialysis residents was to make sure staff found out the days and times of the residents scheduled appointment and the name of the dialysis facility when they are admitted . The DON stated she would care plan dialysis and make sure there was an order. The DON stated the ADON and herself were responsible for making sure nursing staff knew who to call (dialysis facility and staff member) and the information should have been on the physician order, and it would have been put on a communication form given to the nursing staff when resident first started. The DON stated if there was no order in Resident #9's chart, then he could have missed one of his scheduled dialysis days. During an interview on 04/12/23 at 12:11 PM, the Administrator stated the DON was responsible for making sure Resident #9 had an order for dialysis. The Administrator stated nursing staff was responsible for asking Resident #9 to go to dialysis on all of his scheduled days until he was discharged from the dialysis clinic. The Administrator stated he expected Resident #9 to have an order for dialysis, so that nursing staff did not miss anything going on. The Administrator stated, collaboration important with the clinic to provide the best care. The Administrator stated he expected Resident #9's dialysis schedule and dialysis facility information to have been documented somewhere, but he did not know exactly where the nurses should document it. 2. Record review of Resident #15's face sheet dated 04/12/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential (primary) hypertension (high blood pressure), and end stage renal disease (kidney failure). Record review of the quarterly MDS assessment dated [DATE], revealed Resident #15 was understood by others and was able to make self-understood. Resident #15 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment revealed Resident #15 received dialysis while a resident at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 4 of 7 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #15's care plan with a target date of 05/18/2023 revealed a focus of the resident needed dialysis related to renal failure with the goal of the resident would have immediate intervention with any signs and symptoms of complications from dialysis occurred through the review date, and an intervention to check and change dressing daily at the access site and document. Record review of the order summary dated 04/10/2023 revealed Resident #15 had an order to not touch the dialysis port in the left subclavian (central venous catheter inside the vein on the left chest area) and if a problem was observed to call the dialysis center, the dialysis center was to change the dressing when needed. Resident #15 did not have an order to monitor the central venous catheter for signs and symptoms of infection and for the dressing to be intact. Record review of the Treatment Administration record for the month of April 2023 did not reveal Resident #15's central venous catheter was being monitored by the nurses for signs and symptoms of infection and for the dressing to be intact. During an observation and interview on 04/10/2023 at 10:13 AM, Resident #15 stated her dialysis treatments were on hold due to her possibly regaining her kidney function. Resident #15 stated her last dialysis treatment was on 03/30/2023, but she still had her central venous catheter in place. Resident #15's central venous catheter was located on her left chest area. The dressing to the central venous catheter was undated, not completely adhered and the white dressing had a brownish tinge to it. When Resident #15 moved the loose dressing lifted and exposed the exit site (area where the catheter comes out from underneath the skin). Resident #15 stated the facility staff did not check the central venous catheter daily. Resident #15 stated the dressing sometimes was loose due to getting wet when she showered. Resident #15 stated the dialysis clinic was responsible for changing the dressings. During an observation on 04/11/2023 at 8:27 AM, Resident #15 central venous catheter dressing was undated, loose and had the same brownish tinge to it. During an interview on 04/12/2023 at 9:41 AM, RN B, the nurse at the dialysis clinic, stated the dressing to the central venous catheter was changed by the nurses at the dialysis clinic. RN B stated the dressing should not have gotten wet and it should be intact. RN B stated if Resident #15's central venous catheter dressing got wet or was loose the nurses at the facility should have contacted the dialysis clinic. RN B stated to her knowledge the nursing home facility staff had not contacted the dialysis clinic to notify them Resident #15's dressing was loose and not intact. RN B stated the central venous catheter dressing not being intact could result in Resident #15 getting an infection. During an interview on 04/12/2023 at 8:55 AM, LVN A stated she was not monitoring Resident #15's central venous catheter. LVN A stated Resident #15 told her over the weekend her central venous catheter was bothering her so she looked at it since her dressing was loose. LVN A stated she assessed the area that day and there were no signs and symptoms of infection. LVN A stated she did not document this anywhere, and she did not notify the dialysis clinic that Resident #15's central venous catheter dressing was not intact. LVN A stated she should have documented this. LVN A stated she did not know why she had not notified the dialysis clinic, but she should have notified the dialysis clinic. LVN A stated the nurses should be monitoring the central venous catheter for the dressing to be intact and for signs and symptoms of infection and documenting it on the treatment administration record. LVN A stated she had not received any training regarding how to care for residents on dialysis, what to monitor, and when to contact the dialysis clinic. LVN A stated the ADON, DON, and the charge nurse were responsible for documenting the monitoring of Resident #15's central venous catheter on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 5 of 7 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment administration record. LVN A stated the central venous catheter dressing not being intact placed Resident #15 at risk for an infection. During an observation and interview on 04/12/2023 at 9:14 AM, Resident #15 stated the facility transported her to the dialysis clinic yesterday (04/11/2023) afternoon and the dressing to the central venous catheter was changed by the dialysis staff. Resident #15's dressing to the central venous catheter was white and adhered on all sides to her skin. During an interview on 04/12/2023 at 9:21 AM, the DON stated Resident #15 should have had an order to monitor her central venous catheter for signs and symptoms of infection, for the dressing to be intact, and for no redness or swelling to the site. The DON did not know why Resident #15 did not have the order. The DON stated the nurses were responsible for documenting the monitoring of the central venous catheter in the treatment administration record. The DON stated if there were any issues with the central venous catheter or the dressing was not intact the nurses should have notified the dialysis clinic for instructions. The DON stated she had instructed the nurses to call the dialysis center for any issues with the dialysis access. The DON stated not monitoring the central venous catheter and the dressing not being intact placed the resident at risk for getting an infection. During an interview on 04/12/2023 at 12:11 PM, the Administrator stated the DON was responsible for ensuring Resident #15 had an order to monitor her central venous catheter. The Administrator stated he expected the nurses to monitor all the dialysis access sites to provide the best care possible to the residents. The Administrator stated he expected the nurses to contact the dialysis clinic if there were any issues with the residents' access sites. The Administrator stated not checking Resident #15's catheter access site placed her at risk for infection and dislodgment. During an interview on 04/12/2023 at 12:36 PM, the ADON stated the nurses were responsible for monitoring Resident #15's central venous catheter for no signs and symptoms of infection and for the dressing to be intact. The ADON stated the nurses should have been documenting this on the treatment administration record. The ADON stated the DON and herself were responsible for making sure the nurses monitored and documented on Resident #15's central venous catheter. The ADON stated she was working the floor a lot and had not been able to review Resident #15's treatment administration record. The ADON stated the nurses should have contacted the dialysis clinic to notify them Resident #15's central venous catheter dressing was not intact. The ADON stated not monitoring Resident #15's central venous catheter placed her at risk for getting a severe infection because the central venous catheter went directly into her bloodstream. Record review of the facility's policy titled, Dialysis, last revised November 2013, indicated, .review and confirm the physician's order for dialysis . The policy did not address care of the central venous catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 6 of 7 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (nurse's cart) reviewed for storage of medications. The facility failed to ensure the nurses' cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: During an observation on 04/11/2023 at 10:31 a.m., LVN A left the nurses' cart unlocked and out of sight, facing Resident #101's room, while checking Resident #101's blood sugar. During an observation on 04/11/2023 at 10:47 a.m., LVN A left the nurses' cart unlocked and out of sight, facing Resident #1's room, while administering Resident #1's medication. During an interview on 04/11/2023 at 10:51 a.m., LVN A stated she should have locked the nurses' cart prior to going in Residents #101 and #1's room. LVN A stated, I get so nervous when state watches me. LVN A stated this failure allowed residents, staff, and visitors access to other residents' medication. During an interview on 04/12/2023 at 9:08 a.m., the DON stated she expected medication carts to be locked when unattended. The DON stated the nurses were responsible for monitoring their own cart. The DON stated she was responsible for training staff on securing/storage of medications. The DON stated she did random checks throughout the day to ensure medication carts were locked when unattended. The DON stated she did not notice any issues during her random checks. The DON stated this failure allowed anyone access to residents' medication. During an interview on 04/12/2023 at 12:36 p.m., the Administrator stated he expected medication carts to be locked when unattended. The Administrator stated this failure could put residents at risk for indigestion of medications. Record review of the facility's Medication Administration Procedures policy, last revised in 2003, revealed . 5. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse 8. After the medication administration process was completed, the medication cart must be completely locked, or otherwise secured FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 7 of 7