Health inspection·September 15, 2022

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation on 09/13/22 at 10:49 AM revealed Resident #21's oxygen concentrator running at 3LPM. The nasal canula was draped over the oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 and connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room [ROOM NUMBER]A stating oxygen in use. In an observation on 09/14/22 09:49 AM of Resident # 21, revealed he was sitting in a chair next to his bed with the nasal canula in his nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. The nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. In an observation on 09/14/22 at 1:00 PM revealed 12 portable oxygen cannisters were delivered to the nursing station. In an observation on 09/14/22 at 2:42 PM of Resident # 21, revealed he was not in his room. The oxygen tubing was not connected. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. The nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. Resident was sitting in dining room connected to a portable oxygen canister. In an observation on 9/15/22 at 9:33 AM revealed Resident #21 was sitting in chair next to his bed with nasal canula on the floor and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. In an observation and interview on 09/13/22 at 11:00 AM with Resident # 21, revealed he was sitting in the dining room without his oxygen. He said he used his oxygen throughout the day and night if he was in his room. He stated he did not have oxygen available to him when he was outside of his room. He stated there were times when he felt short of breath without oxygen. He stated his nose felt dry frequently since he started oxygen therapy. He stated he would stop activities in dining room and go back to his room when he felt short of breath. He said he had not reported this to anyone. In an interview on 09/14/22 09:39 AM with [NAME] LVN she stated sterile saline for oxygen therapy, nasal canula, nebulizer tubing, and nebulizer mask should be changed out weekly and dated. She then changed the oxygen tubing and sterile saline. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights. She stated Resident #21 always put on and took off nasal canula on his own when in his room. She reported he had not told her he was short of breath. In an interview on 09/14/22 09:49 AM with Resident # 21, he said he had double pneumonia not long ago and thought he was going to die. He said he had always put his own oxygen on and off and used nebulizer on his own. He said he did not change the setting on concentrator himself and left it running (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 2 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 at all times. He said he had never been instructed by the facility to put the oxygen tubing or nebulizer tubing and mask in a bag. He stated he did not realize his saline humidifier attached to the oxygen concentrator was empty and his nose felt dry frequently from oxygen. In an interview on 09/14/22 at 3:42 PM the DON stated she was not aware of a policy stating each resident room where oxygen was being used should have a no smoking oxygen in use sign posted outside the door. In an interview on 9/15/22 at 9:33 AM with LVN 1, she said oxygen or nebulizer tubing lying on the floor, draped over oxygen concentrator, or on top of bedside table was putting resident at risk for infection. She stated the tubing and mask should be stored in a bag when not in use. She stated she was aware the facility had put up no smoking oxygen in use signs outside the rooms of residents receiving oxygen therapy today. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 9:38 AM, the ADON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated she had been trained on infection control through in-services once since started 2 months ago. In an interview on 09/15/22 at 9:42 AM, the DON stated oxygen tubing and the nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection She stated she had put up no smoking oxygen in use signs outside the rooms of residents receiving oxygen therapy today. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 10:22 AM, the ADMIN stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. Record review revealed Oxygen Concentrator policy dated 05/2017 to include equipment required, No Smoking signs outside the resident's room. Record review revealed oxygen policy dated 05/2017 stating oxygen tubing and humidification is to be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 3 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 - Some 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 the facility failed to ensure food and equipment were prepared under sanitary conditions consistent with professional standards for all residents receiving meals at facility of practice in that: A. Food in pantry, refrigerator, and freezer were not labeled with open date or expiration date. Food prep areas were left not sanitized after usage. Disposable utensils, cups, bowls and kitchen pots and pans were stored uncovered exposing inside to dust and debris. Baking pans were stored on shelf with visible dried food debris. Floors in kitchen were unclean and sticky. Juice dispenser machine and area were unclean. B. Cook1 did not utilize hygienic practices when handling food Cook1 did not properly wash hands with soap and water to prevent cross-contamination. The dishwasher was seen multiple times in kitchen with mask not covering her nose while food was being prepared. These failures could affect all the residents identified for frequently or occasionally receiving meals in the facility and could place residents who ate from the kitchen at risk of food borne illnesses. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 4 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 - Some In the initial observation of the kitchen on 9/13/22 at 9:12 AM, boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Juice dispenser machine was unclean with a visible buildup of dried juice inside drink dispenser nozzle and storage hanger for nozzle. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/13/22 at 2:12 PM, boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/14/22 at 9:15 AM boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/14/22 at 10:45 AM boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In an interview on 9/13/22 at 9:25 AM with the dietary manager, he stated he was responsible for monitoring and maintaining for everything in the kitchen. He was aware the food was not labeled with open or expiration dates. He stated he had ordered stickers to be used for labeling, but they had not arrived. He stated he was not aware the kitchen was unclean until surveyor pointed out findings. He stated the juice machine nozzles were to be soaked every night and it appeared they had not been cleaned last night. He acknowledged the juice dispenser machine cabinet appeared unclean. He acknowledged the food debris left on food prep table, and the baking pans, utensils, cups, and bowls being exposed to dust and debris. He stated he was aware these findings could put the residents at risk for illness. In an interview on 9/14/22 at 11:13 AM with Admin and Dietary manager, they both stated they were aware the cleanliness of the kitchen needed to be addressed and had professional cleaners scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 5 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 to come into facility overnight tonight to deep clean. The Dietary Manager stated he was in the process of labeling all the food properly and had already begun discarding anything that was already opened without a date. No kitchen policies were available since previous dietary manager resigned 4 months ago. - Residents Affected - Some Finding included: In an observation on 9/13/22 at 9:12 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/13/22 at 10:49 AM oxygen concentrator was running at 3LPM. The nasal canula was draped over oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/13/22 at 11:15 AM dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 9/13/22 at 3:10 PM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 9/14/22 at 9:32 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/14/22 09:49 AM Resident # 21, was sitting in chair next to bed with nasal canula in nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/14/22 at 11:32 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/15/22 at 8:55 AM Cook1 was seen with face mask not covering her nose while she was placing rolls on a baking sheet for lunch. She took her gloved hand pulled mask up over her nose when she saw surveyor. She used the same gloved hand used to move mask to reach into box of frozen rolls and placed them on baking sheet. She then changed gloves without washing hands before continuing to place rolls on baking sheet again. In an interview on 9/13/22 at 11:15 AM the dishwasher stated she knew the face mask was to cover her mouth and nose. She stated leaving her mouth or nose uncovered while in kitchen around food could increase resident risk of infection. In an interview on 09/15/22 at 8:55 AM Cook1 stated she stated she knew the mask was to be covering her nose to prevent the spread of Covid and that is why she pulled mask up after seeing surveyor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 6 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 - Some She said she knew she was supposed to change gloves after touching her mask and that is why she changed them after seeing surveyor. She said she knew she was supposed to wash hands in between glove changes but forgot. She said she knew all of these actions could lead to increased risk of infection for residents. In an interview on 09/15/22 at 9:02 AM dietary manager stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. He stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 9/15/22 at 9:33 AM with LVN 1 she stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 9:38 AM ADON stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 9:42 AM DON stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 10:22 AM ADMIN stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. Record review revealed hand washing policy stating gloves should be changed anytime they become contaminated, and hands should be washed in between gloves being changed. Record review revealed Covid-19 Mask Policy updated 12/31/2021 to include staff shall wear well-fitting mask at all times in resident care areas. The mask should cover both nose and mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 7 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 5 of 6 residents (Resident # 42, Resident 44, Resident # 21,Resident # 45 and Resident # 27) reviewed for wound care, use of wrist blood pressure monitor , incontinence care, oxygen therapy and all residents eating meals at facility for infection control in that: Residents Affected - Some a) LVN-S did not wash her hands before and after wound assessment and care on Resident # 44 and Resident # 42. LVN-S operated the bed remote without changing the contaminated gloves. b) MA-H did not sanitize the wrist blood pressure monitor after using it on Resident # 21 and before and after using on Resident #45 c) CNA-D and CNA- W handled clean items with contaminated gloves while providing incontinent care on Resident # 27. d) Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were left exposed to debris when not in use. e) Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were not dated. f) Resident 21's saline humidification was dated for longer than the facility policy of 7 days. These failures could place the residents at risk for infection. This deficient practice could affect (CENSUS) residents identified for frequently or occasionally receiving meals in the facility and Resident #21 receiving oxygen therapy. Findings included: Review of Resident # 44's medical record reflected a [AGE] year-old man admitted on [DATE]. His diagnoses included Urinary tract infection, Mood disorder due to known physiological condition, MRSA, Type 2 Diabetes Mellitus, Dementia with behavioral disturbance and Aphasia. Review of Resident # 42's medical record reflected a [AGE] year-old woman admitted on [DATE]. Her diagnoses included Unspecified Dementia, Muscle Weakness (generalized), Dysphagia(difficulty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 8 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 swallowing), oral phase, Other abnormalities of gait and mobility, Cognitive Communication Deficit, Hyperlipidemia (too many fat in blood), Depression, Encephalopathy (a disease in which the functioning of the brain is affected by agents like virus or toxins), Cerebral infarction(stroke), Pressure Ulcer of Right Hip, Stage 3 , Pressure Ulcer of left heel, unstageable , Pressure ulcer of other site, unstageable, Pressure ulcer of other site, stage and Osteoarthritis(wear and tear of joints). Residents Affected - Some During an observation on 09/14/2022 at 3.45 pm, the wound nurse LVN-S and LVN-L performed wound assessment on Resident#42 while LVN-L was holding the electronic tablet for Dr-C. LVN-S was assisting DR-C who was on the video call on the electronic tablet for assessing the wounds of the residents in the facility remotely. LVN-S then assessed the ulcers situated on Resident #42's right hip area and right knee by touching and then measuring them with disposable wound measuring strip. After the completion of the assessment LVN-S without changing the contaminated gloves operated the remote control of Resident#42's bed to adjust the height. After that, LVN-S removed the gloves and sanitized her hands with hand sanitizer. She then without washing her hands moved on to Resident# 44. The surveyor stopped her with the intention to avoid the risk of spreading infections if any, when LVN-S about to perform the wound assessment on Resident #44 without washing hands. During the interview on 9/14/22 at 4:00pm LVN-S stated that per her understanding handwashing was not necessary if hand sanitizer was used. LVN-L said she was not aware that washing hand was mandatory before and after wound care. LVN-S and LVN-L did not respond when the surveyor showed the facility's infection control policy and protocol stating washing hands before and after wound care was necessary. Review of the facility policy 'Licensed Nurse procedures, Subject: Dressing, clean revised on 05/2007 stated . Procedures: (3). Place red plastic bag near foot of bed to receive the soiled dressing. (4). Wash hands and apply gloves, (5). Open dressing pack, (6). Pour prescribed solution onto gauze to be used for cleaning, (7). Remove soiled dressing and discard in red plastic bag, (8). Remove old adhesive with adhesive remover, taking care not to get solution into wound, (9). Wash hands and apply clean gloves, . (13). Assist resident to comfortable position. (14). Place call light within reach and instruct resident to call for assistance, if needed, (15). Wash hands. Review of Resident # 21's medical record reflected a [AGE] year-old man admitted on [DATE]. His diagnoses included Pneumonia, unspecified organism, Heart Failure, COPD, Dysphagia (difficulty swallowing), Unspecified, muscle weakness (generalized), Unsteadiness on feet, Cognitive Communication Deficit, Heart Failure, Chronic Kidney Disease, Type 2 diabetes mellitus, Unspecified Dementia, Myocardial Infarction (Heart attack), Cerebral Infarction(stroke), Acute Kidney Failure and Mass and Lump, unspecified lower limb Review of Resident # 45's medical record reflected a [AGE] year-old woman admitted on [DATE]. Her diagnoses included Cerebral Palsy (disorder that affects ability to move and maintain balance and posture), Schizoaffective Disorder, bipolar type(a type of mental disorder), Hyperlipidemia(too many fat in blood), unspecified, Mild Intellectual Disabilities, Major Depressive Disorder and Generalized anxiety disorder. An observation of taking blood pressure using a wrist blood pressure monitor on 09/14/2022 beginning at 9:00 am, revealed MA-H did not sanitize the wrist blood pressure cuff after using it on Resident #21 and before and after using it on Resident #45 until the surveyor asked her about it. During the interview on 09/14/2022 at 9:20 am, MA-H stated that per the facility sanitation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 9 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 policies and procedure for hand and equipment sanitization, all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. She said that it was a mistake from her side and will remember not to repeat the same mistake in the future. Review of the facility's policy Cleaning and disinfection of resident-care items and equipment' dated 01/ 2022 it was stated c. non-critical items are those that come in contact with intact skin but not mucous membranes. 1. non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment) . 3. Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident 4. Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions Review of Resident # 27's medical record reflected a [AGE] year-old woman initially admitted on [DATE] and admitted recently on 06/28/2016. Her diagnoses included Vascular Dementia without behavioral disturbance, Essential (primary) Hypertension, Hyperlipidemia (too many fat in blood), unspecified pain in unspecified joint, Dysphagia (Difficulty swallowing), Primary Osteoarthritis (wear and tear of joints), Cognitive communication deficit, Pain in right ankle and joints, Unsteadiness on feet, and Parkinson's disease (A brain disorder causes unintended or uncontrollable movements). During an observation on 9/14/22 at 12:00pm, CNA D and CNA W provided incontinent care to Resident # 27. CNA- D and CNA -W entered Resident #27's room and donned gloves after washing their hands. CNA-D removed Resident #27's brief which was soaked with urine. CNA D cleaned resident's perineal area, removed soiled gloves, and applied hand sanitizer. She donned new pair of gloves from her scrub's pocket. She turned the resident to the left side with the help of CNA W and cleaned the back of Resident #27. CNA D applied cream at the back and perineal area and then picked up a new diaper without changing the gloves. She removed the disposable liner that was under Resident # 27 and gave to CNA W to dispose. After the disposal, with the same gloves CNA W pulled back the blanket on Resident # 27 and tidied up the bed. Both the CNAs removed the gloves and washed their hands before leaving the room During an interview on 09/13/2022 at 11:10 a.m., CNA -D and CNA -W said they thought they were doing the peri care correctly. CNA- D said she did not remember using the unclean gloves for handling clean items. They said they understood the mistakes and the importance of correct incontinent care practices to control the infections. An interview on 09/15/2022 at 9:00 am with the DON revealed that her expectation was that the nursing staff follow facility policy/procedure for washing the hands before and after wound care, handwashing/sanitization and clean techniques while providing perineal care. She said sanitizing after the use of reusable medical equipment was also important to minimize the spread of infectious diseases. The DON added that they have infection control training annually and in services on regular intervals related to infection control (Eg. Hand washing). The facility identifies deficiencies in infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 10 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 control practices through direct observations. In services provided to the relevant staff members when any deficiencies identified. The DON who had the role of IP was responsible for overseeing infection control Review of a current facility policy on 09/15/2022 titled Infection control: prevention and control program: Handwashing/Hand Hygiene revised 09/2017 stated, This facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the Handwashing/Hand Hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents ., c. Before preparing or handling medications , g. Before handling clean or soiled dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin .k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . Review of the website, https://www.cdc.gov/handhygiene/providers/guideline.html, dated 01/30/2020, the Center for Disease Control (CDC) recommended the following for hand hygiene: Hand Hygiene Guidance The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 11 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. In an observation on 9/13/22 at 9:12 AM revealed the dishwasher was in the kitchen with mask not covering her nose while cook was preparing food. In an observation on 09/13/22 at 10:49 AM Resident #21's oxygen concentrator was running at 3LPM. The nasal canula was draped over oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 and connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/13/22 at 11:15 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 9/13/22 at 3:10 PM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 9/14/22 at 9:32 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 09/14/22 at 09:49 AM revealed Resident # 21sitting in chair next to his bed with nasal canula in nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/14/22 at 11:32 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 09/14/22 at 2:42 PM revealed Resident # 21, was not in his room. Oxygen tubing was not connected. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/15/22 at 9:33 AM Resident #21 was sitting in chair next to bed with nasal canula on the floor and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an interview on 9/13/22 at 11:15 AM, the dishwasher stated she knew the face mask was to cover her mouth and nose and did not have a reason mask was not worn properly. She stated leaving her mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 12 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 or nose uncovered while in kitchen around food could increase resident risk of infection. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/14/22 at 09:59 AM, LVN 1 stated sterile saline for oxygen therapy, nasal canula, nebulizer tubing, and nebulizer mask should be changed out weekly by overnight nurse on Sunday. Residents Affected - Some In an interview on 09/14/22 at 09:49 AM with Resident # 21, he said he puts his own oxygen on and off and uses nebulizer on his own. He said he had never been instructed to put tubing in bag. He stated his nose felt dry frequently from oxygen. In an interview on 9/15/22 at 9:33 AM with LVN 1, she said tubing lying on the floor, draped over oxygen concentrator, or on top of bedside table was putting resident at risk for infection. She stated the tubing and mask should be stored in a bag when not in use. She stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 9:38 AM the ADON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should be worn over nose and mouth at all times while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services once since started 2 months ago. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights to reduce risk for infection to resident. In an interview on 09/15/22 at 9:42 AM, the DON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently and trained staff herself. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights to reduce risk for infection to resident. In an interview on 09/15/22 at 10:22 AM, the ADMIN stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently. Record review of the oxygen equipment policy dated 05/2017 stated in section C.1) Tubing should be replaced every week. 2) Masks should be replaced every week. 3) Cannulas should be replaced every week. D.) When mask or cannula is temporarily no being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. Record review of the oxygen equipment policy 05/2017 stated in section 2. Nebulizer Equipment procedures A.) Nebulizer equipment generates aerosols small enough to be readily deposited in the lungs. Careful technique is required to prevent infecting the resident. D.) Daily dismantle entire (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 13 of 14 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 675889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Manor Healthcare Rehabilitation 3650 S Ih 35 E Waxahachie, TX 75165 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 breathing assembly including all hoses, wash with warm soapy water, rinse well and ensure parts are dry, including inside of hoses. F.) Store, clean and dry until next use. Record review of admission record revealed Resident #21 was a [AGE] year-old male admitted to facility 5/6/22 and to hospice on 7/13/22 with respiratory diagnosis: Pneumonia, Acute systolic Heart Failure, Chronic Obstructive Pulmonary Disease with (Acute) exacerbation, Obstructive Sleep Apnea, and Pleural Effusion -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were left exposed to debris when not in use. -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were not dated. -Resident 21's saline humidification was dated for longer than the facility policy of 7 days. - The dishwasher was seen multiple times in kitchen with mask not covering her nose while food was being prepared. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 14 of 14