Health inspection·June 14, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm staff to administer his G-tube feedings and would administer them himself. She said that the tan liquid in the cups was his feeding formula. She said that she would leave them in his room for him to administer himself. The gloves were over the cups to protect them from getting contaminated. She said the thought that it was care planned for this resident and that it was fine because they had been doing this since he was admitted a little over a week ago. She was unsure as to any assessment documentation. Residents Affected - Few During an interview with the Regional Nurse on 6/12/23 at 11:30 am, she said that staff were not supposed to be allowing Resident #238 to self-administer his G-tube feedings because he had not been properly assessed and did not have the proper orders and approval. She said that she was not aware that this was happening. She said that the charge nurses should have come to her with this issue as she was only in the facility 2-3 times per week. During an interview with the ADON on 6/12/23 at 8:30 am, she said that she had only been here for 3 weeks and was overwhelmed due there being no DON, no Administrator, and she was having to cover the floor for staffing call-ins. She said that Resident #238 could be at risk for aspiration, and aspiration pneumonia if he was not competent to self-administer. She said she just had not had time to ensure all the proper paperwork and assessments were in place to allow him to self-administer his own G-tube feedings. During an interview with the Regional Nurse on 6/14/23 at 11:10 am she said that going forward she would expect her staff to follow proper policy and procedures regarding resident's self-administering medications or G-tube feedings. She said that she would ensure that all staff were properly trained on this. She said that without the proper assessments, residents administering their own G-tube feedings could be at risk for infection, and all feedings would be in labeled containers for safety reasons. Record review of facility policy titled Administering Medications dated 2001 with revision date of April 2019 indicated: .Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . and .Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Record review of facility policy titled Enteral Nutrition dated 2001 with a revision date of November 2018 indicated: .14. Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: a. Aspiration; b. Tube misplacement or migration; c. Skin breakdown around insertion site; d. Perforation of the stomach or small intestine leading to peritonitis; e. Esophageal swelling, strictures, fistulas; and f. Clogging of the tube . and .15. Staff caring for residents with feeding tubes are trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as: a. Nausea, vomiting, diarrhea, and abdominal cramping; b. Inadequate nutrition; c. Metabolic abnormalities; d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 2 of 41 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 06/14/2023 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 0554 Interactions between feeding formula and medications; and e. Aspiration . and Level of Harm - Minimal harm or potential for actual harm .16. Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. Risk of aspiration may be affected by: a. Diminished level of consciousness; b. Moderate to severe swallowing difficulties; c. Improper positioning of the resident during feeding; and d. Failure to confirm placement of the feeding tube prior to initiating the feeding . Residents Affected - Few Record review of facility policy titled Self-Administration of Medication dated 2001 with a revision date of February 2021 indicated: .Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . and .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 3 of 41 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 06/14/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23). The facility failed to train the staff of when to report changes to the physician. An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. While the IJ was removed on 06/14/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident # 35's face sheet dated 04/25/23 indicated Resident #35 admitted [DATE]. and was a 59-year- old-female with diagnosis: Bacteremia (blood infection, sepsis), Diabetes Mellitus a disease that occurs when your blood glucose, also called blood sugar, is too high (abnormal blood sugars) due to underlying condition with neuropathy, chronic viral hepatitis C, (liver disease),neuromuscular dysfunction of the bladder,(bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation, (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus, (pressure sore). Record review of the Physician Orders for Resident #35 dated 04/25/2023: Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicated, there were no physician orders to check resident #35's BS even though nurses were checking BS before administering Insulin. Resident #35 had no parameters for notification of critical BS values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS (activities of daily living), and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident was able to feed herself with set up assistance from staff. Resident had a foley catheter due to diagnosis of neuromuscular bladder, (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had diagnosis of Diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 4 of 41 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 06/14/2023 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 0580 Mellitus, and intervention of: medications as ordered. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #35's progress note dated 05/17/23 at 10:44PM completed by CCM, (previous MDS coordinator) indicated CMS entered room for routine check, resident complained of, my sugar is dropping. Resident #53's Accucheck, (blood glucose monitor) Blood Sugar was 46mg/dl, glass of apple juice with sugar and bowl of cereal with milk given at this time, assisted resident to reposition in bed, Resident requested fan at the foot of the bed to be turned on, this nurse turned on fan as requested, hob elevated and snack set up, resident sitting up in bed eating cereal and drinking juice at this time. The progress note did not indicate that the Physician was notified of critical low blood sugar levels. Residents Affected - Few 11:00 PM Entered room for follow up Accucheck BS 66. Noted to be lying in bed, awake and alert, respiration even and unlabored, skin warm/dry. Offered and accepted package of peanut butter crackers. No signs/symptoms of distress noted, resident states I feel a lot better now, just hungry, but I really like these crackers. Resident encouraged to consume package of crackers and assisted to reposition self and linens in bed for comfort. 11:29PM Repeat Accucheck BS level 82. Noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. No s/s of distress noted. Arouses easily to verbal stimuli, Resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00AM indicated the Treatment Nurse was called to Resident #35's room to check blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes BS 80mg/dl. WCTM. Wound treatment provided this shift. PRN Tylenol #4 administered prior to treatment. Resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, results 130. Stated her thanks to this writer and Good, it should not drop much lower Record review of a progress note dated 05/24/23 at 2:15AM Called to room by resident requesting this nurse, (CCM) to, check my sugar, Accucheck BS level 66. Resident offered and accepted small package of peanut butter crackers at this time. No s/s of distress noted. Record Review of Consultant Pharmacist's Medication Regimen review dated 5/23 indicated there were no recommendations from the Pharmacist for Glucagon, (Hormone, it can treat severe low blood sugar) or parameters for notification to the Physician of critical values. During an interview 06/12/23 at 3:45 PM, Resident # 35 said she had tried to get the nurses to not give her full dosage of Insulin and to only give half, because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. A Record Review of Residents #35 progress notes dated 06/12/23 at 4:11 PM, order received for blood sugar checks BID, but still no parameters to hold Insulin, notify the Physician or Glucagon Orders. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had worked for corporation for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 5 of 41 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 06/14/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She was not aware there were no orders for blood sugars or parameters to hold Insulin on Resident #35. She said she had texted the Physician regarding the Resident's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed by her this morning with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility was for the nurses to follow morning meeting process, monitor vital signs, blood sugars and if out of range notify the Physician. She said she would monitor this when she comes to the facility twice a week. She said she would join the meeting through TEAMS. She said everyone taking Insulin will have BS checks, and parameters to hold Insulin if BS was to low or high and orders to notify the Physician. During a phone interview on 06/13/23 at 9:44 AM, the Physician said, (the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl). The Physician said he would call orders to the facility to notify him if blood sugars were below 100mg/dl. During an interview 06/13/23 at 10:03AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident has a critical lab value. She said resident #35 had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at nursing facility were not aware of sliding scale order. She said she had texted the Doctor multiple times since yesterday when they became aware of no parameters, and physician has not replied. LVN A, said she had notified Physician regarding Resident #35's scheduled Humulin Insulin at bedtime to see if facility could get orders for The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Notification of Changes. Resident #35: Resident's physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 5/17/23 and 5/21/23. New orders received for labs to include hemoglobinA1C, one time order, and accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. Date: 6/12/2023. Resident on 6/13/2023 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. Medical Director, was consulted regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar check orders to: Accuchecks BID, Special Instructions: **NOTIFY MD FOR BLOOD SUGARS <80 OR >400** Twice A Day 06:30 AM, 08:00 PM Blood sugar prn for symptoms of hyperglycemia or hypoglycemia. Special Instructions: Notify MD of results <80 or >400 As Needed PRN 1, PRN 2, PRN 3 Notification parameters have added to all residents with finger stick blood sugar orders per the MD's request. Action 1: Educate all nurses regarding physician notification and change of condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 6 of 41 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 06/14/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The licensed nursing staff will have an understanding to report out of range (less than 80 and higher than 400)/critical blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per physician order). Staff will have an understanding on when to report changes to the physician through the above education physician notification and change of condition. All current, new and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Out of range, per the Medical Director, that he would like notified about, is lower than 80 and higher than 400. These parameters have been added to the accucheck orders. Date of Completion: 6/14/2023 by 11AM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Clinical Resource Nurse and/or Clinical Company Leader to perform blood sugar audit to check for out of range blood sugars for previous 30-days. Any blood sugars identified outside the Physician Prescribed range per his order(s) will be reported to the Medical Director and any new orders received will be entered and followed. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse and/or Clinical Company Leader Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. Clinical Resource Nurse and Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Per the Medical Director he would like to be notified of blood sugar outside the range of 80-400, this reflects in the order set inputted for residents receiving accuchecks. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with interim administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. Date of Completion: 6/13/2023 Staff Responsible for Completion: Administrator and Clinical Resource Nurse On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 7 of 41 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 06/14/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 8 of 41 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 06/14/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents reviewed for MDS assessment accuracy. (Resident #17) Residents Affected - Few The facility incorrectly coded Resident #17 as having not received oxygen in previous 14 days while a resident on her MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings Include: Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Unspecified dementia (A group of symptoms that affects memory, thinking and interferes with daily life), anxiety, Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), Shortness of breath, and Acute systolic (congestive) heart failure (when your left ventricle can't pump blood efficiently). Record review of a Quarterly MDS dated [DATE] for Resident #17 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. Section O, question O0100, 2c indicated that resident had not received oxygen in the previous 14 days. Record review of the medication administration record for Resident #17 for the month of April 2023 indicated that she had received oxygen continuously for the look-back period (previous 14 days) of the MDS. Record review of Resident #17's care plan dated 6/13/23 indicated problem: Decreased cardiac output related to changes in myocardial contractility, CHF (Congestive Heart Failure), with intervention: Administer oxygen (O2) as prescribed. Record review of Resident #17's physician orders dated 6/13/23 indicated that she had the following order: Oxygen @ 3 liters per minute by nasal cannula continuously for hypoxia every shift, with a start date of 1/4/23. During an observation and interview on 06/11/23 at 10:15 am Resident #17 was observed with oxygen on as ordered by nasal cannula at a rate of 3 liters per minute. Resident #17 said that she always wore her oxygen. During an interview with Regional Nurse on 6/12/23 at 3:40 pm, she said that the ADON was responsible for doing the MDS's and she was currently out sick today. During an interview with the ADON on 6/13/23 at 8:30 am, she said that she had been here for 3 weeks and had been so overwhelmed with no administrator, no DON, and covering staffing that corporate nurses were helping her to complete the MDS's. ADON said that she felt like she still needed training on MDS's. She said that she had been trying to do everything that she could to ensure that the residents were taken care of and keep the facility afloat by herself. She was unable to say why oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 9 of 41 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 06/14/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not captured on Resident #17's MDS, but that it most likely just fell through the cracks. She said that going forward, she hoped to receive proper training herself, and have a full time DON and administrator to help lighten her load. During an interview with the Regional Nurse on 6/14/23 at 11:10 am, she said that she would ensure the ADON was properly trained on MDS completion and accuracy of assessments by the corporate nurses. She also said that going forward she would expect the facility staff to be properly trained, notify her with questions/concerns, and follow proper processes and policies. Record review of facility policy titled Certifying Accuracy of the Resident Assessment dated 2001 with revision date of November 2019 indicated .The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 10 of 41 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 06/14/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 3 of 6 residents (Residents #21, #34, and #238) reviewed for baseline care plans. The facility failed to develop a baseline care plan or comprehensive care plan within 48 hours of admission for Residents #21, #34, and #238. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #21, #34, and #238's electronic medical records indicated no baseline care plans were implemented. Record review of a face sheet dated 6/14/23 for Resident #21 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure), and dysphagia (difficulty in swallowing food or liquid). Record review of a face sheet dated 6/14/23 for Resident #34 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia (paralysis of one side of the body), cerebral infarction (stroke), chronic kidney disease (a gradual loss of kidney function), and hypertension (high blood pressure). Record review of a face sheet for Resident #238 dated 6/13/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Gastrostomy status (an opening in the stomach for feeding and treatment), viral hepatitis C without hepatic coma (a viral infection that causes liver inflammation, sometimes leading to serious liver damage), Malignant neoplasm of mandible (mouth cancer), Malignant neoplasm of head, face and neck (head and neck cancer), and Pneumonia (an infection in the lungs). During an interview on 6/12/23 at 3:40 pm the Regional Nurse said that she was aware that there were no baseline care plans being done. She said that the ADON did the care plans and had been doing all of this by herself. There was no DON currently, and she said that it was just a lot to keep up with. She said that she expected going forward that her staff would discuss all new admissions in the morning meetings and would do baseline care plans timely. She said that in their system it was too time consuming for the charge nurse to do with admissions. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not formally shown how to staff the facility and has been doing the best she can. She said the facility had been without a DON since 5/26/2023 but the regional nurse did come to the facility a couple times a week as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 11 of 41 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 06/14/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. She said there were no baseline care plans being done at admission due to LVN's needing training. She said the nursing staff needed training on the admission process and had not been shown how to accurately complete an admission. During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she had worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing, completing MDS assessments and care plans. She said she was new to completing MDS assessments, but she was being trained by corporate staff. She said she would generate a baseline care plan when a new resident entered the facility, and the DON was supposed to look over the care plans to make changes as needed. She said the baseline care plan would be generated within the first 24-48 hours of admission. She said if a resident admitted to the facility on a Friday, she would not generate the baseline care plan until the following Monday and the DON would make changes. During an interview on 6/14/23 at 11:10 am, the Regional Nurse said that not having baseline care plans done within 48 hours of admission could put the residents at risk of not receiving appropriate medical treatments. She said that going forward, she would ensure that all staff were properly trained. She said that she has been with company 2 years, has 4 buildings to cover, 2 of which currently have no DON. She would expect her staff going forward to be properly trained, and to notify her with any questions or concerns. She said that she would do TEAMS meetings with staff when she was not able to be in the building to help ensure nothing was missed. Record review of the facility policy titled Care Plans - Baseline dated 2001 with revision date of December 2016 indicated .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 12 of 41 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 06/14/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #7 and #34) reviewed for care plans. The facility failed to ensure Resident #7's care plan accurately reflected her hospice status. The facility failed to ensure Resident #34's care plan accurately reflected her ADL status. This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs. Findings include: Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction, dysphagia, and hypertension. Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Section O of same MDS assessment indicated that she had received hospice care within the last 14 days while a resident of the facility. Record review of a care plan for Resident #7 with last care conference date of 9/9/22 indicated that hospice status was not addressed on care plan. Record review of physician orders for Resident #7 dated 6/13/23 indicated that she had a physician order dated 2/6/23 stating the following: Admit to Heart-to-Heart Hospice; Primary Hospice Diagnosis: CVA Record review of a face sheet for Resident #34 undated indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage, chronic kidney disease, depression, and hypertension. Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had a BIMS score of 10, indicating that she had moderately impaired cognition. She required extensive to total dependence in most ADLs with one to two-person assist. She was always incontinent of bowel and bladder and required extensive assist of one person with toileting and personal hygiene. Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene amount of assist and toileting amount of assist dated 4/7/2023 that was incomplete. During an interview on 6/12/23 at 3:40 pm, the Regional Nurse said that the ADON was responsible for care plan updates and revisions, and she was currently out sick. She said that ADON was currently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 13 of 41 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 06/14/2023 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 0656 overwhelmed without a DON, administrator and covering staffing. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/13/23 at 8:10 am, the ADON said that she had been employed at the facility for 3 weeks. She said she has not had a DON or Administrator since the end of May 2023. She said that a resident's hospice status and ADL status should be addressed on their care plan. She said that residents could be at risk of staff not getting a complete picture of resident and resident could possibly not get appropriate care. She said that going forward, she would hope to have a full time DON, administrator, and leadership to help with getting care plans initiated and training of staff. Residents Affected - Few Record review of facility policy titled Care Plan, Comprehensive Person-Centered dated 2001, with revision date of December 2020 indicated: .The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 14 of 41 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 06/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plans to reflect the current condition for 3 of 5 residents of the facility (Residents #7, #17, and #18). The facility failed to ensure Residents #7, #17, and #18 care plans conferences and reviews were held quarterly. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings: Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), dysphagia (trouble swallowing), and hypertension. Record review of a Quarterly MDS Assessment for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Record review of Resident #7's medical record indicated that last care conference was held on 9/9/22. Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (A group of symptoms that affects memory, thinking and interferes with daily life), anxiety, Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and congestive heart failure (when your left ventricle can't pump blood efficiently). Record review of a Quarterly MDS dated [DATE] for Resident #17 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. Record review of Resident #17's medical record indicated that last care conference was held on 9/26/22. Record review of face sheet dated 6/14/23 for Resident #18 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, cerebral infarction, and hypertension. Record review of a Quarterly MDS for Resident #18 dated 5/16/23 indicated that BIMS assessment should not be conducted due to resident being rarely/never understood. Record review of Resident #18's medical record indicated that the last care plan conference was held on 9/26/22. During an interview on 6/13/23 at 8:30 am, the ADON said that she had been employed here for approximately 3 weeks and was overwhelmed trying to everything by herself. She said she had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 15 of 41 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 06/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administrator, no DON, and no one to cover staffing, so she had also been trying to cover all the call-ins. She said that care plan conferences and reviews were not being done, at least since she has been here, as she has had no training on this. She said that going forward, she would hope to have an administrator, a DON, and additional help to cover everything that needs to be done in the facility. During an interview on 6/14/23 at 11:10 am, the Regional Nurse said that she knew care plan conferences were not being done properly in the facility, but that they just did not have the staff. She said that residents could be at risk of not receiving proper care without care plans being implemented and reviewed appropriately. She said that going forward she would expect staff to address in morning meetings all residents who had care plan reviews coming up in the following week. She said she would ensure proper training for all staff, have the MDS corporate nurses training the current ADON and hold TEAMS meetings with staff when she could not be in the facility to ensure that things were done correctly, and things did not get missed. Record review of the facility policy titled Care Plan, Comprehensive Person-Centered dated 2001, with revision date of December 2020 indicated: .The Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 16 of 41 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 06/14/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 of 8 residents (Resident #35), reviewed for quality of care. Residents Affected - Few The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. An Immediate Jeopardy (IJ) situation was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 3:03pm, while the IJ was removed on 06/14/23. The facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm, due to the facility's need to evaluate the corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident #35's face sheet dated 04/25/23 indicated Resident #35 admitted to the facility on [DATE] and was a 59-year- old-female with diagnoses: Bacteremia (blood infection, sepsis), Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), (abnormal blood sugars) due to underlying condition with neuropathy, (dysfunction of peripheral nerves), (chronic viral hepatitis C (liver disease), neuromuscular dysfunction of the bladder (bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus (pressure sore). Record review of Physician Orders dated 04/25/2023 Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicates, there were no physician orders to check resident's BS and no parameters for notification of abnormal values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS, and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident #35 was able to feed herself with set up assistance from staff. Resident #35 had a Foley catheter due to diagnosis of neuromuscular bladder (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx (small triangular bone at the base of the spine) and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had a diagnosis of Diabetes Mellitus, and intervention of: medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 17 of 41 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record Review of Physician orders dated 04/25/23 through 06/12/23 indicated Resident #35 had no orders for routine finger stick blood sugars, no parameters to hold insulin if blood sugar reading below 70mg/dl, and no orders to notify the physician of critical blood sugar levels of below 70mg/dl and above 250 mg/dl. Record review of MAR (medication administration record) indicates nurses were checking residents BS twice a day before Insulin administration but had no Physician orders to check Resident's BS and no parameters to hold Insulin or parameters to notify the Physician of critical values. Record review of Resident #35's progress note dated 05/17/23 at 10:44 PM completed by the CCM (previous MDS coordinator) indicated the CCM entered the room for a routine check and the resident complained of, my sugar is dropping. Resident #35's Accucheck (blood glucose monitor) Blood Sugar was 46mg/dl. A glass of apple juice with sugar and a bowl of cereal with milk was given at that time. The resident was assisted to reposition in bed. The resident requested a fan at the foot of the bed to be turned on, and the nurse turned on the fan as requested. The head of bed was elevated, and a snack was set up. The resident was sitting up in bed eating cereal and drinking juice at this time. At 11:00 PM, CCM entered room for follow up Accucheck, BS at 66. Resident noted to be lying in bed, awake and alert, respiration even and unlabored, skin was warm/dry. The resident was offered and accepted a package of peanut butter crackers. There were no signs/symptoms of distress noted, and the resident stated she felt a lot better now, was just hungry, but he really like the crackers. The resident was encouraged to consume package of crackers and was assisted to reposition self and linens in bed for comfort. At11:29 PM a repeat Accucheck, BS level 82. The resident was noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. There was no signs/symptoms of distress noted. The resident aroused easily to verbal stimuli. The resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00 AM indicated the Treatment Nurse was called to Resident #35's room to check his blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes and BS 80mg/dl. WCTM. Wound treatment was provided on shift. PRN Tylenol #4 was administered prior to treatment. The resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, and results were 130mg/dl. Stated her thanks to this writer (CCM) and Good, it should not drop much lower. Record review of a progress note dated 05/24/23 at 2:15 AM CCM called to resident #35's room by resident, requesting this nurse, (CCM) to, check my sugar, Accucheck BS was level 66. The resident was offered and accepted a small package of peanut butter crackers at the time. There were no signs/symptoms of distress noted. Record Review of the Consultant Pharmacist's Medication Regimen Review dated May 2023 indicated there were no recommendations from the Pharmacist for Glucagon, (hormone, it can treat severe low blood sugar,) parameters to hold insulin, or parameters for notification to the Physician of critical values. During an interview on 06/12/23 at 3:45 PM, Resident #35 said she had tried to get the nurses to not give her a full dosage of Insulin 20mg/dl and to only give half (10mg/dl) because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 18 of 41 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dropping. She said she has seen the Physician but didn't think to tell him. Resident #35 said she experienced sweating and shakiness when her blood sugar fell below 80mg/dl. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had notified the Physician regarding the Resident #35's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed with no signs or symptoms of Hypoglycemia. The Regional Nurse said she had worked for corporate for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at nursing documentation. She was not aware there were no orders for blood sugars or parameters to hold insulin for Resident #35. During an interview 6/12/23 a 4:10 PM, the Regional nurse said Resident #35 had been assessed today with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility is for the nurses to follow the morning meeting process, (look at documentation, monitor vital signs, blood sugars and if out of range to notify the Physician). She said she would join the meeting through TEAMS. (Messaging APP). She said everyone taking insulin will have BS checks, and parameters to hold Insulin if BS is to low or high. Record Review of a Progress notes dated 06/12/23 at 4:11 PM revealed, new order for HbA1C (blood test for diabetes determines the three-month average blood sugar level), next lab draw and Accuchecks twice a day. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she [NAME] formally been shown how to do an admission but said the nurses should have known to get blood sugar checks and parameters with insulin orders. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed. She said she was often called to work the floor and was doing the best she could. During a phone interview on 06/13/23 at 9:44 AM the Physician said, the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl. Physician said he had not been notified of Resident #35's critical low blood sugar levels or her requesting to have Insulin dosage lowered. During an interview 06/13/23 at 10:03 AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident had a critical lab value. She said the resident had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at the nursing facility were not aware of the sliding scale order. She said she had texted the Physician multiple times since yesterday when they became aware of no parameters, and the physician has not replied. LVN A said she had notified the Physician regarding Resident #35's scheduled Humulin 70/30 U-100 Insulin (NPH and regular Human) [OTC] suspension; 100 unit/ml (70-30); Amount to Administer: 20 units; subcutaneous twice a day, to see if the facility could get orders for parameters. LVN A notified the Physician that Resident #35 was requesting to get half of her insulin dosage when her blood sugar is low. During an interview 06/13/23 at 10:15 AM, the Treatment Nurse said she had worked at the facility for two years. She said if the facility was short staff she got pulled from doing treatments to work the floor. She said Resident # 35 was a very brittle diabetic and her blood sugars were hard to control. She said they do check the resident's blood sugar before giving her insulin. She said there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 19 of 41 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were no physician's orders to check her blood sugar or parameters as to when to notify the physician. She said she had to give her orange juice and sugar before and a snack to bring her bloodsugar up. She said once the blood sugar was stable she did not think to notify the Physician. During an interview 06/13/23 at 10:34 AM the Interim Administrator said she expected her staff to notify the Physician of any change in the resident including low or high blood sugars. She said she expects her staff to be trained and have competency checks offs regarding Hypoglycemia or Hyperglycemia and to know when to notify the Physician. The Administrator said the resident could have gone into a coma if her BS is not controlled. She said she expects her staff to follow protocol for hypoglycemia, and the Regional Nurse was inservicing the staff on the policy today, she hopes to improve education for the staff. She said she will meet with families during care conference meetings and make sure they are doing everything they can to take care of the residents During an interview 06/13/23 at 10:47 AM Resident #35 said she didn't always get her snacks at bedtime, and that her blood sugar would drop. She said she could feel her blood sugar dropping sometimes and would call the nurse to come check it. She said the nurse would give her orange or apple juice with sugar and give her snacks to bring it up. She said she tried to keep snacks in her room. Resident #35 said she had tried to get the night nurse to only give her half of her insulin dosage because she kept dropping. The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Resident #35: The resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day with hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by the Clinical Resource Nurse and there were no signs or symptoms of hypo or hyperglycemia (low or high blood sugar). The Medical Doctor was consulted regarding current orders. The Medical Director has changed Resident #35's finger stick blood sugar; changed orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl; and Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED PRN 1 PRN 2, PRN 3. Action 1: Educate all nurses regarding the diabetic/managing hypoglycemia policy, physician notification, and change of condition (to include blood sugars out of range per the Physician's prescription below 80 and above 400). The licensed nursing staff will have an understanding to report out of range blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per the Physician's preference below 80 and above 400). Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 20 of 41 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility will ensure competency of licensed nursing staff and ensure licensed nursing staff understand our management of hypoglycemia policy through the above education. The charge nurses will notify the doctor immediately if the blood sugar reading is above or below the parameters set by the residents' physician (the MD would like to be notified if blood sugar is outside 80-400), the charge nurse at that time will follow the MD's orders. The updated orders read as follows per the physician: Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Policy Managing Hypoglycemia has been updated to reflect follow provider orders/instructions for blood sugars under 80 and over 400 and/or to administer oral glucose/glucagon/call emergency services per policy. Orders will reflect PRN oral glucose/glucagon per policy and MD orders for residents receiving accuchecks. All nurses will be educated regarding the policy and policy changes. All current, new, and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Date of Completion 6/14/23 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Perform Blood Sampling- Capillary (Finger Stick) Competency competencies on all licensed nurses. All new and temporary (agency) nurses shall be checked off on Blood Sampling- Capillary (Finger Stick) Competency prior to working their next shift/first shift. Date of Completion: 6/14/2023 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. The Clinical Resource Nurse and the Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference and physician's order/instruction upon notification of blood sugars lower than 80 and higher than 400. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with the Interim Administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 21 of 41 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 06/14/2023 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 0684 Date of Completion: 6/13/2023 Level of Harm - Immediate jeopardy to resident health or safety Staff Responsible for Completion: Administrator and Clinical Resource Nurse Residents Affected - Few These interventions were completed based on staff (Interim Administrator, ADON, Clinical Resource Nurse, and 4 LVNs (Treatment Nurse, Nurse A, Nurse G, Nurse H) on the morning and evening shift, were interviewed to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would follow the policy, Management of Hypoglycemia, the parameters of notification. A policy, Management of Hypoglycemia-Diboll Specific, updated 06/14/23 was reviewed by Surveyors. MANAGEMENT of HYPOGLYCEMIA: The following is a suggested protocol thaat should be implemented without the approval of the Medical Director and Director of Nursing. If there is already a protocol in place, disregard this and follow the existing approved protocol instead. 1. Classification of hyperglycemia: a. Level 1 hypoglycemia:blood glucose <80 mg/dl and >54 mg/dl b. Level 2 hypoglycemia: blood glucose is <54mg/dl: and c. Level 3 hypoglycemia: altered mental and or physical status requiring assistance for hypoglycemia. 2. For Level 1 hypoglycemia (<80mg/dl a. Give resident an oral form of rapidly absorbed glucose 1tube/15grams Notify the Physician immediately. b. Remain with the resident c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 22 of 41 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 06/14/2023 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 0684 Recheck blood sugar in 15 minutes: Level of Harm - Immediate jeopardy to resident health or safety 1. Residents Affected - Few 2. If blood glucose within establish reference range, pprovide the resident with a meal or snack. If blood sugar is greater than established reference range (rebound Hyperglycemia) administer diabetic medication as ordered or 3. If blood sugar remains <80mg/dl, repeat oral glucose and notify physician for further orders. 3. For Level 2 hypoglycemia (<54mg/dl) a. Administer glucagon 1 vial/1mg I b. Notify the Physician Immediately c. Remain with the Resident d. Place resident in a comfortable and safe place (bed or chair) e. Monitor vital signs and f. Recheck blood glucose in 15 minutes (as Above) 4. If a resident has a Level 3 hypoglycemia and is unresponsive a. Call 911(in accordance with resident's advance directives b. Administer Glucagon 1 vial/1mg IM. c. Notify the Physician immediately d. Remain with the resident e. Place the resident in a comfortable and safe place (bed or chair); and f. Monitor vital signs During an interview on 6/14/2023 at 4:00 PM, the Interim Administrator said she had been at the facility since Monday 6/12/23. She said they had no DON, and the last DON left two weeks ago. She said her expectations were for the staff to be in-serviced on the Management of Diabetes. She said the Regional Nurse had audited the physician's orders on all resident to be ensure BS checks, and parameters to hold Insulin, and to notify the Physician of abnormal values, BS <80 and >400mg/dl had been implemented on all diabetics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 23 of 41 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 24 of 41 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 06/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 courtyard reviewed for accident hazards. The facility failed to store laundry detergent and bleach away from residents. These failures could place the residents at risk of accidents hazrds in the environment in which they live. Findings included: Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.) During an observation on 6/12/2023 at 08:45 AM of the courtyard and smoking area revealed upon exit at the door near the laundry area, there were 5 3-gallon containers filled with liquid detergent and one damaged 3-gallon container filled with liquid bleach labeled caustic/hazard (clear liquid was visible through a hole in the container and cigarette butts were floating in the liquid ). During an observation and interview on 6/12/2023 at 9:09 AM, revealed the Laundry Supervisor was aware of the containers on the stoop of the exit door. She said she had been employed at the facility since February 2022. She opened the door leading out to the courtyard and smoking area and looked at the containers of detergent and damaged container of bleach. The Laundry Supervisor said the containers had been there since she started to work at the facility, and she wasn't concerned about them. When asked if the bleach could cause harm if a resident tampered with it, she said the caustic chemicals in the bleach could harm a resident if it was spilled on them or was ingested and the detergent could make them sick also. She stated the resident that came out to the courtyard walked by the containers and they could pose a safety hazard if they stumbled on them or the bleach splashed on them. During an interview on 06/12/23 at 10:00 AM with Resident #24 he said he uses the exit at the door next to the laundry room multiple times to smoke and the other 4to 6 smokers use the exit door also. Resident 24 said some of the smoker are confused but there is a staff member that goes out with them. Resident #24 said there are some resident that come outside that have trouble walking and they could fall on the bleach container that was cracked. Resident #24 said the residents could fall over the stacked containers of detergent since they were close to the door and if the fell on the cracked container of bleach it might get on them. During an observation on 06/12/23 at 10:15 AM of the smoking area at the Gazebo revealed there appeared to be multiple ash marks on the bricks, and concrete near the exit door. Cigarette butts were in a coffee can and a damaged 3-gallon plastic bleach container (labeled-Hazard Caustic) filled with bleach at the doorway leading out to the Gazebo. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 25 of 41 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 06/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/12/2023 at 3:45 PM, the Maintenance Director said he had been employed at the facility since 09/2020. He said he was responsible for anything that was broken and needed repair in the facility. He said his supplies were in the two metal buildings in the courtyard and he frequently used the exit door where the detergent and bleach had been stored for a long time. He said the bleach and detergent had been placed outside because a new vendor was under contract to supply cleaning products and the 6 containers were scheduled to be picked up by the old vendor but they never came to get them. When asked if the bleach or detergent could cause harm if a resident tampered with it, he said the caustic chemicals in the bleach could harm a resident if it was spilled on them or ingested and the detergent also. He said he would dispose of them immediately. During an Interview on 6/13/2023 at 7:45 AM, the Interim Administrator said she had been at the facility for a week, and the last Administrator left at the end of May 2023. She said she was not aware of the detergent and bleach being outside next to the laundry exit door, that the resident use to go outside and the smokers use to go to the smoking Gazebo. She said the bleach and detergent sitting outside the door in the resident courtyard were a hazard and posed a risk of poisoning or burns if a resident came in contact or ingested the contents of the containers. During an observation on 6/14/2023 at 9:00 AM revealed the containers of bleach and detergent were no longer by the exit doorway. Record review of a facility policy titled Maintenance Service with a revised date of December 2022 indicated, .1. Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times 2. A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 26 of 41 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 06/14/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 5 of 5 months reviewed. (January 2023-May 2023) The facility did not have RN coverage for 4 days in January 2023. The facility did not have RN coverage for 17 days in February 2023. The facility did not have RN coverage for 17 days in March 2023. The facility did not have RN coverage for 3 days in April 2023. The facility did not have RN coverage for 2 days in May 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the CMS Payroll Based Journal report for the 2nd quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there were no RN hours for the following dates: 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11(WE); 01/12 (TH); 01/13 (FR); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/23 (MO);01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/28 (SA); 01/29 (SU); 01/30 (MO); and 01/31 (TU). 02/01 (WE); 02/02 (TH); 02/03 (FR); 02/06 (MO); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11(SA); 02/12 (SU); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/20 (MO); 02/21 (TU);02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 02/27 (MO); and 02/28 (TU). 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11(SA); 03/12 (SU); 03/13 (MO); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU);03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); and 03/31 (FR). Record review of the daily nurse staffing sheets for January 2023 indicated there were no RN hours worked on the following dates: 01/07 (SA); 01/08; 01/28 (SA); and 01/29 (SU). Record review of the daily nurse staffing sheets for February 2023 indicated there was no RN hours worked on the following dates: 02/01 (WE); 02/02 (TH); 02/03 (FR); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11 (SA); 02/12 (SU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); and 02/26 (SU). Record review of the daily nurse staffing sheets for March 2023 indicated there was no RN hours worked on the following dates: 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/08 (WE); 03/09 (TH); 03/10 (FR); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 27 of 41 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 06/14/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm 03/11 (SA); 03/12 (SU); 03/20 (MO); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); and 03/31 (FR). Record review of the daily nurse staffing sheets for April 2023 indicated there was no RN hours worked on the following dates: 04/11 (TU); 04/12 (WE); and 04/13 (TH). Residents Affected - Many Record review of the daily nurse staffing sheets for May 2023 indicated there was no RN hours worked on the following dates: 05/10 (WE); and 05/11 (TH). During an observation and interview on 6/11/2023 at 10:00 AM, revealed RN K was in the facility by the nurse station and said she was one of the weekend RN's who worked at the facility. She said she had been employed since August 2022 and alternated weekends with another RN. She said she only worked weekends at the facility. During an interview on 6/12/2023 at 2:00 PM, HR said she had been employed at the facility since August 2022. She said she was responsible for making sure hours were submitted to payroll. She said she was not responsible for submitting anything to the PBJ system. She said the ADON was responsible for staffing and the facility did utilize agency staff at times. She said if agency staff worked at the facility, she was not able to access their time sheets and would have to reach out of corporate to get them. She said the facility always had a nurse in the facility and was never without a nurse any day but a RN was not always there. She said she was not aware the facility triggered for no RN hours in January 2023 to March 2023. She said the only RNs who clocked in or out were the RNs who worked the weekends. She said the DON or the Regional Nurse when she visited did not clock in or out either because they were salary employees. She said the nurse staffing sheets that were posted by the nurse station daily would reflect if they had RN coverage on the specific dates and she was responsible for updating the sheet daily according to the staffing schedule. She said the facility had a DON who left on 1/31/2023 who had been employed full time since 9/1/2022. She said the facility did not have another DON until 4/1/2023 and she left 5/26/2023. She said the facility did not currently have a full time DON but the Regional Nurse would come to the facility about twice a week. She said the facility always had a licensed nurse in the facility to take care of the residents. During an interview on 6/12/2023 at 9:55 AM, the Regional Nurse said the facility had been without a full time DON since 5/26/2023. She said she had been going to the facility about two times a week. She said the last DON was employed at the facility from 4/1/2023 to 5/26/2023. She said the DON worked Monday-Friday 8 hours a day which provided coverage for the RN hours. She said the facility had weekend RNs who worked alternating weekends. She said the ADON was responsible for staffing at the facility. She said while the facility did not have a DON, she would cover and work 8 hours days on the days she visited the facility. She said the facility did not have a RN in the facility 8 hours a day 7 days a week at this time. During an interview on 6/12/2023 at 2:20 PM, the Compliance Officer said he was the person who was responsible for the PBJ submissions. He said he had been in that position for the last two quarters of the fiscal year 2023 that was submitted to CMS. He said the facility utilized their payroll system which pulled time punch detail hours for employees except for corporate staff that was submitted to PBJ. He said the hours did not include the DON and Regional Nurse who was paid salaries and clocking in and out was not required for them. He said the time punch detail hours that was submitted for the second quarter of 2023 were the hours for the RN's that were not salaried. He said he had not received any training on PBJ submissions and how to get the data from the different payroll systems. He said corporate was looking into getting another system in place for time reporting. He said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 28 of 41 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 06/14/2023 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 0727 current system was not collecting accurate hours worked for the RN coverage. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not shown how to staff the facility and had been doing the best she could. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed but did not stay at the facility for the 8 hours that was required. She said the facility had never been without nurse coverage since her employment started. She said a RN must be in the facility to provide guidance for the nursing staff and not having a fulltime RN present could affect the resident's overall quality of care. She said the facility did not have a RN in the facility 8 hours a days 7 days a week at this time. Residents Affected - Many During an interview on 6/14/2023 at 8:30 AM, the Treatment Nurse said she had been employed at the facility for 2 years but only 2 months as the treatment nurse. She said the facility had weekend RNs that worked. She said after 1/31/2023 the facility was without a DON until the beginning of April 2023. She said the Regional Nurse would come to the facility a couple of days a week. She said when a RN was not in the facility if the charge nurses had issues or concerns, they would report to the ADON, and the ADON would contact the Regional Nurse if needed. She said the ADON was responsible for staffing and made sure the facility had nurse coverage in the facility. During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing. She said from February 1, 2023, to April 1, 2023, the facility did not have a fulltime DON or Administrator. She said the Regional Nurse would come to the facility a few days a week. She said if the staff had an issue or situation that required a RN, then she would contact the Regional Nurse. She said the residents could be at risk of having a medical condition that would require a RN. During a follow up interview on 6/14/2023 at 10:40 AM, the Regional Nurse said they had two applicants that would be interviewed for the DON position this week. She said RNs were critical thinkers and should be in the facility 8 hours a day 7 days a week as required and without them present it could impact the residents' medical conditions. She said going forward she would review the clock hours each day to ensure hours were met for nursing hours. She said the facility had weekend RNs that worked. She said she would review with the ADON on a weekly basis for RN coverage. During an interview on 6/14/2023 at 11:00 AM, the Interim Administrator said she had been employed with the company for years but 6/12/2023 was her first day at the facility. She said she was not aware of the facility having days that triggered for no RN hours from January 2023 to March 2023 according to the PBJ submission report. She said the facility should have an RN in the facility 8 hours a day 7 days a week. She said a resident could be at risk of not receiving needed nursing care. She said the facility did not have a policy for RN hours. Record review of the Facility Assessment Tool dated 7/28/2022 with next review date for the QAPI committee review date of 8/23/2022 indicated an average census was thirty-two. Their plan for staff indicated one RN for days and one LVN for days, evenings and nights and a DON 24/7. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 29 of 41 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 06/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (February 2023, and May 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion. Findings: During a record review of the facility's drug destruction log for the last 12 months (June 2022 to May 2023), revealed the drug destructions for controlled drugs dated 02/15/23 and 05/15/23 indicated that the attached pages of medication destruction were ot numbered and did not include the initials of the consultant pharmacist and two witnesses. During an interview on 06/13/23 at 9:50 a.m., the ADON said there was no DON currently employed at the facility, and she was unaware that the cover page had to be signed by the Pharmacist and another witness and that there had to be two witnesses initialing each page and that she thought the cover sheet was all that was needed. She said she took this position three weeks ago and would implement a new system that would ensure the cover sheets and all attachment pages were numbered and signed/ witnessed appropriately going forward. She said she did not think a drug diversion could happen, but anything might be possible if the correct procedure was not followed. During an interview on 06/1/23 at 2:03 p.m., the Regional Nurse said there was no DON currently employed at the facility, and she was unaware there had to be two witnesses initialing each page of the listed drugs and each page should be numbered. She said that she thought the signed cover sheet was all that was needed. She said she would ensure the cover sheets were signed as required and all attachment pages were numbered and witnessed appropriately going forward. She said the risk could be a possible drug diversion. During an interview on 06/13/23 at 4:00 p.m., the Interim ADMIN said she would check the regulations with the Pharmacist to ensure the drug destruction occurred appropriately and said that going forward she expected her staff to follow correct policy regarding drug destruction. Record review of facility policy titled Discarding and Destroying Medications revised October 2014 indicated .Schedule II, II and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The facility may contract with a DEA registered collector for proper disposal of non-hazardous schedule II, III, IV and V controlled substances. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 30 of 41 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 06/14/2023 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 0755 regulations Level of Harm - Minimal harm or potential for actual harm Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated. Residents Affected - Few (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed. (v) unique identification number assigned to the prescription by the pharmacy. (vi) name of dispensing pharmacy. (vii) name, strength, and quantity of drug. (viii) signature of consultant pharmacist destroying drugs. (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet , provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator. (II) director of nursing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 31 of 41 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 06/14/2023 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 0755 (III) acting director of nursing; or Level of Harm - Minimal harm or potential for actual harm (IV) licensed nurse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 32 of 41 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 06/14/2023 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023 to March 31, 2022) The facility failed to submit accurate licensed nursing coverage 24 hours a day for 1/3/2023, 1/27/2023, 3/2/2023 and 3/7/2023. These failures could place residents at risk for personal needs not being identified and met. The findings included: Record review of the CMS PBJ report for the second quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there was no licensed nursing coverage 24 hours/day for the following dates: 1/3/2027, 1/27/2023, 3/2/2023 and 3/7/2023. During an interview on 6/12/2023 at 2:00 PM, HR said she had been employed at the facility since August 2022. She said she was responsible for making sure hours were submitted to payroll. She said she was not responsible for submitting anything to the PBJ system. She said the ADON was responsible for staffing and the facility did utilize agency staff at times. She said if agency staff worked at the facility, she was not able to access their time sheets and would have to reach out to corporate to get them. She said the facility always had a nurse in the facility and was never without a nurse any day. She said she was not aware the facility triggered for 4 days in the second quarter for licensed nurse coverage 24 hours a day. During an interview on 6/12/2023 at 2:20 PM, the Compliance Officer said he was the person who was responsible for the PBJ submissions. He said the facility utilized their payroll system which pulled time punch detail hours for employees except for corporate staff that included the regional nurses and DONs that was submitted to the PBJ system. He said the hours did not include the DON and the regional nurse who were paid salaries and clocking in and out was not required for them. He said the time punch detail hours that were submitted for the second quarter of 2023 were the hours for the RNs that were not salaried. He said he had not received any formal training on PBJ submissions and how to get the data from the different payroll systems. He said corporate was looking into getting another system in place for time reporting. He said the current system was not collecting accurate hours that was worked for all staff. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not shown how to staff the facility and had been doing the best she could. She said the facility had a lot of call in's and it had been difficult to get shifts covered. She said since the facility had been short staffed, and she implemented a nurse coming in to work 4 pm to 10 pm to work and help administer medications to the residents since she started at the facility. She said the facility had never been without nurse coverage since her employment started. During an interview on 6/14/2023 at 8:30 AM, the Treatment Nurse said she had been employed at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 33 of 41 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 06/14/2023 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many facility for 2 years but only 2 months as the Treatment Nurse. She said her hours to work were usually from 8 am until 5 pm. She said the ADON was responsible for staffing and made sure the facility had nurse coverage in the facility. She said the ADON would cover for the nurses if there was only one nurse in the facility so they could take a break. She said on 3/2/2023 she came in to work that day at her normal time at 8 am because that was her schedule since being the Treatment Nurse at the facility. She said when she arrived, someone must have called in and she had to work as a charge nurse, and she also provided wound care and treatments to the residents that day. She said she clocked out at 6:20 pm and that would have indicated she worked as a charge nurse that day because the nurses worked 12 hours shifts from 6 am to 6 pm on the day shift. During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she was a LVN who worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing. She said the facility always had numerous nurses in the facility all the time and was never without one. She said if the facility was short a nurse, then she would cover the shift if she could not get coverage from agency staffing. During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said going forward she would review the clock hours for each day to ensure hours were met for nursing hours. She said she was not aware of the facility having days that triggered for licensed nurse coverage 24 hours a day according to the PBJ submission report. During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said she had been employed with the company for years but 6/12/2023 was her first day at the facility. She said she was not aware of the facility having days that triggered for licensed nurse coverage 24 hours a day according to the PBJ submission report. She said a nurse would not leave or take a break without another nurse being present and if a licensed nurse was not in the facility, they were to notify her immediately. She said a resident could be at risk of not receiving needed nursing care. She said the facility did not have a policy for licensure nurse coverage for 24 hours a day. Record review of the Facility Assessment Tool dated 7/28/2022 with next review date for the QAPI committee review date of 8/23/2022 indicated an average census was thirty-two. Their plan for staff indicated one RN for days and one LVN for days, evenings and nights and a DON 24/7. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 34 of 41 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 06/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #34) reviewed for infection control. Residents Affected - Few TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34. TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an undated face sheet for Resident #34 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage (weakness on one side after a brain bleed), chronic kidney disease (loss of kidney function), depression (sadness or loss of interest in activities), and hypertension (high blood pressure). Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had moderate impairment in thinking with a BIMS score of 10. She required extensive to total dependence in ADL's with one to two person assist. She was always incontinent of bowel and bladder. Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene and required assistance. During an observation on 6/11/2023 at 1:50 PM, revealed the Activity Director and TNA B were present in the room of Resident #34. Both washed their hands in the bathroom and applied gloves. Resident #34 was transferred from a wheelchair to her bed using a mechanical lift with both the Activity Director and TNA B assisting. The Activity Director left the room and TNA B provided incontinent care. TNA B pulled the resident's pants down to her legs and opened her brief and placed it between Resident #34's thighs. TNA B removed wipes from a plastic bag and wiped Resident #34's perineal area from front to back and placed the wipes in the trash. TNA B rolled Resident #34 to her left side and a large amount of feces was observed. TNA B removed wipes and wiped Resident #34's rectal area from front to back multiple times and placed the wipes in the trash. TNA B ran out of wipes and removed her gloves and placed them in the trash and did not wash or sanitize her hands. TNA B pulled the privacy curtain and left the room to get more wipes. TNA B entered the room after about a minute with more wipes in a plastic bag and placed the bag on the bed and went into the restroom to wash her hands. TNA B placed gloves on both hands and proceeded with incontinent to Resident #34. TNA B cleaned Resident #34's buttocks with wipes and placed them in the trash along with the dirty brief. TNA B placed a clean brief underneath Resident #34 buttocks with dirty gloves on and then removed the gloves and placed them in the trash. TNA B applied another pair of gloves to both hands without washing or sanitizing them and secured the brief on Resident #34 who was then repositioned in the bed and her pants were pulled back up. TNA B went to the door to get the Activity Director to come back in the room to assist with transferring Resident #34 from her bed to the wheelchair using a mechanical lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 35 of 41 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 06/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #34 was safely transferred by both staff to the wheelchair. TNA B removed her gloves and placed them in the trash and sanitized her hands. During an interview on 6/11/2023 at 2:10 PM, TNA B said she had only been employed at the facility for 3 weeks as a temporary nurse aide. She said she had taken her skills examination but still needed to take the written test for certification as a nurse aide. She said she should have had more supplies in the room when she was providing care to Resident #34. She said she should have washed or sanitized her hands when she changed her gloves. She said she touched a clean brief with dirty gloves and should have had clean gloves on before applying the brief. She said she had only had a few days of training with staff and was trained by other CNAs in the facility. She said she had not received any training from the ADON or DON. She said the CNAs showed her how to perform incontinent care. She said a resident could be at risk of infection if hands were not washed or sanitized in between gloves changes and contamination of clean items with dirty gloves. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 4 weeks. She said the facility had not had a DON or Administrator since the end of May 2023. She said the DON was responsible for training staff on infection control. She said staff should wash or sanitize hands between glove changes and should not use dirty gloves to touch anything clean. She said there was a risk for infection control to the residents along with cross contamination. She said going forward she would look at the facility's policy and procedures to educate staff. She said she would conduct a skills check off with TNA B. During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said the ADON started an in-service with all staff on handwashing and perineal care on 6/13/2023. She said any time staff changed gloves, they should wash or sanitize their hands before putting on new gloves. She said staff should take gloves off when going from dirty to clean. During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said staff should take gloves off when going from dirty to clean. She said staff should wash or sanitize hands when gloves are changed. She said they started in-services with staff on pericare, handwashing, and infection control on 6/13/2023. She said they put a PIP in place for the issues on 6/13/2023. She said the TNAs started skills check offs yesterday, 6/13/2023. She said going forward direct staff would have competency check offs before providing care. She said residents could be at risk of infections by staff not washing or sanitizing their hands when changing gloves. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of 1/20/2023 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections, 5. Hand hygiene must be performed prior to donning and after doffing gloves FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 36 of 41 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 06/14/2023 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention . Residents Affected - Many This failure has the potential to affect all 36 residents of the facility due to potential outbreaks infections. (There was no full time Infection Preventionist at the facility.) Findings include: During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks and was not a Certified Infection Preventionist. She said the facility did not currently have a DON/IP and the DON/IP's last day was 5/26/2023. She said if an infection control nurse was not certified they could have an outbreak of infections at the facility, and that could have an adverse effect on the 36 residents. During an interview on 6/13/2023 at 2:15 PM, the Regional Nurse said she had been employed with the company for 2 years and was not a Certified Infection Preventionist. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON/IP from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. During an interview on 06/13/32 at 2:15 PM the Regional Nurse Consultant acknowledged the facility was to have a certified individual who was responsible for the infection control program at all times. The Consultant Nurse Consultant was able to confirm there was no other nurse that was certified in infection control employed at the facility as required by regulation. During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said she had been at the facility since 6/13/23. She said she had obtained certification in Infection Prevention as of 6/14/2023 through TRAIN. A policy was requested on 6/14/2023 at 12:30 PM concerning the Infection Preventionist Role and employment in the facility. None was provided at time of exit. Record review of the facility's infection control policy titled, Antimicrobial Stewardship, dated 2019, reflected in part licensed nursing staff will receive training related to antibiotic stewardship, the facilities criteria for initiating antibiotics .this training will occur as part of the nurse's orientation. Record review of the facility's infection control plan titled, Infection Control Plan: Overview, dated 2019, reflected in part The facility will establish and maintain an Infection Control Program designed to .help prevent the development and transmission of disease and infection. Record review of a facility policy titled Employee Training on Infection Control with a revised date of January 2022 indicated .The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs . 2. The Infection Preventionist and Administrator will identify those disciplines or individuals who need task or job specific infection control training, 3. Infection control training topics will include at least a. Standard precautions, including hand hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 37 of 41 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 06/14/2023 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 0926 Have policies on smoking. 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 follow established policy regarding smoking, smoking areas, and smoking safety for 2 (back porch smoking area and gazebo smoking area) of 2 smoking areas. Residents Affected - Some The facility failed to keep cigarette butts out of the plastic trash can containing paper and plastic in the smoking area (back porch smoking area), and there were no red metal trash cans (fire-proof) available for residents to extinguish their cigarettes. The residents were putting their cigarettes out on the bricks of the building at the exit door next to the laundry (Gazebo smoking area). The residents were then placing the cigarettes in a coffee can and plastic bleach container at the doorway. This failure could place residents who smoke at risk of physical harm, burns, fires and lead to an unsafe smoking environment. Findings included: Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.) Record review of the care plan for Resident #24 dated 5/04/23 indicated Problem: Resident is a daily cigarette smoker and keeps his personal cigarettes at bedside. Staff and Administration are aware that resident keeps personal cigarettes at bedside. During an observation on 06/12/23 at 8:45 AM revealed the back porch of the facility was designated as a smoking area. There were no ash trays or red metal trash cans available for residents to extinguish their cigarettes. There was a large plastic trash can with cigarette butts and paper in the trash can. During an interview on 06/12/23 at 10:00 AM with Resident #24 he said they only smoked out back on the porch when it rained, otherwise they use the smoking gazebo, located out back. He said when residents use the smoking Gazebo a staff member goes with them, and they exit at the door next to the laundry room. During an observation on 06/12/23 at 10:15 AM of the smoking area at the Gazebo revealed there appeared to be multiple ash marks on the bricks, and concrete near the exit door. Cigarette butts were in a coffee can and a damaged 3-gallon plastic bleach container (labeled-Hazard Caustic) filled with bleach at the doorway leading out to the Gazebo. During an interview on 6/12/23 at 3:45 PM, the Maintenance Director said the back porch area was used for smoking by staff, residents, and visitors when it rained. He said there was a fire extinguisher out on the back porch . He said he was not aware that cigarettes were being put out on the side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 38 of 41 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 06/14/2023 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of the building, butts were being put in a coffee can or that butts where being kept in a plastic bleach container at the exit door near the laundry room leading the Gazebo and courtyard. He said he was not aware that there where cigarette butts and flammable trash (paper and plastic items) in the plastic trash can on the back porch. He said he would immediately remove the plastic trash can and replace with a metal one. The maintenance man said he would remove the bleach container and the coffee can. He said there was a risk of fire and injury if the cigarettes were not extinguished properly. During an interview on 6/13/23 at 8:30 AM, the Interim Administrator said she had just started at the facility 3 days ago. She said the back porch area was used for smoking by staff, residents, and visitors. She said she was not aware that cigarettes were being put out on the side of the building, that the coffee can was being used to contain butts or the bleach container was being used to extinguish butts at the doorway near the laundry room leading out to the Gazebo. She said there was a risk of fire and injury if the cigarettes were not extinguished properly. During an observation on 6/14/2023 at 9:00 AM revealed the container of bleach and coffee can were no longer by the exit doorway. Record review of a facility smoking policy-Residents dated August 2019 Policy Statement: This facility shall establish and maintain safe resident smoking practices .2. Smoking is only permitted in designated resident smoking areas, which are located outside of the facility. Smoking is not allowed inside the facility under any circumstances .6. Metal containers with a self-closing cover device, are available in smoking areas. 7. Ashtrays are only emptied into designated receptables FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 39 of 41 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 06/14/2023 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for all new and existing staff consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse, infection control, dementia, and behavioral health for 9 of 13 employees (ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, CNA F) reviewed for training. Residents Affected - Some The facility failed to ensure required trainings were provided to: ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, and CNA F. These failures could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were : Record review of the personnel file for the ADON indicated she was hired at the facility on 4/24/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health. Record review of the personnel file for LVN G indicated she hired at the facility on 3/6/2023. She received training on abuse on hire. She had an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia. Record review of the personnel file for the Activity Director indicated she was hired at the facility on 8/16/2019. She received training on abuse on hire. She had an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia. Record review of the personnel file for the FSS indicated she was hired at the facility on 9/1/2020. She received training on abuse on hire. She received an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia. Record review of the personnel file for the Rehab Director indicated she was hired at the facility on 7/31/2019. She received training on abuse on hire. She received an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia. Record review of the personnel file for TNA C indicated she was hired at the facility on 5/8/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health Record review of the personnel file for CNA D indicated she was hired at the facility on 9/19/2022. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 40 of 41 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 06/14/2023 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the personnel file for CNA E indicated she was hired at the facility on 2/17/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health. Record review of the personnel file for CNA F indicated she was hired at the facility on 11/21/2022. She received abuse training on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health. During an interview on 6/14/2023 at 10:15 AM, HR said she had been employed at the facility since August 2022. She said she was responsible for the training at the facility for staff. She said new staff were supposed to receive training on resident rights and abuse/neglect. She said staff were supposed to complete the required trainings through an online training program or during in-service training at the facility She said staff were supposed to complete the required training through an online training program. She said the program did not show any enrollment for the staff in the facility and did not know why. She said staff were given specific trainings during the in-services that were conducted at the facility. She said she did not know what trainings were required on hire or annually. She said going forward, she would make a packet and start training staff on resident rights, abuse, and neglect, dementia care/behavioral health, and infection control . She said residents could be at risk of abuse/neglect and staff not being taught how to take care of the residents for situations. During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said the trainings should include infection control, resident rights, abuse/neglect and be given the first 3 days of orientation. She said going forward the staff would receive the required training and she would conduct an in-service with the ADON and HR to go over the required trainings to ensure they knew what trainings was required for all staff . She said they were unable to find any in-services on dementia care, behavioral health, and communication. During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said the twelve mandatory trainings should be scheduled when staff were hired, and the abuse/neglect should be given before staff were allowed to provide direct patient care. She said all mandatory in-services would be provided to the staff going forward. She said the potential risk to residents would be staff providing care without updated education. Record review of a facility policy titled Staff Development Program with a revised date of June 2021 indicated, .All personnel must participate in initial orientation and regularly scheduled in-service training classes. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills, and critical thinking necessary to provide excellent resident care. 5. Training topics may include: a. Effective communication with residents and family (direct care staff), b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, or misappropriation of property; dementia management, e. the infection prevention and control program standards, policies, and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675907 If continuation sheet Page 41 of 41