Health inspection·May 21, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/21/24 at 9:05 a.m., MDS nurse B said she had been educated on completion of MDSs. She said she was responsible for Resident #24 MDS's. MDS nurse B said Resident #24 used oxygen daily and it should have been documented on the MDS but was not. She said it was overlooked. She said they did not have a backup to double check MDS's for accuracy. MDS nurse B said the risk of oxygen not documented on the MDS was not a risk to the resident, but it may affect revenue for the facility. Residents Affected - Few During an interview on 05/21/24 at 1:20 p.m., the DON said the MDS nurses were responsible for all MDS in the facility. She said the MDS nurses had been educated on completing MDS and were certified. The DON said Resident #24's oxygen not documented on the MDS was overlooked. She said the facility has a scrubber system that reviewed information for discrepancies in MDS from one MDS to the next. The DON said the risk of not having accurate MDS was a financial risk. She said oxygen therapy received and not documented on the MDS was a risk of inaccuracy and an incorrect explanation of why new residents were on long term care. The DON said her expectation was all MDS reflect the patients' needs and conditions. During an interview on 05/21/24 at 1:54 p.m., the Administrator said MDS nurse B and C were responsible for MDS's in the facility. He said the risk of not documenting oxygen therapy was a financial risk a RUG (Resource Utilization Group System- shows the type and quality of care) may go down. The Administrator said his expectation was the MDS nurses capture everything the facility did for the resident. Record review of a facility policy, implemented 01/06/22, titled, Resident Assessment- RAI, indicated, . This facility makes a comprehensive assessment of each resident's needs, strengths, goals life history and preferences using the resident assessment instrument (RAI) specified by CMS. 2. The assessment will include at least the following: . o. Special treatments, and procedures. Record review of the, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated, October 2023, indicated, . Section O: Special treatments, procedures, and programs Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or perform during the specified time periods. Health-related Quality of Life - The treatments, procedures, and programs listed in Item O01I0. Special Treatments, Procedures, and Programs can have a profound effect on an individual's health status, self-image, dignity, and quality of life. O0110C1, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. This item may be coded if the resident places or removes their own oxygen mask, cannula. O0110C2, Continuous Check if oxygen therapy was continuously delivered for 14 hours or greater per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 2 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the acting Dietary Supervisor indicated no documentation that she had completed the certified Dietary Manager course. During an interview on 05/19/24 at 8:45 a.m., the Dietary Supervisor said she had not completed or started the dietary manager classes. She said she was working as dietary supervisor until the facility could hire a certified dietary manager. During an interview on 05/20/24 at 10:45 a.m., the HR staff said the Dietary Supervisor was not a certified dietary manager and had assumed the position on 04/20/24. She said the facility had tried to hire a certified dietary manager or hire staff and have them become a certified dietary manager since April 2024. During an interview on 05/21/24 at 2:44 p.m., the Administrator said his expectation was for the DM to be certified to oversee the dietary services. He said the facility had been actively seeking to hire a certified DM. Record review of a facility policy titled Dietary Manager and dated 01/01/24 indicated .The facility will employ a full-time dietary manager .Minimum requirements include certification as a dietary manager FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 3 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen reviewed for dietary services. Residents Affected - Many The facility failed to ensure food items were properly labeled with product and expiration date in the refrigerators. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the dietary supervisor on 05/19/2024 at 8:45 a.m. indicated the following: Refrigerator #1 contained *½ browning avocado in a gallon size bag with not labeled or dated. Refrigerator #2 contained *2 single serve sippy cups containing a white colored substance not labeled or dated; *1 single serve covered container with orange slices that was not labeled or dated; *a piece of ham (approximately 4 inches by 3-inches) covered with foil wrap and was not labeled or dated; and *a disposable Styrofoam serving dish containing sliced cucumbers not labeled or dated. The acting dietary supervisor said the sippy cups contained nectar thickened liquids made today but she forgot to label and date them. She said she thought the cucumbers were from yesterday, but she was not sure and threw them away. She said she was unsure when the orange slices were placed in the refrigerator, and she threw them away. ham should have been labeled and dated. The dietary supervisor said all dietary staff were to label and date items, so old food would not be served to residents. During an interview on 05/21/24 at 2:44 p.m., the Administrator said he was the direct supervisor of all dietary staff until a new dietary manager could be hired. He said he expected for all foods in the kitchen to be stored properly including labeling and dating. He said food not being labeled and dated could result in expired foods being served to residents. Record review of a facility policy titled Food Storage dated 2005 indicated . Refrigerated foods should be covered, labeled, and dated. Record review of the 2022 Food Code dated 01/18/23 indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 4 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 5 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW). The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings included: During an interview on 05/19/24 at 10:45 a.m., the Administrator said the facility did not currently did not have a SW. He said the SW quit about a month ago. He said they were actively looking for one. Record review of a Social Services Policy dated 01/01/24 indicated Policy: The facility will employ a full/part time Social Worker Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 6 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 ensure individuals providing services under a contractual arrangement had trainings consistent with their expected roles and failed to keep records of these trainings for 4 of 4 contracted staff. (Dietician, PT, OT, and ST). Residents Affected - Some The facility failed to ensure required trainings were provided for the dietician working in the dietary department at the facility under a contractual agreement. The facility failed to ensure required trainings were provided for PT, OT, and ST working in the therapy department at the facility under a contractual agreement. This failure could place residents at risk of being cared for by contracted staff who have been insufficiently trained to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. Findings included: During an interview on 05/20/24 at 03:30 p.m. the HR said she did not know if there were files for the dietician and therapy staff. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she did not think the facility provided trainings for the contracted staff. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the ADON indicated the facility did not provide training for the contracted staff. She indicated she did not have any trainings for the contracted staff. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 7 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 11 of 17 employees (Administrator, Assistant Administrator, LVN F, RN G, AD, MD, HS, CNA K, CNA L, CNA M, and CNA N) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, RN G, CNA L, CNA M, and CNA N during orientation. The facility did not ensure effective communication training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed effective communications training during orientation: * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA L, hire date 09/07/23; * CNA M, hire date 01/24/24; and * CNA N, hire date08/14/23. Record review of employee files indicated the following staff had not completed effective communications training annually: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * AD, hire date 10/06/97 * MD, hire date 07/01/04; * HS, hire date 02/05/14; and * CNA K, hire date 10/25/21. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 8 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not triggered the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 9 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 5 of 17 employees (DON, LVN D, LVN F, CNA K, and CNA N) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN F and CNA N during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by DON, LVN D, and CNA K annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training during orientation: * LVN F, hire date 08/07/23; and * CNA N, hire date 08/14/23. Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training annually: * DON, hire date 01/19/15; * LVN D, hire date 02/08/22; and * CNA K, hire date 10/25/21. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 10 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0942 Level of Harm - Minimal harm or potential for actual harm Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 11 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 11 (DON, LVN F) and dementia management for 1 of 11 employees (LVN F) reviewed for training. The facility did not ensure ANE and dementia management training was completed by the LVN F during orientation. The facility did not ensure ANE training was completed by the DON annually. The facility did not ensure ANE training was completed by the HS annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of the employee files indicated: * LVN F, hire date 08/07/23, had not completed ANE and dementia management training during orientation; and * DON, hire date 001/19/15, last completed ANE training on 01/31/23. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 12 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated QAPI training was not done for the following staff: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire date 05/03/12; * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA H, hire date 11/29/17; * CNA J, hire date 09/17/13; * CNA K, hire date 10/25/21; * CNA L, hire date 09/07/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 13 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0944 * CNA M, hire date 01/24/24; and Level of Harm - Minimal harm or potential for actual harm * CNA N, hire date 08/14/23. Residents Affected - Many During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 14 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 2 of 17 staff (LVN F and MD) reviewed for training. The facility did not ensure infection prevention and control training was completed by LVN F during orientation. The facility did not ensure infection prevention and control training was completed by the MD annually. These failures could place residents at risk of illness due to lack of staff training. Findings included: Record review of employee files indicated: * LVN F, hire date 08/07/23, had not completed infection prevention and control training during orientation; and * MD, hire date 07/01/04, had not completed infection prevention and control training annually. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 15 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. Residents Affected - Many The facility did not ensure compliance and ethics training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire date 05/03/12; * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA H, hire date 11/29/17; * CNA J, hire date 09/17/13; * CNA K, hire date 10/25/21; * CNA L, hire date 09/07/23, * CNA M, hire date 01/24/24; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 16 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0946 * CNA N, hire date 08/14/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. Residents Affected - Many During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 17 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 2 of 6 CNAs (CNA K and CNA N) reviewed for training. The facility did not ensure ANE and dementia management trainings were completed by CNA N during orientation. The facility did not ensure ANE and dementia management trainings were completed by CNA K annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated CNA N, hire date 12/07/23, had not completed ANE and dementia management trainings during orientation. Record review of employee files indicated CNA K, hire date 10/25/21, hot not completed ANE and dementia management annual trainings. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 18 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to ensure training on behavioral health was completed for 11 of 17 employees (Administrator, Assistant Administrator, AD, MD, HS, LVN F, RN G, CNA K, CNA L, CNA M and CNA N) reviewed for training. The facility did not ensure behavioral health training was completed by LVN F, RN G, CNA L, CNA M and CNA N during orientation. The facility did not ensure behavioral health training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not behavioral health training during orientation: * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA L, hire date 09/07/23, * CNA M, hire date 01/24/24; and * CNA N, hire date 08/14/23. Record review of employee files indicated the following staff had not completed behavioral health training annually: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; and * CNA K, hire date 10/25/21. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 19 of 20 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 676011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676011 If continuation sheet Page 20 of 20