Inspection·November 21, 2025

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ombudsman asked in the e-mail if this clarifying information would be sufficient to allow readmission of Resident #1, but no response message was included in the file. In an interview with Resident #1's family member on 11/20/2025 at 12:08 PM, she said she acted as Resident #1's POA and coordinated his medical care. She said she was not notified by the facility during Resident #1's hospitalization beginning on 10/17/2025, that Resident #1 would not be readmitted to the facility. She said she was not contacted by the Admin. at any time during the hospitalization, and she was notified by the hospital's case manager that the facility was refusing readmission. She said she did not receive any documentation, including e-mails or letters, notifying her of Resident #1's discharge. She said Resident #1 had not severed the patient-doctor relationship with MD B at the facility, and he intended to resume care from MD B upon return to the facility. She said she was satisfied with the care provided by MD B, and Resident #1 remained under the care of MD B as of the date of the interview. She said she notified the ombudsman that they wanted to appeal the discharge, but Resident #1 was still refused readmission. Due to the unexpected difficulty with finding new placement, Resident #1's family member said the discharge from the acute care hospital was delayed, and Resident #1 experienced anxiety and sadness about remaining in the hospital without a place to discharge. In an interview with the ombudsman on 11/20/2025 at 2:50 PM, he said that when he became aware of the refusal of the facility to readmit Resident #1 during the hospitalization beginning on 10/17/2025, he notified the Admin. that Resident #1 had a right to return to the facility, and that the actions of the facility constituted dumping. He said the Admin. told him that the facility Resident #1 did not have a physician overseeing his care properly, so he could not return. He notified the facility that Resident #1 was formally appealing the discharge, but the facility informed him that Resident #1 could not return despite the appeal. He felt the facility was refusing to readmit Resident #1 due to conflicts with Resident #1's family member, not the issue regarding Resident #1's physician because Resident #1 had an attending physician willing to oversee his care when the facility refused his readmission. In an interview with the Admin. on 11/20/2025 at 2:35 PM, he stated Resident #1 was initially terminated as a patient by the facility's MD, MD A, in August 2025, and the facility's second physician was not accepting new patients. Resident #1 then selected his outpatient physician, MD B, to be his physician at the facility, but he said MD B did not meet their expectations of responsiveness when the facility staff attempted to contact him after hours. Because of the lack of responsiveness from MD B, the Admin. said he felt readmitting Resident #1 under MD B's care would be a disservice. Since MD A had previously terminated Resident #1 and would not be accepted as a patient, he felt Resident #1's needs could not be met at the facility. He said he did not notify Resident #1 or his family member about the discharge by conversation or letter, and he was communicating only with the ombudsman. He said he was aware Resident #1 had appealed the discharge, but he was not permitted to return while the appeal was pending because the facility felt like there was not a physician available to oversee his care during the appeal period. He was unsure if Resident #1 had been given an opportunity to select a different physician prior to the refusal to readmit. He said the facility requested a discharge summary from MD B at the end of October, but the document had not been returned. In an interview with MD B's office on 11/21/2025 at 2:16 PM, MD B's medical assistant stated MD B was the physician overseeing Resident #1's care at the facility effective 9/4/2025. She said the last communication made by the facility to MD B's office was on 10/16/2025 to the after hours on-call service regarding a change in condition. She said MD B had not been notified by the facility that Resident #1 had been discharged from the facility.Record review of the facility policy titled Physician Responsibility: Documentation, Coverage and Rounding dated 2025 (no month) reflected the following:The Community is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675947 If continuation sheet Page 2 of 5 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 675947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Care Manor 2736 Farm to Market 775 LA Vernia, TX 78121 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 0555 Level of Harm - Minimal harm or potential for actual harm committed to ensuring that each resident is under the care of a licensed physician who assumes responsibility for medical care while the resident/patient resides in the community. In cases where a resident's primary care physician does not round, does not hold privileges, or refuses to provide direct oversight or 24 hour on-call, the community will assign or offer access to an attending physician approved and/or credentialed privileges at the community to ensure continuity of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675947 If continuation sheet Page 3 of 5 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 675947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Care Manor 2736 Farm to Market 775 LA Vernia, TX 78121 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for 1 of 3 residents (Resident #1) reviewed for discharge rights. The facility failed to allow Resident #1 to return to the facility after hospitalization on 10/17/2025. This failure could lead to psychosocial harm and decreased quality of life. Findings included:Record review of Resident #1's face sheet dated 11/20/2025 reflected an [AGE] year-old-male admitted to the facility on [DATE] and discharged on 10/16/2025 to an acute care hospital. Relevant diagnoses included malignant neoplasm (cancer) of left bronchus or lung. Record review of Resident #1's quarterly MDS reflected a BIMS score of 13, which indicated intact cognition. Record review of Resident #1's EMR did not reveal a discharge summary signed by the resident's physician. Record review of Resident #1's physician orders active as of 10/16, 2025, the date of discharge, did not reveal and order to discharge Resident #1. Record review of Resident #1's hospital records dated 10/19/2025 revealed the following:In fact patient was feeling much better was ready to go home and clinically stable we placed the discharge orders andeven did the discharge summary. Later on I was notified by the nursing that doctors at the facility where the patient isresiding are not willing to accept him due to some dispute with the patient's [family member].As such patient will stay in the hospital until this is figured out. Will place a consultation with case management [sic]Record review of an e-mail dated 10/20/2025 from the Admin. to the facility's ombudsman indicated the facility would not allow Resident #1 to return to the facility after discharge from the acute care hospital due to concerns about his chosen facility. The Admin. said the resident's chosen physician was not responsive to the urgent messages communicated by the facility regarding Resident #1, and thus the facility felt the physician could not meet the needs of Resident #1. Therefore, they would not readmit Resident #1. Record review of an e-mail dated 10/21/2025 from the ombudsman to the facility reflected information from the TAC 554.1204 and 554.1201 sent to the facility advising them that it was the facility's responsibility to provide physician services 24-hours a day in the event of an emergency, as well as the responsibility to have a back-up physician available in the event that the primary physician was unavailable. The ombudsman asked in the e-mail if this clarifying information would be sufficient to allow readmission of Resident #1, but no response message was included in the file. Record review of Resident #1's hospital discharge records dated 10/24/2025 revealed Resident #1 was discharged from the acute care hospital on [DATE] to a skilled nursing facility. In an interview with Resident #1's family member on 11/20/2025 at 12:08 PM, she said she acted as Resident #1's POA and coordinated his medical care. She said she was not notified by the facility during Resident #1's hospitalization beginning on 10/17/2025, that Resident #1 would not be readmitted to the facility. She said she was not contacted by the Admin. at any time during the hospitalization, and she was notified by the hospital's case manager that the facility was refusing readmission. She said she did not receive any documentation, including e-mails or letters, notifying her of Resident #1's discharge. She said Resident #1 had not severed the patient-doctor relationship with MD B at the facility, and he intended to resume care from MD B upon return to the facility. She said Resident #1 remained under the care of MD B as of the date of the interview. She said she notified the ombudsman that they wanted to appeal the discharge, but Resident #1 was still refused readmission. Due to the unexpected difficulty with finding new placement, Resident #1's family member said the discharge from the acute care hospital was delayed, and Resident #1 experienced anxiety and sadness about remaining in the hospital without a place to discharge. In an interview with the ombudsman on 11/20/2025 at 2:50 PM, he said that when he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675947 If continuation sheet Page 4 of 5 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 675947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Care Manor 2736 Farm to Market 775 LA Vernia, TX 78121 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete became aware of the refusal of the facility to readmit Resident #1 during the hospitalization beginning on 10/17/2025, he notified the Admin. that Resident #1 had a right to return to the facility, and that the actions of the facility constituted dumping. He said the Admin. told him that the facility Resident #1 did not have a physician overseeing his care properly, so he could not return. He said he also told the facility that Resident #1 should be issued a notice of discharge, but the facility refused. He notified the facility that Resident #1 was formally appealing the discharge, but the facility informed him that Resident #1 could not return despite the appeal. He felt the facility was refusing to readmit Resident #1 due to conflicts with Resident #1's family member, not the issue regarding Resident #1's physician. In an interview with the Admin. on 11/20/2025 at 2:35 PM, he stated Resident #1 was initially terminated as a patient by the facility's MD, MD A, in August 2025, and the facility's second physician was not accepting new patients. Resident #1 then selected his outpatient physician, MD B, to be his physician at the facility, but he said MD B did not meet their expectations of responsiveness when the facility staff attempted to contact him after hours. He said that because of the lack of responsiveness from MD B, he felt readmitting Resident #1 under MD B's care would be a disservice. Since MD A had previously terminated Resident #1 and would not be accepted as a patient, he felt Resident #1's needs could not be met at the facility. He said he did not notify Resident #1 or his family member about the discharge by conversation or letter, and he was communicating only with the ombudsman. He said he was aware Resident #1 had appealed the discharge, but he was not permitted to return while the appeal was pending because the facility felt like there was not a physician available to oversee his care during the appeal period. He was unsure if Resident #1 had been given an opportunity to select a different physician prior to the refusal to readmit. He said the facility requested a discharge summary from MD B at the end of October, but the document had not been returned. In an interview with MD B's office on 11/21/2025 at 2:16 PM, MD B's medical assistant stated MD B was the physician overseeing Resident #1's care at the facility. She said the last communication made by the facility to MD B's office was on 10/16/2025 to the after hours on-call service regarding a change in condition. She said MD B had not been notified by the facility that Resident #1 had been discharged from the facility.Record review of the facility policy titled Admission, Transfer, and discharge date d September 2022, revealed the following:The notice of transfer or discharge must be given at least 30 days before the resident is transferred or discharged . The community permits residents to return to the community after they are hospitalized or placed on therapeutic leave . If the community determines that a resident who was transferred with an expectation of returning to the community, the community will comply with the transfer and discharge requirements as they apply . Event ID: Facility ID: 675947 If continuation sheet Page 5 of 5