Health inspection·January 31, 2024

F 0550 they did not have a cover on it. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/31/2024 at 11:09 AM, the DON and Administrator said nursing staff were responsible for making sure the foley catheter bags were covered at all times. She said she was made aware of Resident #58 being out of her room without a privacy cover over her foley drainage bag. She said Resident #58 was able to transfer herself and would take the privacy cover off at times. She said if she had a foley catheter she would not want anyone to see the drainage bag being uncovered with urine in it. She said going forward, the residents would be educated along with staff to ensure catheter bags would have privacy covers. The Administrator said when residents were out of their rooms and had a foley catheter, they should have a privacy bag. Residents Affected - Few Record review of a facility policy-undated titled Urinary Catheter Policy indicated, .The purpose of this policy is to prevent catheter-associated urinary tract infections. Nursing is to ensure; privacy bag shall always be in place unless care is being provided. Nursing staff shall remind/educate residents who are able to provide self-care that privacy bag should be in place. Nursing staff shall assist with the task as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 2 of 24 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 01/31/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable and homelike environment for 2 of 17 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for homelike environment. The facility failed to ensure the walls in rooms [ROOM NUMBERS] were free from holes. The facility failed to ensure the walls in room [ROOM NUMBER] were kept clean. These failures could place residents at risk for diminished quality of life due to the lack of a well- kept and clean environment. Findings: During initial rounds and observations on 01/29/24 at 9:40 am revealed room [ROOM NUMBER] had a hole in the sheet rock measuring approximately one foot by one foot on the wall next Resident #3's bed and had splatters of a thick brown and tan substance on the same wall. Resident #3 did not have anything to say about the wall. During initial rounds and observations on 01/29/24 at 10:52 am revealed room [ROOM NUMBER] had a hole in the sheetrock behind the head of Resident #24's bed near the floor measuring approximately two feet by one foot . Resident #24 did not have anything to say about the hole in the wall. During an interview on 1/29/2024 at 11:02 am LVN D stated that if there was an issue with something being broken or holes in the wall it should be reported to maintenance or put in the maintenance logbook. She stated she worked as an agency nurse and was not aware of the issues in rooms [ROOM NUMBERS]. She stated that if rooms were not cleaned it could cause infections and holes could be a danger to residents. During an interview on 1/30/2024 at 8:11 am the Maintenance Director stated anytime there was a hole in the wall the staff would either tell him directly or place in the maintenance logbook . He stated he was not aware of the holes in the sheetrock in rooms [ROOM NUMBERS] but he would address the issue and begin the repair. He stated he did not see a risk to the residents for the damaged walls, but it was not pretty to have holes in the walls. During an interview on 1/30/2024 at 8:28 am HSK H stated she had been in housekeeping for 6 months. She stated that every room should be deep cleaned at least two times a week and that included cleaning the walls in the room. She stated she cleaned the rooms on the 100 hall and had not noticed room [ROOM NUMBER]'s wall being that dirty. She stated she had not cleaned the walls in room [ROOM NUMBER] in many weeks. She stated if walls were left dirty it could cause the resident to get sick or be embarrassed that they were dirty. During an interview on 1/30/2024 at 8:35 am the Housekeeping Supervisor stated he had been the supervisor for 7 years. He stated he expected the housekeepers to clean the entire room including the walls at least weekly and more often if needed when soiled or dirty. He stated if rooms were not kept clean it could cause infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 3 of 24 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 01/31/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/31/24 at 1:41 pm the Administrator stated that the maintenance and housekeeping supervisors were responsible for the physical environment of the facility, but it was all staffs responsibility to report issues when they were found. She stated she expected the facility process to be followed for keeping the building in good repair and clean. Record review of an undated facility guideline titled Physical Environment indicated, .ensure the community environment is safe, functional, sanitary, and comfortable for residents . Record review of an undated facility document titled Notification of Maintenance regarding new issues or concerns indicated, .as part of the ongoing preventative maintenance program this facility shall keep a log/book with any equipment or room concerns regarding repairs. Any issues are followed up by the maintenance or designee and documented . Record review of a facility policy titled Cleaning and Disinfecting Resident's Rooms dated 1/2024 indicated, .walls, blinds, and window curtains in resident areas will be cleaned when surfaces are visibly contaminated or soiled. Example: deep cleaning every 2 weeks . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 4 of 24 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 01/31/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 6 residents (Resident #62) reviewed for MDS assessment accuracy. Residents Affected - Few The facility did not accurately document Resident #62's oxygen therapy on the quarterly MDS dated [DATE]. This failure could place residents at risk of not receiving care and services to meet their needs. Findings: Record review of a facility face sheet indicated Resident #62 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. During an observation and interview on 1/29/24 at 9:55 am Resident #62 had an oxygen concentrator next to her bed. She stated she used the oxygen every night when she was sleeping. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #62 had a BIMS of 09 indicating moderate cognitive impairment. MDS assessment did no capture oxygen therapy. Record review of comprehensive care plan dated of 11/10/2023 did not indicate Resident #62 required oxygen therapy. Record review of a consolidated physician's order list indicated no orders for oxygen therapy or changing and cleaning respiratory equipment and supplies. During an interview on 1/29/24 at 3:45 pm the MDS coordinator stated she had been completing MDS assessments and care plans for 22 years. She stated she was responsible for completing comprehensive assessments through the MDS assessment and care plans. She stated if a resident was receiving oxygen therapy there should have been an order, the use would have been captured on the MDS and the care plan would reflect need for oxygen with interventions and goals. She stated if the resident's orders were not accurate, she would not have known to mark oxygen use on the MDS and updated the care plan. Stated when she visits with the resident, she picked up in resident care needs like oxygen use. She stated she was not aware Resident #62 used oxygen at night. She stated if the MDS assessment and care plan was not accurate the resident needs would not be reflected, and delay of care could occur. During an interview on 1/29/24 at 3:48 pm the DON stated the MDS nurse was responsible completing an accurate comprehensive assessment on each resident. She stated if the orders were not accurate the MDS assessment and care plan would not be accurate and could affect resident care. The DON stated there was no policy for MDS accuracy and they followed the RAI manual. She stated she expected all residents care needs were accurately reported in the MDS assessment and the care plan to reflect resident care needs. During an interview on 01/31/24 at 1:41 pm the Administrator stated the MDS coordinator was responsible for the accuracy of the comprehensive assessment of each resident and the IDT was responsible for reviewing the assessment before transmission. She stated she expected assessment data to be accurate and reflect all care needs of the resident to prevent resident care issues. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 5 of 24 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 01/31/2024 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 0641 stated there was not a policy for MDS accuracy and the facility followed the RAI manual. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 6 of 24 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 01/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 18 residents (Residents #3, #7, #58 and #65) reviewed for care plans. The facility failed to care plan the use of oxygen therapy for Resident #3. The facility failed care plan the use of oxygen therapy for Resident #7. The facility failed to care plan the use of oxygen therapy for Resident #58. The facility failed to care plan the use of oxygen therapy for Resident #65. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a facility face sheet indicated Resident #3 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #3 had a BIMS of 05 indicating severe cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 8/29/2023 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing) but no intervention for oxygen therapy. Record review of a consolidated physician's order list for Resident #3 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. There was no order for oxygen therapy. During an observation and interview on 01/29/24 at 10:12 am revealed Resident # 3 had oxygen on at t 2 liters via nasal cannula. Resident #3 stated she wore her oxygen all the time and had for a long time. During an observation on 1/30/2024 at 8:06 am revealed Resident # 3 had oxygen on in place [NAME] nasal cannula. 2. Record review of an admission Record for Resident #7 dated 1/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Iron deficiency anemia (body does not produce enough iron to produce oxygen in the blood), chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart), hypertensive heart disease with heart failure (high blood pressure in the heart) and age related osteoporosis (brittle, bone disease). Record review of a Modification of admission MDS dated [DATE] for Resident #7 indicated she had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 7 of 24 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 01/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm BIMS score of 6. She had special treatments, procedures and programs that included oxygen therapy while a resident. Record review of a physician order summary report dated 1/30/2024 for Resident #7 indicated she had an order for oxygen on 2 Liters per nasal cannula continuous with a start date of 11/17/2023. Residents Affected - Some Record review of a care plan dated 1/30/2024 for Resident #7 indicated she had oxygen therapy related to ineffective gas exchange with interventions of oxygen setting O2 via nasal cannula that was added on 1/30/2024. During an observation and interview on 1/29/2024 at 9:45 AM, revealed Resident #7 was up in a wheelchair and said she was going to therapy. She had on portable oxygen that was at the back of her wheelchair. During an observation and interview on 1/30/2024 at 9:10 AM, revealed Resident #7 was sitting up in a wheelchair in her room and using portable oxygen. She said when she was in the room, in bed, she used the concentrator and was on oxygen all the time. 3. Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), Asthma (narrowed airways that make it difficult to breathe), type 2 diabetes, and COPD (a group of lung diseases that make it difficult to breathe). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for Resident #58 indicated she had a BIMS score of 14. The MDS reflected for Special treatments, procedures and programs indicated on admission and while a resident she received oxygen therapy. Record review of a care plan dated 1/30/2024 for Resident #58 indicated she had oxygen therapy related to ineffective gas exchange with diagnoses of COPD with interventions for oxygen settings O2 via nasal cannula that was added on 1/30/2024. Record review of active physician's orders for Resident #58 dated 1/29/2024 indicated an order to change and date oxygen tubing/humidifier bottle and clean concentrator filter. Clean outside of concentrator weekly and prn with disinfectant every night shift Sunday with a start date of 9/10/2023. During an observation and interview on 1/29/2024 at 10:17 am, revealed in the room of Resident #58 who was in bed and awake was on oxygen at 2.5 Liters/min. She said used oxygen all the time. 4. Record review of the facility face sheet indicated Resident #65 admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (the lungs inability to exchange oxygen and carbon dioxide in the blood), morbid obesity and muscle weakness. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #65 was cognitively intact with a BIMS of 14. The assessment, section O indicated the resident received oxygen. Record review of a care plan updated 2/11/23 through current date indicated Resident #65 had no interventions for oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 8 of 24 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 01/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of active physician orders for Resident #65 did not indicate an order for administration of oxygen During an observation on 01/29/24 at 10:45 a.m., revealed Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 2.5 L/min portable concentrator was in use. Residents Affected - Some During an interview on 01/29/24 3:27 PM LVN D stated she worked at the facility as needed through an agency staffing company. She stated the care plan was updated by the MDS nurse and oxygen should be on the care plan. She stated if care plans were not accurate it could affect resident care and coordination of services. During an interview on 1/29/24 at 3:34 pm LVN F stated she had been an LVN for 24 years. She stated the care plan was entered and updated by the MDS nurse. She stated if the care plan was not accurate it could cause care delivery issues. During an interview on 1/29/24 at 3:45 pm the MDS coordinator stated she had been completing MDS' and care plans for 22 years. She stated she was responsible for completing and revising the residents' care plans. She stated if a resident was receiving oxygen therapy the care plan should reflect the need for oxygen with interventions and goals. She stated if care plans were not accurate the resident needs would not be reflected, and delay of care could occur. During an interview on 1/29/24 at 3:48 pm the DON stated the MDS nurse was responsible for care plan completion and revision. DON stated there was no policy for care plans and they followed the RAI manual for care plan completion. She stated she expected all resident care plan were accurate to reflect resident care needs. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the MDS coordinator was responsible for revising care plans along with the IDT members who had access to the care plans also. She said residents could be at risk of no continuum of care and everyone not being on the same page. Record review of an undated facility policy titled Care Plan Process indicated, .the facility IDT team utilizes the CMS requirements of RAI as policy for reviewing and revising care plans. Residents preferences and goals may change throughout their stay and changes should be reflected in the comprehensive care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 9 of 24 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 01/31/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 10 residents (Resident #8, Resident #16) reviewed for ADL's. Residents Affected - Few The facility failed to ensure Resident #8's and Resident #16's nails were kept clean. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings: 1. Record review of a facility face sheet indicated Resident #8 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS of 00 indicating severe cognitive impairment and was dependent on staff for all ADL care. Record review of a comprehensive care plan dated 2/23/2023 indicated Resident #8 had a self-care ADL deficit and was totally dependent on staff for personal hygiene. During an observation on 01/29/24 at 9:39 AM revealed Resident # 8's fingernails had a black substance under them. During an observation on 1/30/2024 at 7:58 am revealed Resident # 8's fingernails had a black substance under them. She was unable to verbalize who or when they were last cleaned. During an interview on 01/30/24 at 12:03 PM CNA K stated she worked at the facility through an agency staffing company but had been a CNA for 29 years. She stated the CNAs were responsible for checking and cleaning residents' nails and care should be performed daily. She stated she gave Resident #8 a bed bath earlier that day and should have cleaned her nails. She stated if nails were left unclean it could lead to infections. 2. Record review of a facility face sheet indicated Resident #16 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS of 06 indicating severe cognitive impairment and was dependent on staff for personal hygiene. Record review of a comprehensive care plan dated 2/15/2023 indicated Resident #8 had a self-care ADL deficit and was dependent on staff for personal hygiene. During an observation and interview on 01/29/24 at 9:40 am revealed Resident # 16's fingernails on both hands had a thick black substance under them. Resident #16 stated the staff were cleaning her fingernails but stopped. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 10 of 24 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 01/31/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 01/29/24 at 4:32 PM revealed Resident #16 was sitting up in bed eating a cracker and the black substance remained under her fingernails. During an observation and interview on 1/30/2024 at 7:55 am revealed Resident #16 was in the bed eating breakfast. Her fingernails on both hands continued to have a dark thick black substance under them. She stated she did not remember the last time they were cleaned or when her shower/bath days were. She stated her nails were nasty and she wanted them cleaned. During an interview 01/30/24 at 11:43 am CNA G stated she had been a CNA at the facility for 11 years. She stated she had provided care to Resident #16 on 1/29/2024 and 1/30/2024 and had given Resident #16 a bath this morning, 1/30/2024. She stated the CNAs were responsible for nail care and nails should be cleaned when the resident received a bath. She stated if a resident's nails were left uncleaned it could cause infections. During an interview on 01/31/24 at 1:39 pm the DON stated the CNAs were responsible for providing personal hygiene and care, but all staff were responsible for recognizing a care need and ensuring resident care was performed. She stated if dependent residents did not receive ADL care it could affect them negatively and she expected all residents to receive all care needed daily. During an interview on 01/31/24 at 1:41 pm the Administrator stated that the nursing staff were responsible for resident personal care and hygiene, but the DON was overall responsible for oversight of the nursing department. She stated if resident personal care was not completed it could affect resident condition and expected all dependent residents to receive all ADL care they needed daily. Record review of an undated facility policy titled Routine Resident Care indicated, .Residents should receive necessary assistance to maintain good grooming and personal hygiene. 3. Nail care should be encouraged as needed and as allowed by the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 11 of 24 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 01/31/2024 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 observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 10 of 13 residents reviewed for respiratory care (Residents #3, #50, #62, #65, #43, #7, #25, #58, #66 and #21). Residents Affected - Some 1.The facility failed to ensure Resident #3's had an order for oxygen, the humidifier and tubing for the oxygen concentrator were dated and the filter was clean and free of dust buildup. 2.The facility failed to ensure Resident #50's oxygen concentrator had an external filter and was free of dust buildup. 3.The facility failed to ensure Resident #62's had an order for oxygen, the oxygen tubing was changed per the facility's policy and the concentrator filter was free of dust buildup. 4.The facility did not obtain orders for Resident #65's oxygen. 5.The facility did not clean the oxygen concentrator filter as ordered for Resident #43. 6. The facility failed to ensure the internal filter of Resident #7's oxygen concentrator was free of dust buildup. 7. The facility failed to ensure Resident #25 had an order for oxygen and the external filter was free of dust buildup. 8. The facility did not obtain an order for Resident #58's oxygen administration and did not ensure the oxygen concentrator was free of dust buildup. 9. The facility did not obtain an order for Resident #66's oxygen administration. 10. The facility did not obtain an order for Resident #21's oxygen administration. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators and exacerbation of respiratory distress. Findings included: 1. Record review of a facility face sheet indicated Resident #3 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #3 had a BIMS of 05 indicating severe cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 8/29/2023 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing) but no intervention for oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 12 of 24 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 01/31/2024 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 - Some Record review of a consolidated physician's order list for Resident #3 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. There was no order for oxygen therapy. During an observation and interview on 01/29/24 at 10:12 am revealed Resident # 3 had oxygen on at 2 liters via nasal cannula. The oxygen concentrator filter had thick buildup of dust. The oxygen tubing and humidified water bottle were not dated. Resident #3 stated she wore her oxygen all the time and had for a long time. She was not sure on who or when her oxygen supplies were changed or when the concentrator was cleaned. During an observation on 1/30/2024 at 8:06 am Resident # 3's oxygen concentrator filter continued to have thick dust buildup and resident had oxygen in place via nasal cannula. 2. Record review of a facility face sheet indicated Resident #50 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis to one side). Record review of a quarterly MDS assessment dated [DATE] indicted Resident #50 had a BIMS of 12 indicating moderate cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 9/15/2023 indicated Resident #50 required oxygen therapy. Record review of a consolidated physician's order list I for Resident #50 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. During an observation and interview on 01/29/24 at 10:41 am revealed Resident #50 had an oxygen concentrator with no external filter. The internal filter had thick layers of dust buildup. Resident #50 stated no one cleaned the oxygen filters and the concentrator had not had an outside filter in some time. He stated he had different concentrators but had the current oxygen concentrator since October 2023. 3. Record review of a facility face sheet indicated Resident #62 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. During an observation and interview on 1/29/24 at 9:55 am revealed Resident # 62 had an oxygen concentrator next to her bed. She stated she used the oxygen every night when she was sleeping. The oxygen tubing was not dated, and she stated she tended to her oxygen and changed the tubing when needed. The internal filter was observed with buildup of a black residue on filter and the resident stated no one had changed or cleaned the filter since her admission in November 2023. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #62 had a BIMS of 09 indicating moderate cognitive impairment. The MDS assessment did not reflect oxygen therapy use. Record review of comprehensive care plan dated of 11/10/2023 did not indicate Resident #62 required oxygen therapy. Record review of a consolidated physician's order list indicated no orders for oxygen therapy or changing and cleaning respiratory equipment and supplies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 13 of 24 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 01/31/2024 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 - Some 4. Record review of the physician orders dated January 2024 indicated Resident #65, admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (the lungs inability to exchange oxygen and carbon dioxide in the blood), morbid obesity and muscle weakness. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #65 was cognitively intact with a BIMS of 14. The assessment, section O indicated the resident received oxygen. Record review of a care plan updated 2/11/23 through current date indicated Resident #65 had no interventions for oxygen therapy. Record review of active physician orders for Resident #65 indicated there was no documentation on the physician orders for administration of oxygen. During observation and interviews on 01/29/23 at 10:45 a.m., revealed Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 2.5 L/min portable concentrator was in use, and the nasal cannula was dated 12/04/23 Resident #38 said she did not know when her tubing was last changed, and she was unable to see the concentrator beside her bed. 5. Record review of the physician orders dated January 2024 indicated Resident #43, admitted [DATE], was [AGE] years old with diagnoses of acute respiratory failure, with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Orders included oxygen at 2 L/min per nasal cannula, an order dated 9/10/23 to change the filter and clean, change and date oxygen tubing/humidifier bottle, clean the concentrator filter and clean the outside of concentrator weekly and PRN with disinfectant, night shift every Sunday. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #43 had a BIMs of 7 out of a total score of 15 indicating the resident had severe cognitive impairment. Record review of care plans for Resident #43 indicated oxygen therapy with interventions. During observation on 01/29/24 at 10:00 a.m., revealed Resident #43 was sleeping in a reclining chair with oxygen infusing at 2 L/min via nasal cannula via a concentrator at bedside. The concentrator filter was built up with a thick grey dust underneath it was black foam. The oxygen tubing and humidifier was dated 1/28/24. 6. Record review of an admission Record for Resident #7 dated 1/30/2024 indicated she was [AGE] years old with diagnosis of Iron deficiency anemia (decreased iron in the blood that carries oxygen), chronic ischemic heart disease (heart weakening caused by reduced blood flow to your heart), hypertensive heart disease with heart failure (high blood pressure in the heart) and age-related osteoporosis (brittle, bone disease). Record review of a Modification of admission MDS dated [DATE] for Resident #7 indicated she had severe impairment in thinking with a BIMS score of 6. She had special treatments, procedures and programs that included oxygen therapy while a resident. Record review of a care plan dated 1/30/2024 for Resident #7 indicated she had oxygen therapy related to ineffective gas exchange with interventions of oxygen setting O2 via nasal cannula. Record review of a physician order summary report dated 1/30/2024 for Resident #7 indicated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 14 of 24 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 01/31/2024 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 an order for O2 on 2L via nasal cannula continuous with a start date of 11/17/2023 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 1/29/2024 at 9:45 AM revealed in the room of Resident #7, the resident was present sitting up in a wheelchair and said she was going to therapy. The oxygen concentrator had internal filters with about an inch of dust noted. Residents Affected - Some During an observation and interview on 1/30/2024 at 9:10 AM revealed in the room of Resident #7, the oxygen concentrator still had a lot of dust inside on the filters. Resident #7 was sitting up in a wheelchair on portable oxygen and said when she was in the room in bed, she used the concentrator and was on oxygen all the time. She said she had never seen any staff clean the filters. 7. Record review of an admission Record dated 1/30/2024 for Resident #25 indicated she admitted to the facility on [DATE] and discharged on 1/23/2024 to the hospital and was [AGE] years old with diagnosis of encephalopathy (disease that affects the brain), type 2 diabetes, hypertensive heart disease with heart failure (high blood pressure in the heart), COPD (group of lung diseases that make it difficult to breathe) and GERD (acid reflux). Record review of a nurse progress noted dated 1/23/2024 by LVN P at 11:15 am for Resident #25 indicated, Resident returned from therapy sob noted. O2 sat at 81%. O2 increase to 3 L per nasal cannula. O2 sat up to 84%. Pulse running between 61 and 64. New order to transfer to ER for eval and treatment. Unable to reach granddaughter message left. EMs notified. Resident transferred to ER via stretcher. Personal belongings left in room. Record review of active physician orders for Resident #25 dated 1/30/2024 indicated she did not have an order for oxygen or as needed use. During an observation on 1/29/2024 at 9:30 AM, revealed Resident #25 still in the hospital and an oxygen concentrator was present with an external filter with a lot of dust buildup. 8. Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic respiratory failure (airways become narrow and damaged), Asthma (airways become inflamed, narrow and swell), type 2 diabetes, and COPD (group of lung disease that make it difficult to breathe). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for Resident #58 indicated she did not have any impairment in thinking with a BIMS score of 14. Special treatments, procedures and programs indicated on admission and while a resident she received oxygen therapy. Record review of active physician orders for Resident #58 dated 1/29/2024 indicated an order to change and date oxygen tubing/humidifier bottle and clean concentrator filter. Clean outside of concentrator weekly and prn with disinfectant every night shift Sunday with a start date of 9/10/2023. There was no order for oxygen administration. Record review of a care plan dated 1/30/2024 for Resident #58 indicated she had oxygen therapy related to ineffective gas exchange with diagnoses of COPD with interventions for oxygen settings O2 via nasal cannula. During an observation and interview on 1/29/2024 at 10:17 am, revealed in the room of Resident #58, the resident was in bed awake with oxygen on at 2.5 Liters/min. The filter was clean, but the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 15 of 24 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 01/31/2024 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 concentrator was dirty with dust buildup. She said the tubing was changed last night and she used oxygen all the time. During an observation on 1/30/2024 at 9:32 AM, in the room of Resident #58 revealed the oxygen concentrator was still dirty with dust buildup. Residents Affected - Some 9. Record review of an admission Record dated 1/30/2024 for Resident #66 indicated he admitted to the facility on [DATE] with diagnoses of unspecified fracture of left leg (broken leg), hypertensive heart disease with heart failure (high blood pressure in the heart), COPD (group of lung disease that make it difficult to breathe), and Type 2 diabetes. Record review of an admission MDS dated [DATE] indicated Resident #66 did not have an impairment in thinking with a BIMS score of 14 and had special treatments, procedures and programs that included oxygen therapy as a resident within the last 14 days. Record review of a care plan for Resident #66 dated 1/18/2024 indicated he had oxygen therapy related to ineffective gas exchange. Record review of active physician orders dated 1/19/2024 indicated Resident #66 did not have order for oxygen administration. During an observation and interview on 1/29/2024 at 9:55 AM revealed in the room of Resident #66, the resident was in bed on oxygen via nasal cannula at 3 L/min. The Resident said he had been at the facility for 2 weeks and was on oxygen all the time. 10. Record review of an admission Record dated 1/31/2024 for Resident #21 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of sarcopenia (loss of muscle tissue as part of the aging process), heart failure and obstructive sleep apnea. Record review of an MDS dated [DATE] for Resident #21 revealed the resident was coded as using oxygen. Record review of a care plan for Resident #21 dated 1/19/2024 indicated oxygen use. The Care Plan initiated on 9/5/2023 included oxygen use. Record review of doctors' orders dated 1/29/2024 indicatedthat Resident #21 did not have an order for oxygen. During an observation and interview on 1/29/2024 at 10:45 AM, revealed Resident #21 said she had been at the facility for 5 years. She said she needed a new oxygen concentrator. She stated that if I the settings on the concentrator were more than 2 liters it would beep She stated that they did not change oxygen tubing regularly because they ran out of tubing. She said she needed a new concentrator, but they did not have enough to replace hers. During an interview on 01/29/2024 at 10:46, LVN D stated she was an agency nurse and worked prn at the facility for 3 years. She stated oxygen tubing was changed by the nurse every Sunday. She stated the outside filter should be cleaned weekly but was unsure who checked and changed the internal filter. She stated if the filters were not kept clean it could lead to infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 16 of 24 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 01/31/2024 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 - Some During an interview on 01/29/2024 3:27 PM, LVN D stated she worked at the facility as needed through an agency staffing company. She stated that a resident that used oxygen should have an order for the oxygen to include the flow rate and frequency of use as well as an order to change tubing and clean filters. She stated if resident orders were not accurate it could affect resident care and coordination of services. During an interview on 1/29/2024 at 3:34 pm, LVN F stated she had been an LVN for 24 years. She stated the nurses were responsible for ensuring the orders were accurate and if a resident required oxygen there should be an order. She stated by not having an order it could affect resident care. She the night nurses were responsible for changing and cleaning the oxygen tubing and filters. She stated she was not aware there was an internal filter but felt that every filter should be checked, cleaned, and changed as needed to prevent infection or oxygen delivery issues. During an interview on 1/29/2024 at 3:42 pm, the DON stated the charge nurses were responsible for changing the oxygen tubing and cleaning the filters weekly. She stated she was not aware of who was to replace the internal filter or how often it should be replaced. She stated by not doing so could cause oxygen delivery issues or infections. She stated there was no policy or procedure for cleaning or replacing the internal filters. During an interview on 1/29/2024 at 3:48 pm, the DON stated the charge nurse was responsible for entering the orders, but she was responsible for checking orders periodically for accuracy. She stated if the orders were not accurate the MDS assessment and care plan would not be accurate and could affect resident care. During an interview on 1/30/2024 at 8:11 am the Maintenance Director stated he was not aware that the oxygen concentrators required the internal filter to be changed. He stated previously the oxygen company maintained the concentrators however in the last year the concentrators became the property of the facility, and he was now responsible for the maintenance and filter changes. He stated there was not a system in place previously but now he had started a log of each concentrator and would be replacing all the filters. During an interview on 1/31/2024 at 11:09 AM, the Administrator said nursing was responsible for cleaning the oxygen concentrators, changing the tubing and bottles every Sunday and as needed. She stated the DON was to oversee that the nursing staff were following the respiratory care policy and expected respiratory equipment to be cleaned and changed weekly. She stated she expected all resident orders to be accurate and reflect resident care needs to prevent adverse event from occurring. She said going forward she would do a follow up plan to ensure the tasks were done on Sundays. She said she would have the DON or designee do an audit to check that they were done. She said residents could be at risk for inadequate air flow if the concentrators were not cleaned and infections. Record review of a facility policy with a revised date of November 2022 titled Oxygen Concentrator and other Respiratory Equipment indicated, .distilled water used in respiratory treatment must be dated and initialed when opened and discarded after 24 hours, change the oxygen cannula and tubing every 7 days, wash filters for oxygen concentrators every 7 days . Record review of an undated facility policy titled Oxygen Administration indicated, a resident will receive oxygen therapy when ordered by a physician FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 17 of 24 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 01/31/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 ( Resident #70) residents reviewed for pharmaceutical services, in that: Resident #70's medications (Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Systane lubricant eye drops and a bottle of ninety soft gel capsules of PreserVision eye supplements) were found on the bedside table with no attached labels for use. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process. Findings included: During a record review physician order summary dated January 2024 for Resident #70 indicated she was [AGE] years old with diagnosis of colostomy and muscle weakness with an admission date of 08/01/13. Resident #70 Physician orders indicated no current orders for preservision eye vitamins, Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Sysytane lubricant eye drops. During a record review of Resident #70's MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 15. During an interview and observation on 01/29/24 at 11:00 AM Resident #70 said she had recently gone to the eye doctor and was given medications for her eyes. Resident #70 said the nurses put her eye drops in, but she keeps them at her bedside. Resident #70 showed this surveyor three vials of unlabeled eye drops, including Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Systane lubricant eye drops and an unlabeled bottle of ninety soft gel capsules of PreserVision eye supplements. During an interview on 01/29/24 at 11:45 AM the DON said that resident #70 could not keep her drops at bedside without an MD order and an assessment for safe medication administration. She said she would remove the eye drops and the interdisciplinary would have to decide if it was appropriate for her to have medications in her room. She said if the resident was unable to safely administer her eye drops it could cause an eye infection or under dosing and overdosing of the vitamins at bedside. Interview with on 01/30/24 RN B she said she removed the medication when the DON made her aware the resident could not have these items at bedside and notified resident #70's daughter that she could not have medications at bedside. RN B said the risk to the resident was inappropriate medication administration due to no labels on the drops and infection due to contamination of the eye drops if they were allowed to stay in the resident's room. During an interview on 1/31/24 at 11:00 AM, CNA A said they she has worked at the facility 24 years and was aware that resident #70 had eye drops and vitamins at bedside, she said resident #70 should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 18 of 24 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 01/31/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not have any medications at bedside and going forward she would tell the nurse or DON if she found medications at bedside. She said the residents might take too many pills or not use the medications correctly. During an interview on 1/31/23 at 2:00 PM the Administrator said that resident #70 could not self-medicate without an assessment and an order from his medical doctor. The administrator said the medication had been removed. She said that the DON and ADON were responsible for ensuring medications were administered according to regulation. The administrator said there was a risk to the resident for infection or incorrect dosages. The administrator said that the staff would be Inserviced for safe administration of medication to ensure this problem is corrected. Review of a Nursing Services policy and procedure for long term care 2001 Med pass Revised April 2019 Administering Medications, policy statement: Medications are administered in a safe and timely manner, and as prescribed .28. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 19 of 24 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 01/31/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #38) and 2 of 6 staff (CNA E and CNA L) reviewed for infection control. Residents Affected - Some CNA E failed to perform proper hand hygiene during meal service on 1/29/2024. CNA L failed to perform proper hand hygiene while providing incontinent care to Resident #38 on 01/30/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings: 1. During an observation on 1/29/2024 between 12:33 pm and 12:43 pm revealed CNA E was passing the meal trays for the lunch meal. She was observed entering room [ROOM NUMBER] setting up the resident tray by opening containers and cutting up food, adjusting the resident in the bed and then returned to the hall. CNA E obtained another tray from the cart and entered room [ROOM NUMBER]. CNA E set up the tray by opening containers and cutting food, adjusted the resident by use of the bed remote then returned to the hall for another tray. CNA E obtained another tray from the cart and entered room [ROOM NUMBER]. She set up the tray by opening containers and cutting up food and then propped the resident with pillows. She exited room [ROOM NUMBER] and did not wash or sanitize her hands before, during, or after meal service and between resident care. During an interview on 1/29/24 at 12:44 pm, CNA E stated she had been a CNA for 2 years and had been trained on passing meal trays. She stated she should have performed hand hygiene between residents to prevent spread of infection. During an interview on 01/29/24 at 3:27 PM, LVN D stated that she was an agency nurse and had worked at the facility 3 years. She stated that in between resident care hand hygiene should always occur to prevent the spread of infection. During an interview on 1/29/24 at 3:42 pm the DON stated that all staff were responsible for hand hygiene and had been trained on when to perform hand hygiene. She stated if staff were not performing appropriate hand hygiene it could cause infections and expected all staff to properly clean their hands to protect the residents. 2. Record review of an admission Record dated 1/30/2024 for Resident #38 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (group of lung diseases that make it difficult to breathe), Type 2 diabetes, GERD (acid reflux disease) and hypertension. Record review of an Annual MDS assessment dated [DATE] for Resident #38 indicated she did not have any impairment in thinking with a BIMS score of 15. She was frequently incontinent of bladder and always incontinent of bowel. Record review of a care plan dated 2/14/2023 for Resident #38 indicated she had an ADL performance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 20 of 24 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 01/31/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some deficit related to dementia, fatigue, limited mobility with interventions the was totally dependent on one staff for incontinent care. She had bladder incontinence with interventions to check every two hours and as required for incontinence. During an observation on 1/30/2024 at 9:54 AM, CNA L provided incontinent care to Resident #38 with the assistance of CNA M. Both washed their hands in the bathroom and applied gloves. CNA L opened the brief on Resident #38 and pulled it down between her thighs, CNA M assisted with positioning and holding. CNA L wiped Resident #38's perineal area from front to back using 3 different wipes and placed them in the trash. CNA M rolled Resident #38 onto her left side and CNA L wiped Resident #38's buttocks from front to back and placed the wipes in the trash. CNA L removed the brief and placed it in the trash. CNA L placed a clean brief underneath Resident #38's buttocks and brief was secured and then removed her gloves and placed them in the trash without washing or sanitizing her hands and placed clean gloves on. CNA M removed her gloves and placed them in the trash and sanitized her hands. CNA L placed a mechanical lift sling underneath her buttocks. CNA L and CNA M both transferred Resident #38 using the mechanical lift from her bed to her power chair. During an interview on 1/30/2024 at 10:12 AM, CNA L said she had been employed at the facility for 6 months and worked 6a-6p on hall 200 where Resident #38 resided. She said during the incontinent care provided to Resident#38, she should have sanitized her hands between gloves changes and changed her gloves when going from dirty to clean. She said Resident #38 was joking with them both as always and she did not realize her mistakes until after the care was provided. She said she had not been checked off for competency skills check with any of the nursing staff. She said residents could get an infection of any kind if staff did not wash or sanitize their hands between glove changes or change their gloves. Record review of a competency check off for CNA L dated 8/16/2023 indicated she had a competency review with the DON which showed proficiency in hand washing. During an interview on 1/31/2024 at 11:09 AM, the DON said between the ADON and charge nurses they conducted skills check offs with staff on hire, annually and as needed if they noticed any concerns. She said staff should be washing or sanitizing their hands any time they were dirty, and before and after glove changes. She said CNA L had a check off on hire. She said going forward she would reeducate the nurses and aides on infection control and hand hygiene. She said residents could be at risk of infections. During an interview on 1/31/2024 at 11:09 AM, the Administrator said she expected all staff to follow infection control practices. She said going forward she would ensure all staff were educated on hand hygiene and residents could be at risk of infections if staff did not follow infection control practices. Record review of a facility handwashing skills form dated 9/11/2019 indicated, .handwashing should be done at the following times: b. before and after caring for each resident . Record review of a facility policy titled Standard Precautions Infection Control undated indicated, .All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand Hygiene after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 21 of 24 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 01/31/2024 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 0880 ppe . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 22 of 24 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 01/31/2024 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 1 of 15 employees (CNA O) new and existing staff reviewed for training. Residents Affected - Few The facility failed to ensure CNA O was trained on fall prevention on hire. This failure could place residents 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 include: Record review of CNA O's personnel file indicated she was hired at the facility on 9/6/2023 and there was no documented evidence the aide completed training on fall prevention on hire. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the required trainings. She said she ensured the trainings were completed and corporate sets up the curriculum with online training. She said all staff should be getting trainings annually and on hire and was not aware that CNA O did not receive training on falls on hire. She said corporate added fall prevention training to the online training program yesterday, 1/30/2024. She said the last time staff at the facilty received training on fall prevention was on 8/4/2023. She said December 2022 the facility had a change in ownership, and they were completing their trainings on paper but have since transitioned to online training. She said if not trained on falls, there could be an increase in falls with the residents. She said going forward, she would ensure the staff received the required trainings and would conduct an audit monthly. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the facility utilized an online training program and staff received the required trainings on hire during orientation, monthly and as needed when things came up. She said corporate assigned the trainings and she would ensure staff received trainings. Record review of an In-Service Training Program dated April 2019 indicated, .The Director of Human Resources and the Director of Clinical Services are responsible for developing the company's in-service training plan for each year and for assigning all mandatory annual in-service training to associates provided via the Company's computer based in-servicing program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 23 of 24 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 01/31/2024 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 1 of 15 employees (LVN N) reviewed for training, in that: The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted by LVN N annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of LVN N's personnel file revealed he was hired on 6/17/2020 and had not completed annual training on rights of the resident and responsibilities of a facility to properly care for its residents. The last time he received training on resident rights was on 7/2/2022. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the required trainings. She said she ensured the trainings were completed and corporate sets up the curriculum with online training. She said all staff should be getting trainings annually and on hire and was not aware that LVN N did not receive the annual resident rights training. She said corporate added the resident rights trainings to the online training program on yesterday 1/30/2024. She said December 2022 the facility had a change in ownership, and they were completing their trainings on paper but have since transitioned to online training. She said if not trained on resident rights, staff would not know what was included in resident rights and residents could be at risk for a lot of things to happen. She said going forward she would ensure the staff received the required trainings and would conduct an audit monthly. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the facility utilized an online training program and staff received the required trainings on hire during orientation, monthly and as needed when things came up. She said corporate assigned the trainings and she would ensure staff received trainings. Record review of an In-Service Training Program dated April 2019 indicated, .The Director of Human Resources and the Director of Clinical Services are responsible for developing the company's in-service training plan for each year and for assigning all mandatory annual in-service training to associates provided via the Company's computer based in-servicing program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 24 of 24