Health inspection·November 15, 2023

F 0580 -Nortel 1/35 - 28 day 1 tablet PO QD [active pills only] Level of Harm - Minimal harm or potential for actual harm -Atorvastatin 10mg 1 tablet PO Q HS -Quetiapine 100mg 1 tablet PO Q HS Residents Affected - Some -Midodrine 5mg 1 tablet PO TID -Calcium+ D 600/400 1 tablet PO BID -Oivalproex 500mg 1 tablet PO BID -Pantoprazole 40mg 1 tablet PO BID -Spironolactone 25mg 1 tablet PO Q AM -Multivitamins 1 tablet PO QAM -Escitalopram 10mg + 20mg (total 30mg) 1 tablet each PO Q AM -Folic Acid 1mg 1 tablet PO Q AM -Furosemide 40mg 1 tablet PO QAM, and -Levothyroxine 100mcg 1 tablet PO Q AM before food or other meds. Record review of psych service initial assessment note dated 08/26/2022 reported Staff requested visit to assess mental status, mood and to review/manage psych meds. Assessment revealed resident had negative and intrusive thoughts towards herself. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: Prazosin 1 mg Capsule /QHS for night terrors. Record review of psych service subsequent assessment note dated 12/31/2022 reported chief complaint of staff requesting visit due to recurring psychosis and aggression Resident #166 displayed to other residents. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: 175 mg PO daily. The reason for dose change was due to ineffective therapy. Record Review of medication order for Resident #166 reported: -08/14/2023 - Ambien - 5 mg Tablet give 1 tablet at bedtime for insomnia. -08/26/23 - Prazosin HCL 1 mg capsule -Give 1 mg at bedtime for night. -11/04/2022- Loperamide 2 mg tablet Give 2 tablets PRN for Diarrhea. -11/12/2023 - Seroquel 25 mg added per day for psychosis. DC'd 12/31/2023. -12/31/2023 - Seroquel 50 mg added per day for psychosis. -02/05/2023 - Milk of Magnesia Suspension 400 mg/ 5 ml, give 30 ml per day prn for constipation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 2 of 17 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 11/15/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with FM #1 dated 11/14/2023 at 3:56 PM revealed she had conflicts with the care that was provided toward Resident #166. Resident #166's family member stated that R31 had a mind of a 3-year-old and needed staff to communicate to her any changes in her therapy so she can decide if it is necessary. Resident #166's family member stated that staff including management were not communicating to her the adjustments that were being med to Resident #166 medications. Resident #166's family member stated she was first made aware of the medications Resident #166 was on when Resident #166 discharged from the facility and her medication list was different from when she admitted to the facility. Resident #166's family member stated that she would not have had Resident #166 on the medications regimen she was on had she known about it. Interview with Medical Records Supervisor (MRS) dated 11/14/2023 at 12:55 PM revealed the following: upon being asked for medication list of Resident #166 she responded that it was in the EMR. MRS stated that as soon as the records get uploaded the DON is supposed to communicate with physician which meds should be continued or discontinued and/or other adjustments that need to be made. Interview with Nurse Practitioner (NP) dated 11/14/2023 at 01:42 PM revealed that Resident #166 was ordered Seroquel for severe paranoia. NP stated Resident #166 would sometimes report signs and symptoms of auditory hallucinations. NP stated that she saw Resident #166 on 11/12/23. NP stated she added 25 mg Seroquel daily because Resident #166 was verbally and physically abusive to other residents.NP stated she witnessed physical assaults and asked about it and it was confirmed with staff. NP stated she increased another dose of Seroquel because staff called in stating resident was continuing with her aggressive behavior. NP stated Resident #166 had night terrors. told me of them. She stated she would have nightmares. I am not the one who gave her Ambien. I believe Ambien is what she came in with. I don't think the medication adjustment had a role in her going to her hospital. She was attention seeking. I felt it was needed for her to be on those medications but if there was no change in her condition, I would have taken the medication off. NP Stated that residents RP was supposed to be communicated by nursing so that they are aware of what medications Resident #166 is on. Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor. Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor. Record review of Resident #CR#1's undated care plan, revealed: Focus: [CR #1] has left inner ankle wound x2. Goal: [CR#1] will maintain or develop clean and intact skin by the review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 3 of 17 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 11/15/2023 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 0580 Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Level of Harm - Minimal harm or potential for actual harm Provide treatment per physician order. Residents Affected - Some Specialty mattress to bed. Pressure reduction mattress. Turn and reposition per facility protocol and PRN. Use a draw sheet or lifting device to move resident. In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said she observed the wound on 07/29/2023 while visiting. In an interview with LVN A on 08/02/2023 at 12:39pm, she said she first saw CR#1 had two wounds to her left ankle on 07/24/2023. She said she worked at the facility for 3 months. She said when a new wound was identified the appearance should be documented. She said the primary doctor, wound care doctor, and family should be notified. She said the Treatment Nurse, ADON, and DON are to be notified. She said she notified Physician C on 07/24/2023. She said she did not notify the family or primary doctor after the wound was identified. She said she did not notify the ADON or DON when the wound was identified. She said she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR when the wound was assessed on 07/24/2023. She said she did not complete the tasks which caused a delay in CR#1's treatment. In an interview with DON on 08/01/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress notes completed by LVN A who identified the wound initially on 07/24/23. She said that LVN A documented that she notified the wound care doctor but not the family or DON. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound identified. She said that LVN A did not follow up on treatment orders after CR#1 was assessed by the wound care doctor on 07/24/2023. She said that because she did not complete the tasks CR#1's treatment was delayed. She said that LVN A did not follow the facilities protocol, and she will receive disciplinary action. Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, .4. Unless otherwise instructed by the resident, a nurse will notify the residents representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 4 of 17 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 11/15/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #32 and Resident #51) of 2 residents reviewed for wound care. Residents Affected - Few The facility failed to provide wound care as ordered for Resident #32. The facility failed to document wound care for Resident #32 and Resident #51. These failures could place residents at risk of worsening pressure injuries. Findings included: Resident #32: A record review of Resident #32's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), repeated falls, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cognitive communication deficit (problems with communication). A record review of Resident #32's MDS assessment dated [DATE] reflected a BIMS of 12, which indicated moderately impaired cognition. A record review of Resident #32's care plan last revised on 10/02/2023 reflected she had an unstageable DTI on her left heel . Interventions included nursing staff were to follow facility protocol for treatment of injury. A record review of Resident #32's physician order dated 10/10/2023 reflected an order to cleanse open area to left buttocks with normal saline, apply calcium alginate, collagen powder and dressing daily until healed. A record review of Resident #32's physician order dated 10/24/2023 reflected an order to cleanse with NS, pat dry, apply povidone iodine topical (topical anti-infective) liberally and keep her unstageable DTI to left heel covered with a dry dressing for wound protection three times a day. A record review of Resident #32's physician order dated 11/02/2023 reflected an order to cleanse with NS, pat dry, apply calcium alginate, collagenase (topical medication used for removing damaged skin to allow for wound healing and growth of health skin) and cover her unstageable DTI to left heel daily and PRN. A record review of Resident #32's physician order dated 11/08/2023 reflected an order to cleans with NS, pat dry, apply povidone-iodine (topical anti-infective), Kerlix wrap (woven gauze) and tape her unstageable DTI to left heel two times a day for wound care. A record review of Resident #32's TAR dated November 2023 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 5 of 17 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 11/15/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Treatments for daily wound care to her left buttocks were not documented on 11/02/2023, 11/05/2023, and 11/08/2023. Treatments for daily wound care three times a day were not documented one of three shifts on 11/01/2023 and on 11/02/2023, respectively. Residents Affected - Few Treatments for daily wound care to her left heel were not documented on 11/05/2023 and 11/08/2023. Treatments for twice daily wound care to her left heel were not documented on the evening shift on 11/09/2023, nor on the day or evening shifts on 11/13/2023 and 11/14/2023. A record review of Resident #32's progress notes dated 10/17/2023-11/14/2023 reflected no documented wound care. During an observation and interview on 11/13/2023 at 10:55 a.m., Resident #32 was observed sitting in her wheelchair in her room with her heel bandaged and dated 11/12/2023. Resident #32 stated sometimes it gets changed and sometimes it does not and that the Wound Care Physician wanted wound care to happen more than it had been happening. Resident #32 stated the facility was short-staffed and they tried the best they could. During an interview on 11/15/2023 at 3:43 p.m., LVN D stated she did wound care for Resident #32 that day, 11/15/2023, but she did not do it on Tuesday 11/14/2023. LVN D stated no wound care did not get done for Resident #32 on 11/14/2023 either because the Wound Care Physician usually came on Mondays and we were waiting on him to come. LVN D stated LVN E also did treatments on the 600-hall where Resident #32 and Resident #51 resided. LVN D stated possibly wound care was not done if no one signed off on it on the TAR. LVN D stated wound care did not get done Monday because the Wound Care Physician did not come to the facility. LVN D stated yes there was a lot going on and maybe it got missed. LVN D stated there were a lot of falls on Monday 11/13/2023 and Tuesday 11/14/2023, and they were moving a lot of residents to different rooms. LVN D stated the facility did not have a wound care/treatment nurse and I wish we did. LVN D stated we need one because we have a lot of bumps. Resident #51: A record review of Resident #51's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), cardiomegaly (enlarged heart), hemiplegia and hemiparesis (paralysis of one side of the body), stage 4 pressure ulcer of sacral region, hyperlipidemia (high cholesterol), major depressive disorder (depression), hypertension (high blood pressure), heart failure, and atrial fibrillation (irregular heartbeat). A record review of Resident #51's MDS assessment dated [DATE] reflected a BIMS of 14, which indicated minimally impaired cognition. A record review of Resident #51's care plan last revised on 11/08/2023 reflected she had a stage 4 pressure ulcer to her sacrum. Interventions included nursing staff were to administer treatment as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown. A record review of Resident #51's physician order dated 10/24/2023 reflected an order to cleanse her state 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent silicone dressing daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 6 of 17 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 11/15/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident #51's physician order dated 11/02/2023 reflected an order to cleanse her stage 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, apply collagen powder, and cover with superabsorbent silicone dressing daily and PRN. A record review of Resident #51's TAR dated November 2023 reflected treatments for wound care to her stage 4 sacral pressure injury were not documented on 11/01/2023, 11/02/2023, 11/04/2023, 11/05/2023, 11/13/2023 and 11/15/2023. A record review of Resident #51's progress notes dated 10/16/2023-11/15/2023 reflected no documented wound care. During an observation and interview on 11/14/2023 at 11:07 a.m., Resident #51 stated she got her wounds from the hospital because her doctor told her she had not been repositioned for five weeks. Resident #51 stated the facility did wound care and voiced no concerns. During an interview on 11/15/2023 at 3:03 p.m. the DON stated she started working at the facility in mid-October of 2023. An interview was attempted with LVN E on 11/15/2023 at 3:53 p.m. but contact with LVN E was unsuccessful. During an observation and interview on 11/15/2023 at 4:31 p.m., LVN D was asked where wound care might be documented if not on the TAR, LVN D turned away and did not answer. During an interview on 11/15/2023 at 4:32 p.m., the DON stated it was her expectation that nursing staff followed wound care orders. The DON stated staff were supposed to click off and document wound care but if you don't see it clicked off, you can go to the patient and see if the wound care was done. The DON stated, some nurses don't click off on it. The DON said floor nurses were responsible for doing wound care and yes they had enough time. The DON stated there were not that many wounds and there was enough time. The DON stated staff were trained on wound care through in person demonstrations and in-service trainings. The DON stated all nurses were aware they needed to do wound care. The DON stated, if it's a trend, we would pick up on it. When asked how not following orders and documenting wound care could affect wounds, the DON stated, I would have to see the orders and said it depended on the type of wound dressing and the actual wound the DON stated if it were stable or eschar (slough or piece of dead tissue that is cast off from the surface of the skin) only, it can stay on a couple days. A record review of the facility's policy titled Wound Care & Treatment Guidelines dated May 2007 reflected the following: POLICY: It is the policy of this facility to provide excellent wound care to promote healing. PROCEDURES: 13. Documentation of the treatment should be completed. A record review of the facility's policy titled Physician Orders dated October 2022 reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 7 of 17 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 11/15/2023 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 0686 following: Level of Harm - Minimal harm or potential for actual harm POLICY: Residents Affected - Few It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 8 of 17 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 11/15/2023 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 - Many 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for sanitation. The facility failed to ensure all food items were sealed and properly covered. CK H failed to wash and sanitize the food processor in between uses. DA I failed to wash her hands after handling trash and prior to beginning a food preparation activity. The Dietary Supervisor failed to ensure the dish machine was operating at the proper temperature for ware washing. These failures could place residents at risk of foodborne illness. Findings included: Observations of the kitchen's walk-in refrigerator on 11/13/2023 from 9:02 a.m. through 9:04 a.m. revealed the following: -At 9:02 a.m., the walk-in refrigerator contained a bag of opened tortillas inside a resealable bag which was not completely sealed and open to outside air. -At 9:03 a.m., the walk-in refrigerator contained two containers of red potatoes dated 11/13/2023, uncovered and with ice on top. -At 9:04 a.m., the walk-in refrigerator contained an opened bag of shredded cheddar cheese dated 11/12/2023 which was not sealed off to open air. During an observation on 11/13/2023 at 11:32 a.m., CK H pureed sauerkraut in a blender, washed off the lid and proceeded to puree hot dogs. CK H did not wash or sanitize the blender. During an observation on 11/13/2023 at 11:35 a.m., CK H finished pureeing hot dogs, rinsed the blender blade and lid and proceeded to puree cornbread. CK H did not wash or sanitize the blender. During an observation on 11/13/2023 at 11:40 a.m., DA I was observed wearing gloves. DA I picked up an item off the floor, touched the trash can lid, discarded items and proceeded to bag cornbread without changing gloves or washing her hands. During an observation on 11/13/2023 at 11:44 a.m., CK H finished pureeing cornbread, rinsed the blender, blade and lid under running water, and proceeded to mechanicalize sausage. CK H did not wash or sanitize the blender. During an interview on 11/14/2023 at 11:35 a.m., CK H stated the blended needed to be washed and sanitized between each pureed item and there was no excuse, he just forgot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 9 of 17 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 11/15/2023 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 During an observation and interview on 11/14/2023 at 2:15 p.m., the Dietary Supervisor was observed washing dishes using the dish machine. The Dietary Supervisor measured the water using a digital thermometer during the wash and rinse cycles, and the water reached a maximum of 113.6 degrees Fahrenheit. The Dietary Supervisor stated it was supposed to be at 120 degree Fahrenheit and she would call their technician to fix it. Residents Affected - Many During an interview on 11/14/2023 at 2:35 p.m., the Administrator stated the facility adhered to the TFER which had adopted the FDA Food Code for food storage guidelines. The Administrator stated she would look for a policy on the dish machine and ware washing but this was not provided before exit. During an observation and interview on 11/14/2023 at 2:42 p.m., the Maintenance Supervisor was observed on the floor in the kitchen, working on the dish machine. The Dietary Supervisor stated the Maintenance Supervisor was checking the hot water heater. During an interview on 11/14/2023 at 2:43 p.m., the RD stated the dish machine should operate at 120 degrees Fahrenheit and was a low temperature machine which utilized chemicals to sanitize. The RD stated foods needed to be closed with a fitted lid or sealable bag. The RD stated she expected staff to wash their hands between every task and they needed to wash their hands before going back to a food preparation activity. The RD stated staff should wash the blender between pureeing every food item to prevent cross contamination and allergies. The RD stated the Dietary Supervisor trained staff on food storage and sanitation through hands on training. The RD stated she followed up with in-services throughout the year. The RD stated CK H and DA I were new employees. The RD stated the Dietary Supervisor was there daily, so she monitored those policies and procedures daily and the RD audited once monthly. The RD stated if food storage and sanitation policies were not followed, there could be infection control issues or foodborne illness. During an interview on 11/15/2023 at 2:19 p.m., the Administrator stated yes staff should wash hands after picking up trash and before preparing a food item. The Administrator stated the dish machine should run at 120 degrees Fahrenheit and the blender should be washed and sanitized between blending food items. The Administrator stated food items in the walk-in refrigerator should be covered so there was no air exposure. The Administrator stated the Dietary Supervisor monitored the kitchen in these areas throughout every shift by looking at logs and working with staff to make sure they were doing what they were supposed to be doing. The Administrator stated dietary staff were trained upon hired and received in-services from the Dietary Supervisor. The Administrator stated if policies were not followed, there could be potential infection control issues. A record review of the 2017 FDA Food Code reflected the following: FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning. 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 10 of 17 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 11/15/2023 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 - Many 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49°C (120°F). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 11 of 17 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 11/15/2023 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 observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 8 residents (Resident #7) reviewed for infection control practices, and 5 of 8 staff (CNA G, DON, ADOR, Medical Records Supervisor, and MA F) reviewed for infection control practices. Residents Affected - Some 1) The Medical Records Supervisor and CNA G failed to don and doff PPE prior to entering Resident #7's, who was on contact precautions, room. 2) The facility failed to ensure 4 of 9 staff were tested for tuberculosis upon hire/ re-hire. These failures could place residents at risk for infection. Findings included: 1) A record review of Resident #7's face sheet dated 11/15/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of sepsis (infection of the blood stream), muscle weakness, dysphagia (difficulty swallowing), pneumonia, type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high cholesterol), and COPD. A record review of Resident #7's MDS assessment dated [DATE] reflected she had not yet been assessed for a BIMS score. A record review of Resident #7's care plan last revised on 11/09/2023 reflected she had Shingles and was to be on contact isolation. A record review of the Resident #7's physician orders reflected an active order dated 11/09/2023 for her to be on contact isolation. An observation on 11/13/2023 at 9:00 a.m. revealed Resident #7's room had no contact precautions sign on her door or PPE bin outside her room. An observation of 600-hall on 11/13/23 at 12:55 p.m. revealed a nurse put a red sign on the door that read stop check with nurse before entering. An observation on 11/13/2023 12:59 p.m. revealed CNA G entered Resident #7's room with a meal tray without donning PPE. An observation on 11/13/2023 at 1:07 p.m. revealed the Medical Records Supervisor medical records supervisor was putting a white sign on Resident #7's door that read contact isolation. An observation on 11/13/2023 at t 1:20 p.m. revealed the Medical Records Supervisor entered Resident #7's room with no PPE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 12 of 17 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 11/15/2023 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 During an interview on 11/13/2023 at 1:02 p.m., CNA G stated she did not know what kind of precautions Resident #7 was on. CNA G said she believed they started today with precautions but she was not sure because she was on a different hall yesterday (11/12/2023). CNA G said she asked her nurse and was told standard precautions. CNA G stated when she asked what she needed to wear, she was told to 'wear gloves and a mask if not providing direct care but to wear gloves, mask, and gown if providing direct care.' Residents Affected - Some During an interview on 11/13/23 at 1:25 p.m. with Medical Records Supervisor, she said Resident #7 had been on isolation for about a week and knew it was due to shingles. The Medical Records Supervisor said she was told by nurses to suit up every single time she went into the room no matter what. During an interview on 11/15/2023 at 2:45 p.m., the DON stated the policy on contact precautions/isolation depended on the disease process. The DON stated some infections like shingles, isolation time would vary depending on symptoms or signs of active lesions. The DON said the expectation for anyone on contact isolation was for them to have contact isolation signage on the door and a PPE bin outside the door stocked with gowns and gloves. The DON said PPE was to be put on prior to entering a contact isolation room. The DON said staff were trained on infection control practices during annual in-services and all current staff were up to date on training. The DON stated herself along with the help of charge nurses monitored for infection control compliance in the building. When asked what the potential negative outcome to residents would be if policy was not followed, the DON said infections could spread. A record review of the facility's policy titled Infection Prevention and Control Program dated October 2022 reflected the following: Policy The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals o Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o Ensure compliance with state and federal regulations related to infection control o Promote individual resident's rights and well-being while trying to prevent and control the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 13 of 17 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 11/15/2023 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 spread of infection. Level of Harm - Minimal harm or potential for actual harm o Monitor personnel health and safety. Scope of the Infection Control and Prevention Program: Residents Affected - Some The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. (Personnel covers staff, volunteers, visitors, and other individuals providing services under a contractual agreement). 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. a. Facility personnel with a communicable disease or infected skin lesion will not directly contact. residents or their food, if direct contact could transmit the disease; and b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. c. Validation of the personnel infection prevention and control practices are monitored by the infection preventionist through skills competency evaluation such as observation of hand hygiene. A record review of the facility's policy titled IPCP Standard and Transmission-Based Precautions dated October 2022 reflected the following: Policy It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In Long Term Care (LTC), it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least. restrictive approach possible that adequately protects the resident and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being. Where possible, the goal is to isolate the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 14 of 17 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 11/15/2023 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 organism, not the resident. Level of Harm - Minimal harm or potential for actual harm Transmission-Based Precautions are the second tier of basic infection control and used in addition to Residents Affected - Some Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Procedure 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection i. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). b. Hand hygiene; c. Safe injection practices; d. Respiratory hygiene and cough etiquette; e. Environmental cleaning and disinfection; and f. Reprocessing of reusable medical equipment. 2. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment (e.g. MDROs). Note: Contact precautions/isolation are required for the patients with MDROs with: o Draining wounds or secretions/excretions that cannot be covered and contained, o Acute diarrhea, or o Ongoing transmission within the unit or facility a. Room Placement: i. Residents on Contact Precautions should be restricted to their rooms and restricted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 15 of 17 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 11/15/2023 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 from participation in group activities; Exception is for medically necessary care. Level of Harm - Minimal harm or potential for actual harm ii. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation due to room restrictions. Residents Affected - Some iii. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be cohorted or per an alternative risk-based approach. Room placement decisions are made balancing risks to other patients. b. Personal protective equipment (PPE): i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. 6. Implementation: a. The facility will implement a system to alert staff, residents and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident room. c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. e. Provide education to residents and visitors as needed. The facility's policy titled IPCP Standard and Transmission-Based Precautions dated October 2022 also reflected gloves and gown were to be used with any room entry into a resident room on contact precautions. 2) A record review of the DON's personnel file reflected she was hired on 10/09/2023 and was not screened and tested for TB. A record review of the ADOR's personnel file reflected she was hired on 1/09/2023 and was not screened and tested for TB. A record review of the Medical Records Supervisor's personnel file reflected she was hired on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 16 of 17 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 11/15/2023 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 10/13/2023 and was not screened and tested for TB. Level of Harm - Minimal harm or potential for actual harm A record review of MA F's personnel file reflected she was rehired on 10/18/2023 and was not screened and tested for TB. Residents Affected - Some During an interview on 11/14/2023 at 3:45 p.m., the HR Manager with the HR Manager stated TB tests were performed on site as needed. The HR Manager stated if staff members arrived with a prior test, they would accept it. The HR Manager stated they tried to ensure testing for TB was done within the first two weeks of hire. During an interview on 11/15/2023 at 2:45 p.m., the DON stated in regard to the facility's policy on new hires, employees should be tested upon hire. The DON stated if staff brought a prior test from a facility they were previously employed with, then that would be accepted. The DON stated screening assessments were done annually, but that did not include an actual TB test. The DON stated the annual screening processing was composed of a signs and symptoms questionnaire. The DON said the HR Manager monitored the TB screening process. The DON said no there would not be a negative outcome to residents if staff were not up to date with TB screening and testing. The DON stated if staff came from other facilities, they have been tested. The DON said a screening was fine and they did not need to be tested upon hire for TB. A record review of the facility's undated policy titled Personnel Requirements - TB reflected the following: POLICY It is the policy of this facility to ensure Personnel meet state and federal regulatory requirements for employment. PROCEDURE: All staff and volunteers who work in the facility: 1. Will have documented upon hire and screening annually, as evidence of freedom from pulmonary tuberculosis. The following are acceptable: a. A report of a negative Mantoux skin test administered within six months of submitting the report, b. A written physician's statement dated within six months of submitting the statement, indicating freedom from pulmonary tuberculosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 17 of 17