Health inspection·October 19, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them and ask if they need somewhere to pump and store. She also said that she was aware that there was a risk of certain viral illnesses if resident #46 were to have ingested it, or if any other resident had wandered in and drank it. She stated that some residents were like toddlers and did not know what they were doing. During an interview on [DATE] at 09:45am with administrator, she stated that going forward she would expect her staff to know that storing their breast milk in a resident's personal refrigerator was not acceptable, and they should know that the facility offered staff a room to pump with a storage freezer available. She also said that she had spoken to the director of the agency and that he would be in servicing all the agency staff on this. She said that she was not aware of any risk of illnesses related to the ingestion of breast milk. Record review of quarterly MDS dated [DATE] for Resident #46 revealed a BIMS score of 10, and reveals that resident was independent with locomotion once in chair, and was able to eat and drink independently. Record review of face sheet dated [DATE] for Resident #46 revealed that she was a [AGE] year-old female originally admitted to the facility [DATE] and subsequently readmitted on [DATE] with diagnoses including: personal history of traumatic brain injury, noninfective gastroenteritis and colitis, gastrointestinal hemorrhage, mild cognitive impairment, acute kidney failure, diabetes mellitus, and dementia. Reference article Transmission of Infectious Diseases Through Breast Milk and Breastfeeding states .the concern is about viral pathogens, known to be blood-borne pathogens, which have been identified in breast milk and include but are not limited to hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV), [NAME] Nile virus, human T-cell lymphocytic virus (HTLV), and HIV . Citation: [NAME], RM. Transmission of Infectious Diseases Through Breast Milk and Breastfeeding. Breastfeeding. 2011; 406-473. DOI:10.1016/B978-1-4377-0788-5.10013-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152307/#__ffn_sectitle Found on National Library of Medicine website. According to CDC.gov, . Ebola virus disease is spread through direct contact with blood and other bodily fluids including urine, saliva, sweat, feces, vomit, breast milk, and semen, of a person who is sick with or has died from EVD . and .HIV is a virus that attacks the body's immune system and is spread through certain body fluids, including breast milk . .Breast milk transmission of maternal viral infection is well established for CMV and HIV-1 . Citation: Stiehm ER, [NAME] MA. Breast milk transmission of viral disease. Adv Nutr Res. 2001;10:105-22. doi: 10.1007/978-1-4615-0661-4_5. PMID: 11795036. https://pubmed.ncbi.nlm.nih.gov/11795036/ Record review of facility policy titled Resident Refrigerators dated [DATE], stated .it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators . Record review of facility titled Expressing Breast Milk, undated, states .provide access to a freezer to store expressed milk. (A freezer is located in the employee breakroom) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 2 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 each resident had an environment that was free from accident hazards for 2 of 34 residents (Resident #37 and Resident #49) reviewed for accidents, hazards, and supervision in that: Resident #37 had a personal microwave in her room that was not allowed by the facility. Resident #49 had a personal microwave in her room that was not allowed by the facility. These failures could place residents at risk of injuries and contribute to avoidable accidents. The findings were: 1. Record review of a Face Sheet for Resident #37 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral palsy (a brain disability that causes weakness and problems with using the muscles), acute on chronic diastolic congestive heart failure (heart not able to pump effectively), vitamin d deficiency (not enough vitamin d in the body), type 2 diabetes, and osteoporosis (thin, brittle bones). Record review of a Care Plan for Resident #37 dated 8/15/2022 indicated an ADL functional/rehabilitation potential and she required staff assistance x2 Cna's for ADLs such as transfers, bed mobility, toileting and extensive to total assist with ADL's. An approach for staff to assist with all ADL's due to her being unable to perform independently. Record review of a Quarterly MDS dated [DATE] for Resident #37 indicated she did not have any impairment with thinking and had a BIMS score of 15. Her functional status indicated she required total dependence with bed mobility, dressing, toilet use and personal hygiene. During an observation and interview on 10/17/2022 at 10:34 AM, Resident #37 said she had been at the facility for 4 1/2 years and loved it there. A personal microwave was observed in her room on top of a refrigerator. During an interview on 10/17/2022 at 2:05 PM, the Administrator said the facility does not allow residents to have microwaves in their rooms. During an interview on 10/17/2022 at 3:12 PM, Resident #37 said she has had her microwave since she was admitted to the facility. She said maintenance and the Administrator were aware of it being in her room. She said the staff would use it and warm up foods for her when she wanted. During an observation and interview on 10/18/2022 at 9:18 AM in Resident #37's room the personal microwave was not present, and she said the night nurse removed it last night 10/17/2022 and was told she couldn't have it. 2. Record review of a Face Sheet dated 10/19/2022 for Resident #49 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Type 2 diabetes, COPD (a group of lung diseases), osteoporosis (brittle bones), and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 3 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 Record review of a Care Plan for Resident #49 dated 8/16/2022 indicated an ADL functional/rehabilitation potential of staff assistance x2 Cna's for ADLs such as transfers. Record review of a Quarterly MDS dated [DATE] for Resident #49 indicated no impairment in thinking with a BIMS score of 15. She was totally dependent with bed mobility, transfers, dressing, and toilet use with 2-person physical assist. She required supervision with eating and set up help only. During an interview and observation on 10/17/2022 at 10:48 AM, Resident #49 said she had been at the facility for 10 years and a personal microwave was observed in her room. During an interview on 10/18/2022 at 2:30 PM, Resident #49 said her microwave was removed from her room last night 10/17/2022 by the night nurse. She said the nurse told her that state said she could not have the microwave in her room. She said she has had the microwave since she was admitted to the facility 10 years ago. During an interview on 10/18/2022 at 4:10 PM, the Administrator said she didn't know Resident #37 and Resident # 49 had microwaves in their rooms. She said she had been employed at the facility for 2 1/2 years and shortly after she started work at the facility, majority of the residents had personal microwaves and she had them all removed. She said the facility did not have anyone checking the resident's room routinely such as ambassador rounds. She said the microwaves were a potential for a fire hazard or burns and that's why she got rid of them shortly after her employment started. She said facility staff removed the microwave from Resident #31's room yesterday 10/17/2022. Record review of a facility policy titled Microwave Oven Policy with a revised date of 7/22/2021 indicated, .It is the policy of .not to permit personal microwaves in resident's rooms. Microwave related incidents have the potential to cause injury, fires, burns and even death . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 4 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 3 of 4 CNAs (CNA E, CNA H and CNA I) observed for incontinent care. CNA E did not provide proper incontinent care for Resident #50 and wiped from the anal area toward the urethral area (back to front). CNA H and CNA I did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #31. This failure could place residents at risk for bacterial infections from improper incontinent care. Findings include: 1. Record review of the face sheet dated 10/19/22 indicated that Resident #50 was a [AGE] year-old female originally admitted to the facility on [DATE], and subsequently readmitted on [DATE] with diagnoses including: Congestive Heart Failure, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, Chronic obstructive pulmonary disease, Repeated falls, osteoarthritis, unspecified site, Alzheimer's disease, and hypertension. Record review of the quarterly MDS dated [DATE] indicated that Resident #50 had a BIMS score of 9, which indicated moderate cognitive impairment. She was totally dependent for bed mobility and toileting and required extensive assist with personal hygiene. She was always incontinent of bowel and bladder. During an observation of incontinent care on 10/19/22 at 09:54 AM, CNA E and CNA F were performing incontinent care on Resident #50. CNA E wiped Resident #50 from the anal area towards the urethral area (back to front) when performing care to perineal area. CNA E and CNA F were performing incontinent care due to urinary incontinence. During an interview with CNA E on 10/19/22 at 10:42 AM, she said she had been employed at the facility for 4 years. She stated that she must have been nervous being watched while performing care, but that she knew to wipe from front to back. She said that this could cause residents to develop an infection. During an interview on 10/19/2022 at 10:23 AM, the DON said the staff were in-serviced annually and prn on incontinent care. She said a resident could be at risk for infections if staff wiped back to front. 2. Record review of a Face Sheet dated 10/19/2022 for Resident #31 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included cerebral palsy (a brain disability that causes weakness and problems with using the muscles), aphasia (not able to understand or speak), gastroparesis (delayed stomach emptying), epilepsy (seizure disorder), profound intellectual disabilities (severe learning disability), GERD (gastroesophageal reflux disorder) and gastrostomy status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 5 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 0690 (feeding tube in the stomach). Level of Harm - Minimal harm or potential for actual harm Record review of a Care Plan dated 8/9/2022 for Resident #31 indicated he had urinary incontinence with an approach to provide incontinence care after each incontinent episode. Residents Affected - Few Record review of a Quarterly MDS dated [DATE] for Resident #31 indicated he was rarely/never understood. He required total dependence with two-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. He was always incontinent of bowel and bladder. During an observation on 10/18/2022 at 10:40 AM Resident # 31 's room revealed, CNA H and CNA I were present to provide incontinent care. Both CNA's washed their hands in the bathroom in Resident #31's room and applied gloves. CNA H and CNA I positioned Resident #31 in bed and pulled down his brief. CNA H removed a wipe from a container and cleaned his penis in a circulation motion. CNA H placed the wipe in the trash along with her gloves and applied gloves to her hands without washing or sanitizing them. CNA H removed another wipe and wiped his perineal area on his right side from top to bottom. CNA I used a wipe and wiped his perineal area on his left side from top to bottom. CNA H and CNA I both placed their wipes and gloves in the trash and, applied gloves to both hands without washing or sanitizing their hands. Resident #31 was rolled to his left side by CNA I and CNA H, CNA H took a wipe from the container and wiped his buttocks from front to back using a total of 4 wipes. CNA H placed the wipes in the trash along with her gloves. CNA H applied gloves to her hands without washing or sanitizing them and placed a pad and brief underneath Resident #31's buttocks. Resident #31 was rolled to his right side by CNA I and the soiled brief and under-pad was removed and placed in the trash bag and the new padding and brief were put in place. CNA H and CNA I rolled Resident #31 onto his back, brief was pulled up and secured. Both CNA H and CNA removed their gloves and placed them in the trash. Resident #31 was repositioned in bed with head elevated. Both CNA H and CNA I washed their hands in the bathroom. During an interview on 10/18/2022 at 10:50 AM, CNA H and CNA I both said they were agency staff who worked in the facility as needed. When they were asked if they would have done anything differently with the incontinent care provided to Resident #31, both said they should have washed or sanitized their hands with each glove change. Both said they had received in-service training at the facility on infection control, hand washing and hygiene. Both said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 10/19/2022 at 10:23 AM, the DON said facility staff should change gloves at least one time during incontinent care when going from clean to dirty. She said staff could sanitize their hands between glove changes instead of washing their hands. She said the staff were in-serviced annually and prn on infection control. She said whatever staffing agency the facility used was responsible for skills checkoffs and they relied on the agency staffing to provide the training. She said if there was a problem with agency staffing staff then the staff would be in-serviced at the facility on whatever topics. She said a resident could be at risk for infections if staff did not wash or sanitize their hands between gloves changes. Record review of facility procedure guide titled Incontinent care for the female resident, undated, stated .Thoroughly cleanse perineal area - wiping front to back - using a clean area of the washcloth for each stroke . Record review of the facility's policy titled Infection Prevention and Control Program dated 1/25/21 stated .This facility has established and maintains an infection prevention and control program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 6 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Record review of a facility policy undated on Hand Hygiene indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Event ID: Facility ID: 676025 If continuation sheet Page 7 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 18 residents (Resident #66) observed for respiratory care and services in that: Residents Affected - Few Resident #66 was oxygen dependent with oxygen in place and nasal cannula tubing was dated 09/09/2022. This failure could place residents who receive respiratory care and services at risk of developing respiratory infections and complications. The Findings were: Record review of the face sheet dated 10/18/2022 indicated Resident # 66 was admitted on [DATE] with diagnoses of amputation requiring after care, infection of surgical area, and chronic obstructive pulmonary disease (lung disease). Record review of the physician order dated 3/27/2022 for Resident #66 indicated oxygen per nasal cannula 2 to 4 liters per min continuously. Record review of an MDS dated [DATE] revealed a of BIMS of 11 indicating moderately impaired cognition, and Resident #66 used oxygen daily. Record review of the Comprehensive care plan dated 10/17/2022 indicated Resident #66 required oxygen therapy. During an observation and interview on 10/17/22 at 1:00 pm, Resident #66 was up in her wheelchair with oxygen per nasal cannula in place. The nasal cannula tubing was dated 9/9/2022. When asked, Resident #66 stated she wore her oxygen at all times. During an observation and interview on 10/17/2022 at 1:05 pm, LVN A stated the tubing should have been changed. LVN A removed the outdated nasal cannula and applied new oxygen cannula for Resident #66. LVN A stated oxygen tubing should be changed weekly because of risk for infection. During an interview on 10/18/22 at 1:34 PM, LVN B stated that oxygen tubing was to be changed every Sunday evening on night shift. The medication record will show that it has been done and the tubing was dated to reflect the date it was changed. LVN B stated she received training regarding the oxygen policy. LVN B stated the risk could be infection if it was not changed. LVN B also stated Resident # 66 does wear her oxygen daily at all times. During an interview on 10/18/22 at 1:42 PM, LVN C stated oxygen tubing should be changed weekly, usually on Sundays and as needed. The tubing was then dated so they know if has been done. LVN C stated she tried to check her residents when she was working to make sure oxygen tubing has been changed. LVN C stated if tubing has not been changed, she will change it herself. LVN C stated she was knowledgeable on oxygen use and care from working in the nursing home. LVN C stated she was an agency nurse and has worked at the facility almost one year. LVN C stated the risk could be infection, and improper dispensing of oxygen due to wear and tear of the tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 8 of 9 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 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/18/22 at 1:47 PM, LVN D stated she was an agency nurse and worked at the facility since March 2022. LVN D stated she was knowledgeable on changing out oxygen tubing and tubing should be changed weekly and as needed. LVN D stated at this facility it was usually on Sunday night. LVN D stated she has not worked night shift. LVN D stated she looks at her resident's oxygen tanks to make sure the tubing has been changed. LVN D stated the risk could be infection and oxygen may not deliver at the correct flow. During an interview on 10/18/22 at 1:53 PM, the DON stated oxygen tubing was changed once a week and prn. The charge nurses on night shift were responsible for changing out the tubing and all nurses are responsible for overseeing that oxygen tubing is within date. The DON stated the nurse then signs off on the MAR that it has been done. The DON stated she was responsible for monitoring. The DON stated the risk to the resident could be infection control. The DON stated she would retrain the staff on the policy and make sure that all oxygen tubing was changed weekly and as needed. During an interview on 10/18/22 at 1:56 PM, the ADMIN stated she will do more training with nursing staff and will make sure to check behind to see that all tubing was changed per their policy and procedure. Record review of undated policy titled Oxygen administration indicated .Section 5 other infection control measures include, change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 9 of 9