Health inspection·February 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 stated that he told an aide and a nurse that he wanted to go to the emergency room and he was told they could not help him with that. Resident #2 then called 911 back because nobody helped him and he was taken to the emergency room by ambulance and diagnosed with influenza (flu). During an interview on 01/30/24 at 4:00 pm with hospital RN Director of Emergency Services revealed Resident #2 was brought to the emergency room on [DATE] and was put in the room at 10:12 pm with complaint of cough and shortness of breath and had a runny nose and was positive for Influenza A. Resident #2 had a chest x-ray that was negative for infiltrates (signs of pneumonia). During an interview on 01/30/24 at 1:15 pm with the DON she said Resident #2 told the nurse he wanted to go to the hospital and she started an assessment of Resident #2 and while she was assessing Resident #2 emergency personnel entered the building to transport Resident #2. She stated that Resident #2 only called 911 one time that evening. She also stated Resident #2 had a history of calling 911. Record review of Resident #2's progress notes from 01/29/23 to 01/30/24 revealed no reference to him calling 911. During an interview on 01/31/24 at 2:05 pm with Confidential Emergency Personnel they stated they got to the facility on [DATE] at 9:34 pm and did not see staff on the way to Resident #2's room. They said Resident #2 stated he was having trouble breathing and had a cough for 2 days; he did not appear in obvious distress. Confidential Emergency Personnel stated that they went to find staff as none were on the hall and found staff on the opposite side of the building and staff denied knowledge of Resident #2's desire to be taken to the hospital but said they could not stop him. Staff did not offer demographics and report to the Emergency Personnel but were printing it when it was requested; Resident #2 was transferred to the stretcher, vitals were checked and oxygen was applied because his oxygen was 93% (he was given 2 liters/minute). Resident #2 was taken to the emergency room. During an interview on 01/30/24 at 1:20 pm with the ADM she said that residents have the right to go to the hospital and her expectation was that family and resident requests for transfer to the hospital be respected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 2 of 12 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to: 1. ensure Resident #1 was evaluated and treated for urinary retention which led to Resident #1 requiring emptying of her bladder in the emergency department on 01/27/24 2. ensure Resident #1's pain was addressed by providing her prescribed oxycodone for her bilateral (both left and right) ankle fractures and surgery resulting in uncontrolled pain that caused Resident #1 to call 911 for transport to the emergency room on [DATE] An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could led to urinary retention and uncontrolled pain, both of which required medical intervention in the emergency room, and place residents at risk of not having their needs met to reach their highest practicable mental, physical and psycho-social wellbeing. Findings included: Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure. Record review of Resident #1's EHR Assessments tab revealed an admission assessment on 01/27/24 revealed a BIMS that was 14 (cognitively intact). Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Intervention: Administer analgesia medication as per orders & Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain & Intervention: Pain assessment every shift Record review of the January 2024 orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 3 of 12 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 02/14/2024 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 0600 order for methocarbamol 500 mg q8 prn pain (muscle relaxant). Level of Harm - Immediate jeopardy to resident health or safety Record review of the January orders for Resident #1 revealed no order for Tylenol. Residents Affected - Few Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wanted to go to the ER. Record review of the January 2024 MAR revealed no administration of methocarbamol nor of oxycodone. During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit. During an interview on 01/30/24 at 1:59 pm with LVN A she stated that Resident #1 wanted a foley catheter inserted because she was not able to urinate in the bed pan. LVN A said it was a dignity issue and Resident #1 did not want to urinate in a brief or on the bed pan. LVN A stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A stated Resident #1 was left on the bed pan for 30 minutes on 01/26/24. LVN A said Resident #1 expressed concerns about wearing briefs as a dignity issue and had difficulty using a bed pan. Resident #1 told LVN A that she was uncomfortable using a bed pan due to being continent and requested a foley be placed on 01/27/24. LVN A stated the facility wanted to monitor her due to infection risk of foley. She stated Resident #1 minimally urinated in bed pan on 01/26/24 and aides reported urine in brief on 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery. During an interview on 01/31/24 at 10:45 am (at a different facility) Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (01/26/24). She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility. Record review of the police department call log printed 01/29/24 revealed that Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder was what was causing the pain. During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 4 of 12 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol. In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention. Residents Affected - Few Multiple attempts to reach the pharmacy over 3 days were not successful. Record review of the undated facility policy titled Abuse: Prevention and Prohibition Against revealed each resident has the right to be free from abuse, neglect and misappropriation . Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted. This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified and provided with the IJ template on 01/31/24 at 2:43 PM. The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm and included: PLAN OF REMOVAL

F600: Neglect: In the IJ Template given on 1/31/2024, the facility failed to address Resident #1 pain and urinary retention. 1. The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MDS Nurse and RN/ED Cluster Partners by the Clinical Resource. The training included regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This was completed on 1/31/24. 3. Verbal and written training and knowledge checks were completed with all staff regarding abuse and neglect including goods and services needed to address a resident's needs in relation to pain. This training was given by the ED, DON, ADON, MDS Nurse Clinical Resource and RN/ED Cluster Partners, was initiated on 1/31/24 will be completed on 2/1/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 5 of 12 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse and neglect prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 2/1/24 and will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 6. The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 7. Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance. 8. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. MONITORING THE POR: Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to abuse, neglect, and change in condition - pain and urinary retention. Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director. Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no concerns related to neglect, staff assistance, nor with pain. Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN, 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 6 of 12 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety resident pain and resident concerns. All were able to answer questions related to reporting neglect and abuse. Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain, neglect and urinary retention; this was completed 01/31/24. Residents Affected - Few Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues nor neglect concerns being voiced. Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it was being re-iterated. In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24. The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 7 of 12 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 02/14/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for pain. Residents Affected - Few The facility failed to: 1. ensure Resident #1's prescribed oxycodone was in the facility and provided to Resident #1 for her pain from bilateral broken ankles and surgery An Immediate Jeopardy (IJ) situation was identified on 01/31/24. While the IJ was removed on 02/01/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents by placing them at risk for pain that would prevent residents from achieving their highest practicable physical, mental and psychosocial well-being. Findings included: Record Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of bilateral ankle fracture (post-op), depression, and high blood pressure. Record review of Resident #1's EHR Assessments tab revealed an admission assessment of BIMS that was 14 (cognitively intact). Record review of Resident #1's initial care plan effective 01/27/24 at 12:01 am revealed section V, part a. Pain focus: has acute/chronic pain; goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Intervention: Administer analgesia medication as per orders & Intervention: Anticipate need for pain relief and respond immediately to any complaint of pain & Intervention: Pain assessment every shift Record review of the January orders for Resident #1 revealed that she had an order for oxycodone (narcotic pain reliever) 10 mg q4 hrs prn, started 01/26/24 at 1:13 pm. In addition, she had an order for methocarbamol 500 mg q8 prn pain (muscle relaxant). Record review of the January MAR revealed no administration of methocarbamol nor of oxycodone. During an interview on 01/31/24 at 10:45 am (at a different facility) with Resident #1 said she was left on the bed pan for an hour with no one checking on her on her first day at the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 8 of 12 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 02/14/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (01/26/24) to the point that the metal felt like it was cutting her skin and she could not move from the bedpan which was extremely uncomfortable. She stated she had ankle pain in both ankles the entire time she was in the facility. She said she tried to urinate in the bed pan but was not able on 01/26/24. She said she kept trying to urinate in the brief over the night of 01/26/24 and into the morning of 01/27/24 and she was able to urinate at one point. Resident #1 stated she was in so much pain she did not eat on either day she was in the facility and that she stopped drinking in the afternoon of 01/27/24 due to not being able to urinate. She said she was in 10 out of 10 pain from her ankles the entire day of 01/27/24 and as the day progressed the pain in her abdomen from her full bladder increased to 10 out of 10 as well. She said she called out in pain and was tearful while yelling for assistance and she was only given Tylenol which did not help. Resident #1 stated that she told at least 5 staff each day that she was in pain and that her needs were ignored. She said she was told her oxycodone was not available in the facility and it was on order. Resident #1 said she called 911 for help with her pain and was taken to the emergency room where she cried to the doctors and begged not to be sent back to that facility. Record review of 911 log revealed Resident #1 called 911 herself on 01/26/24 at 5:46 pm stating that the bed pan was cutting into her skin, she cannot move and she wants to go to the ER. During an interview on 01/30/24 at 1:15 pm with DON she said oxycodone was not part of the emergency kit. DON further stated that Resident #1 was not in pain from her ankles, but the nurse could have called the physician for a different pain medicine that was in the emergency kit. In an interview on 01/30/24 at 1:59 pm with LVN A she stated that the DON and LVN A and EMS staff spoke to Resident #1 about the dangers of the foley catheter related to infection and after they talked to Resident #1 she declined transport to the emergency department on 01/26/24. LVN A further stated that Resident #1's oxycodone did not arrive with her other medications on 01/26/24. She contacted the pharmacy as soon as it opened on 01/27/24 at 8:00 am and was told the oxycodone would arrive on the next shipment, around 4:00 pm. The medication did not arrive with the afternoon delivery around 4:00 pm and LVN A contacted the pharmacy again and placed an order for oxycodone STAT and was told it would be 3-4 hours for delivery. LVN A said the resident wouldn't urinate in the urinal due to dignity. She said she did not recall her complaining of ankle pain, but later stated that Resident #1 mentioned her ankle pain the morning of 01/27/24. When asked why the docotr was not asked for a prescription for another pain medicine like hydrocodone to cover until oxycodone arrived LVN could not answer and kept saying the medication was supposed to arrive on the next delivery. Multiple attempts to reach the pharmacy over 3 days were not successful. Record review of 911 log revealed Resident #1 called 911 herself on 01/27/24 at 7:05 pm because she was in pain and the facility was not doing anything for her; operator documented the resident was crying on the phone and stated that broken ankles and bladder is what was causing the pain. Record review of Resident #1's progress notes revealed notes specific to ankle pain on: 01/26/24 1:03 pm (first note on admission) 01/27/24 12:13 pm Pain originates from fracture Located at bilateral ankles Described as ache nonpharmaceutical interventions include elevate and rest Further review revealed a progress note 01/27/24 at 6:00 pm revealed pending pharmacy delivery for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 9 of 12 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 02/14/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Oxycodone 10 mg q4hr PRN, this nurse called in STAT order at 1700 after pharmacy delivered facility meds (resident's medication not present in package), was advised it would be sent on next delivery in 3-4 hours Record review of pain assessment 01/27/24 at 3:36 pm revealed a score of 7. Further review revealed 01/27/2024 6:36 pm used PAINAD and had a score of 2 (1 for being tensed, and 1 for distracted or reassured by voice/touch). Residents Affected - Few Record review of admission assessment titled Pain Management Review revealed resident rated her pain at a 7 and it was in her bilateral ankles. Under staff observation it had checked that Resident #1 Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming) This assessment was signed 01/27/24 at 12:11 am. During an interview with Hospital Nurse 01/30/24 4:00 pm revealed Resident #1 was seen in emergency department 01/27/24 at 7:52 pm for Urinary retention since yesterday (01/26/24) and acute pain after bilateral ORIF of ankles. Resident #1 told Hospital Nurse she had 10 out of 10 pain in bilateral ankles and the facility did not have her pain medicine in stock and gave her Tylenol (no order in facility orders for Tylenol). In addition, hospital nurse stated that Resident #1 had 593 mls of urine removed and her bladder was distended (over 400 requires emptying per nurse). In addition, the resident tested positive for a UTI which the hospital nurse stated could be caused by or exacerbated by urine retention. Record review of the facility policy titled Pain Recognition and Management revealed if pain management is not effective, the MD should be contacted. This was determined to be an Immediate Jeopardy (IJ) on 01/31/24 at 2:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 01/31/24 at 2:43 PM. The following plan of Removal submitted by the facility was accepted on 02/01/24 at 3:14 pm: PLAN OF REMOVAL

F697: Pain Management: In the IJ Template provided on 01/31/2024, the facility failed to administer narcotic medication to Resident #1 as ordered by the Physician. 1. The Medical Director was notified of the IJ on 01/31/2024 at 4:00 pm. 2. Pain assessments were completed for all residents on 1/31/24 and care plans were updated by DON, Cluster RNs and clinical resource RN. Orders for pain assessment for every shift were verified by DON, Cluster RNs and clinical resource RN for all resident on 1/31/24. 3. An ad hoc meeting regarding items in the IJ templates will be completed on 1/31/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 10 of 12 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 02/14/2024 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 0697 plan of removal items and interventions. Level of Harm - Immediate jeopardy to resident health or safety 4. Residents Affected - Few The DON, ADON, MDS Nurse , RN Cluster Partners were in-serviced by the Clinical Resource RN. The DON, ADON, MDS Nurse , RN Cluster Partners and clinical Resource RN will verify Nurse knowledge with 5 Nurses weekly using the pain management knowledge check and all agency nurses prior to working a shift. This will be completed weekly x 4 weeks after the initial training and knowledge checks completed on 2/1/24. 5. The DON or designee will monitor q shift pain assessments daily to verify that interventions are in place and pain medications are given appropriately and will monitor new orders and documentation for pain medication availability daily. The DON or designee will monitor MAR and pain medications stored on carts weekly to ensure pain medication availability. These processes were initiated on 1/31/24 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance 6. Resident requiring pain management will be reviewed during weekly clinical meeting and the Medical Director and Pain Management Physician will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and pain management is reviewed. This meeting will begin on 01/31/2024 will continue x 4 weeks or until substantial compliance and will continue monthly for 90 days to ensure ongoing compliance 7. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/31/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring: MONITORING THE POR: Record review on 02/01/24 of the in-service records revealed in-services on 02/01/24 related to pain. Record review of 10 residents revealed pain assessments were completed every shift starting 01/31/24 and care plans were updated related to pain for residents with pain concerns. Further review on 02/14/24 revealed no missed pain assessments for any resident. Record review of a sign in sheet for a meeting related to the immediate jeopardy were dated 01/31/24 and showed attendance of DON, Medical Director, ADON, Clinical Resource, and Executive Director. Interviews conducted on 02/01/24 between 10:00 am and 12:00 pm with 4 residents revealed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 11 of 12 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 02/14/2024 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 0697 concerns related to pain. Level of Harm - Immediate jeopardy to resident health or safety Interviews conducted on 02/01/24 between 1:00 pm and 5:00 pm with 1 housekeeper, 1 LVN (admitting LVN for Resident #1), 1 PTA, 1 COTA, 1 ST, and 1 CNA revealed that staff were in-serviced on pain, urinary retention, neglect and abuse. All were able to answer questions appropriately related to notification of and response to resident pain. Residents Affected - Few Interviews conducted on 02/14/24 between 11:00 am and 1:30 pm with DON, ADON and MDS nurse revealed they were in-serviced by the corporate RN related to pain; this was completed 01/31/24. Record review of all residents admitted since 01/31/24 revealed no pain related deficient practice. Interviews with all of the residents confirmed no pain related issues. In an interview on 02/14/24 at 11:00 am with DON she stated that every resident had been assessed for pain, pain was added to every care plan, and all residents had standing orders for pain medications that could be used by any nurse for immediate pain concerns. DON stated that all physicians engaged to ensure pain would be addressed for all residents, including new admissions. These procedures were in place by 02/01/24. Interviews on 02/14/24 between 11:00 am and 1:30 pm with 1 ADON/LVN, 1 LVN, the staffing coordinator, 1 RN and 2 CNAs revealed all have been in-serviced daily since 01/31/24 related to pain (identifying, reporting, following up), neglect (listed all types of neglect and gave examples), and urinary retention (all voiced signs, listening to resident concerns, and reporting to nurse and if no action taken reporting to DON directly). All stated they had been in-serviced on all topics 02/01/24 and now it is being re-iterated. The ADM was informed the Immediate Jeopardy was removed on 02/01/2024 at 4:15 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 02/14/24, two attempts were made to contact the pharmacy without success (in addition to the attempts earlier). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675889 If continuation sheet Page 12 of 12