Health inspection·May 18, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some further incidence including inservice for staff, and alleged staff member had been suspended until further investigation . Record review of a Provider Investigation Report dated 2/16/2023 indicated an incident occurred at the facility on 2/14/2023 at 2:00 AM with TNA A and Resident #1. CNA B reported she observed TNA A being verbally and physically abusive to Resident #1 when she provided care. That incident was investigated by the state agency and was unsubstantiated (not proven by evidence). Record review of a Provider Investigation Report dated 4/23/2023 indicated an incident occurred at the facility on 4/22/2023 at 9:00 PM with TNA A and Resident #1. LVN E reported she observed TNA A being rough with Resident #1 while providing care. That incident was investigated by the state agency and was unsubstantiated. During an interview on 5/17/2023 at 8:11 AM, CNA B said she worked at the facility prn (as needed) since January 2022. She said she observed the incident that occurred on 2/14/2023 with TNA A and Resident #1. CNA B said Resident #1 had a bowel accident on the floor in her room. CNA B said TNA A provided care to Resident #1 and TNA A said she was going to show her how she provided care when she worked at a psychiatric facility in the past. CNA B said TNA A started scrubbing Resident #1's body roughly. CNA B said Resident #1 was saying TNA A was hurting her and Resident #1 hit TNA A. CNA B said TNA A said to Resident #1 that she would choke her and called her a bitch in a low tone but it was louder than a whisper. CNA B said TNA A kept saying it was disgusting out loud. CNA B said she tried to help TNA A but she refused and was told to stand by. CNA B said she was going to report the incident at the time it occured but started feeling sick and ended up with an infection. She said she gave her statement to the Administrator a few days later after the incident. She said she had training on abuse/neglect at the facility. She said abuse should be reported immediately to someone at the facility such as the Administrator. During an observation and interview on 5/17/2023 at 8:43 AM, Resident #1 was lying in bed awake, confused and said she had been at the facility for a few months. She said she remembered when TNA A worked at the facility and said she was never mean or verbally abusive towards her. She said TNA A was good to her. During an interview on 5/17/2023 at 10:52 AM, the Corporate Nurse said she had been employed with the facility for 2 years. She said the incident with Resident #1 and TNA A on 2/14/2023 was reported to her on 2/16/2023 by the previous Administrator C when the allegation was received from CNA B. She said Administrator C did not complete a thorough investigation following the incident. She said Administrator C only took a statement from CNA B and terminated TNA A without conducting a thorough investigation. She said she immediately started an investigation and submitted to the state agency at that time. She said the facility conducted safe surveys with residents and also had character witness statements from staff who all said TNA A was a good aide and residents denied her being mean or verbally abusive towards them. She said the decision was made after the investigation to hire TNA A back on 3/13/2023. She said CNA B should have reported the incident immediately to the Administrator. She said the incident that occurred on 4/22/2023 with Resident #1 and TNA A was reported to her on 4/23/2023 by the DON. She said the second incident occurred on 4/22/2023 when LVN E reached out to the DON and reported an allegation of abuse on 4/23/2023. She said the state agency was notified on 4/23/2023 of that incident. SHe said TNA A was immediately terminated following the second incident. She said any abuse/neglect allegation should be reported to the abuse coordinator which was the Administrator immediately. She said any allegations of abuse should be reported to the state agency within 2 hours of the allegation taking place. She said the staff received education in-services on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 2 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0607 abuse/neglect and to whom to report. She said going forward, any allegation of abuse would be reported timely. She said a delay in reporting any allegation of abuse could put residents at risk of further harm. Level of Harm - Minimal harm or potential for actual harm Attempted several phone calls with LVN E on 5/17/2023 and 5/18/2023 with no returned phone call. Residents Affected - Some Attempted several phone calls with TNA A on 5/17/2023 and 5/18/2023 with no returned phone call. During an interview on 5/18/2023 at 9:20 AM, Administrator C said she was only employed at the facility for about 8 weeks from 1/6/2023 until 2/28/2023. She said the incident that occurred on 2/14/2023 was reported to her on 2/16/2202 by CNA B and that was when she reported to the state agency the allegation of abuse. She said CNA B told her that she was sick after the incident and did not report it immediately as she should have reported to the abuse coordinator who was the Administrator. She said residents could be at risk of jeopardy and staff should not try to make the decision if they should report or not as that should be left up to the Administrator or abuse coordinator. She said staff were in-serviced on abuse/neglect following the reporting of the incident and when to report any allegations of abuse along with who to report to and their contact phone numbers. She said they posted signs in the facility to indicate who to contact for abuse/neglect allegations. She said staff should report any suspicion of abuse to her immediately. She said the incident should have been reported within 2 hours to the state agency. She said on a regular basis the facility conducted education on abuse/neglect as that was key to having staff understanding the importance of abuse and who the abuse coordinator was. During an interview on 5/18/2023 at 10:58 AM, the DON said she started at the facility on 4/3/2023. She said she was not aware of the incident that occurred in February that was reported to the state agency with Resident #1 and TNA A. She said LVN E called her on the night of 4/22/2023 at the end of her shift. She said LVN E told her she felt TNA A needed some customer service training and she said she told her to write a statement and slide it under her door. She said on the morning of 4/23/2023 when she read the statement, she immediately notified the Administrator. She said they started investigating and Administrator D notified the state agency at that time. She said staff received education on abuse/neglect, staff burnout, and residents with behaviors. She said abuse allegations should be reported immediately to the abuse coordinator who was the Administrator. She said abuse allegations should be reported to the state agency within 2 hours. She said going forward, any abuse allegation would be reported immediately to the abuse coordinator and would make sure residents were safe. She said residents could be potentially harmed by delaying reporting timely. During an interview on 5/18/2023 at 11:15 AM, Administrator D said she started at the facility on 3/16/2023. She said she was not aware of the incident that occurred with Resident #1 and TNA A in February 2023 until a little while after she was hired. She said she was involved in reporting to the state agency following an incident that occurred on 4/22/2023 with Resident #1 and TNA A. She said on the morning of 4/23/2023. she was notified by the DON of a possible reportable incident of abuse. She said LVN E reported to the DON an incident with TNA A and Resident #1 that occurred on the night of 4/22/2023. She said she reported the incident to the state agency at the time of notification on 4/23/2023. She said she immediately started an investigation and in-serviced staff on abuse/neglect, staff burn out, resident rights, and privacy when providing care. She said going forward they would continue to educate on the importance of reporting sooner rather than later. She said any delay in reporting allegations of abuse could be detrimental to the residents. She said they are advocates for the residents and must keep them safe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 3 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a personnel file for TNA A indicated she hired at the facility on 1/9/2023. Review of previous employment hisory indicated no record of any work at a psychiatrist facility. Record review of a facility policy titled Abuse Prevention Program with a revised date of 1/9/2023 indicated, .1. The Administrator is responsible for the overall and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reports to local, state, and federal agencies. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 2 hours if the alleged violation involves abuse . Event ID: Facility ID: 675907 If continuation sheet Page 4 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily for 1 of 5 residents (Resident #1) reviewed for abuse. The facility did not report to the state agency within 2 hours when an allegation of abuse occurred on 2/14/2023 that involved Resident #1. The state agency was notified of the allegation of abuse on 2/16/2023. The facility did not report to the state agency within 2 hours when an allegation of abuse occurred on 4/22/2023 that involved Resident #1. The state agency was notified of the allegation of abuse on 4/23/2023. This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of abuse. Findings included: Record review of a face sheet for Resident #1 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs and the right side of the heart), manic episode with psychotic symptoms (delusions, disorder thinking and a lack of awareness of reality), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of an admission MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 15. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 13. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag). Record review of a progress note dated 2/15/2023 at 10:40 PM by LVN E for Resident #1 indicated, .An allegation of verbal abuse toward resdient by staff member are currently under investigation at this time. Alleged incident has been reported to Administration, Steps are being taken to prevent further incidence including inservice for staff, and alleged staff member had been suspended until further investigation . Record review of a Provider Investigation Report dated 2/16/2023 indicated an incident occurred at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 5 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility on 2/14/2023 at 2:00 AM with TNA A and Resident #1. CNA B reported she observed TNA A being verbally and physically abusive to Resident #1 when she provided care. That incident was investigated by the state agency and was unsubstantiated (not proven by evidence). Record review of a Provider Investigation Report dated 4/23/2023 indicated an incident occurred at the facility on 4/22/2023 at 9:00 PM with TNA A and Resident #1. LVN E reported she observed TNA A being rough with Resident #1 while providing care. That incident was investigated by the state agency and was unsubstantiated. During an interview on 5/17/2023 at 8:11 AM, CNA B said she worked at the facility prn (as needed) since January 2022. She said she observed the incident that occurred on 2/14/2023 with TNA A and Resident #1. CNA B said Resident #1 had a bowel accident on the floor in her room. CNA B said TNA A provided care to Resident #1 and TNA A said she was going to show her how she provided care when she worked at a psychiatric facility in the past. CNA B said TNA A started scrubbing Resident #1's body roughly. CNA B said Resident #1 was saying TNA A was hurting her and Resident #1 hit TNA A. CNA B said TNA A said to Resident #1 that she would choke her and called her a bitch in a low tone but it was louder than a whisper. CNA B said TNA A kept saying it was disgusting out loud. CNA B said she tried to help TNA A but she refused and was told to stand by. CNA B said she was going to report the incident at the time it occured but started feeling sick and ended up with an infection. She said she gave her statement to the Administrator a few days later after the incident. She said she had training on abuse/neglect at the facility. She said abuse should be reported immediately to someone at the facility such as the Administrator. During an observation and interview on 5/17/2023 at 8:43 AM, Resident #1 was lying in bed awake, confused and said she had been at the facility for a few months. She said she remembered when TNA A worked at the facility and said she was never mean or verbally abusive towards her. She said TNA A was good to her. During an interview on 5/17/2023 at 10:52 AM, the Corporate Nurse said she had been employed with the facility for 2 years. She said the incident with Resident #1 and TNA A on 2/14/2023 was reported to her on 2/16/2023 by the previous Administrator C when the allegation was received from CNA B. She said Administrator C did not complete a thorough investigation following the incident. She said Administrator C only took a statement from CNA B and terminated TNA A without conducting a thorough investigation. She said she immediately started an investigation and submitted to the state agency at that time. She said the facility conducted safe surveys with residents and also had character witness statements from staff who all said TNA A was a good aide and residents denied her being mean or verbally abusive towards them. She said the decision was made after the investigation to hire TNA A back on 3/13/2023. She said CNA B should have reported the incident immediately to the Administrator. She said the incident that occurred on 4/22/2023 with Resident #1 and TNA A was reported to her on 4/23/2023 by the DON. She said the second incident occurred on 4/22/2023 when LVN E reached out to the DON and reported an allegation of abuse on 4/23/2023. She said the state agency was notified on 4/23/2023 of that incident. SHe said TNA A was immediately terminated following the second incident. She said any abuse/neglect allegation should be reported to the abuse coordinator which was the Administrator immediately. She said any allegations of abuse should be reported to the state agency within 2 hours of the allegation taking place. She said the staff received education in-services on abuse/neglect and to whom to report. She said going forward, any allegation of abuse would be reported timely. She said a delay in reporting any allegation of abuse could put residents at risk of further harm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 6 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0609 Attempted several phone calls with LVN E on 5/17/2023 and 5/18/2023 with no returned phone call. Level of Harm - Minimal harm or potential for actual harm Attempted several phone calls with TNA A on 5/17/2023 and 5/18/2023 with no returned phone call. Residents Affected - Some During an interview on 5/18/2023 at 9:20 AM, Administrator C said she was only employed at the facility for about 8 weeks from 1/6/2023 until 2/28/2023. She said the incident that occurred on 2/14/2023 was reported to her on 2/16/2202 by CNA B and that was when she reported to the state agency the allegation of abuse. She said CNA B told her that she was sick after the incident and did not report it immediately as she should have reported to the abuse coordinator who was the Administrator. She said residents could be at risk of jeopardy and staff should not try to make the decision if they should report or not as that should be left up to the Administrator or abuse coordinator. She said staff were in-serviced on abuse/neglect following the reporting of the incident and when to report any allegations of abuse along with who to report to and their contact phone numbers. She said they posted signs in the facility to indicate who to contact for abuse/neglect allegations. She said staff should report any suspicion of abuse to her immediately. She said the incident should have been reported within 2 hours to the state agency. She said on a regular basis the facility conducted education on abuse/neglect as that was key to having staff understanding the importance of abuse and who the abuse coordinator was. During an interview on 5/18/2023 at 10:58 AM, the DON said she started at the facility on 4/3/2023. She said she was not aware of the incident that occurred in February that was reported to the state agency with Resident #1 and TNA A. She said LVN E called her on the night of 4/22/2023 at the end of her shift. She said LVN E told her she felt TNA A needed some customer service training and she said she told her to write a statement and slide it under her door. She said on the morning of 4/23/2023 when she read the statement, she immediately notified the Administrator. She said they started investigating and Administrator D notified the state agency at that time. She said staff received education on abuse/neglect, staff burnout, and residents with behaviors. She said abuse allegations should be reported immediately to the abuse coordinator who was the Administrator. She said abuse allegations should be reported to the state agency within 2 hours. She said going forward, any abuse allegation would be reported immediately to the abuse coordinator and would make sure residents were safe. She said residents could be potentially harmed by delaying reporting timely. During an interview on 5/18/2023 at 11:15 AM, Administrator D said she started at the facility on 3/16/2023. She said she was not aware of the incident that occurred with Resident #1 and TNA A in February 2023 until a little while after she was hired. She said she was involved in reporting to the state agency following an incident that occurred on 4/22/2023 with Resident #1 and TNA A. She said on the morning of 4/23/2023. she was notified by the DON of a possible reportable incident of abuse. She said LVN E reported to the DON an incident with TNA A and Resident #1 that occurred on the night of 4/22/2023. She said she reported the incident to the state agency at the time of notification on 4/23/2023. She said she immediately started an investigation and in-serviced staff on abuse/neglect, staff burn out, resident rights, and privacy when providing care. She said going forward they would continue to educate on the importance of reporting sooner rather than later. She said any delay in reporting allegations of abuse could be detrimental to the residents. She said they are advocates for the residents and must keep them safe. Record review of a personnel file for TNA A indicated she hired at the facility on 1/9/2023. Review of previous employment hisory indicated no record of any work at a psychiatrist facility. Record review of a facility policy titled Abuse Prevention Program with a revised date of 1/9/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 7 of 8 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 675907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, .1. The Administrator is responsible for the overall and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reports to local, state, and federal agencies. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 2 hours if the alleged violation involves abuse . Event ID: Facility ID: 675907 If continuation sheet Page 8 of 8