Inspection·February 7, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few year-old male, originally admitted to the facility on [DATE] with a diagnosis which included encephalopathy (brain disease that alters brain function or structure). Record review of Resident #2's quarterly MDS, dated [DATE], indicated Resident #2 understood others and made himself understood. Resident #2 had a BIMS score of 10, which indicated his cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, revised 12/11/2023, indicated Resident #2 had impaired cognitive function/dementia or impaired though processes possibly related to CVA (stroke). The care plan interventions included, administer medications as ordered, communicate with resident/family regarding capabilities and needs. Record review of the Provider Investigation Report dated on 01/14/2024 indicted an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 01/12/2024 at 6:00 p.m. Resident #1 reported to the nurse Resident #2 yelled at her across from the hall during the evening of 01/12/2024. Resident #1 stated Resident #2 was singing too loud and she told him to shut up, then he told her to shut up. Resident #1 stated she mumbled something back and Resident #2 stated he would kill her motherfucker. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 01/14/2024 at 3:13 a.m. The provider investigation report stated the facility found the incident to be unconfirmed for abuse or neglect. Record review of the Event Nurse's Note dated 01/13/2024 at 9:40 a.m., by LVN E indicated Resident #1 stated to her that last night (01/12/2024) that man (Resident #2) was singing too loud, and she hollered and told him to shut up. Resident #1 stated he told her to shut up and she mumbled something back and then stated, I'll kill you motherfucker. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated she was notified by LVN E via phone on 01/13/2024 regarding the incident that occurred between Resident #1 and Resident #2. Administrator G stated after hearing the details about the incident between Resident #1 and Resident #2, she contacted the Area Director of Operations and was instructed to report in 24 hours. Administrator G stated she should have reported within 2 hours. Administrator G stated it was important to report an allegation of abuse to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. During an interview on 02/07/2024 at 11:03 a.m., the Area Director of Operations stated she was notified by Administrator G regarding the incident between Resident #1 and Resident #2. The Area Director of Operations stated she never told her to report within 24 hours. The Area Director of Operations stated Administrator G was instructed that the incident was reportable and to see if Resident 1's family member witnessed the incident. The Area Director of Operations stated it was important to report allegations to ensure resident safety. 2. Record review of Resident #3's face sheet, dated 02/07/2024, indicated Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #3's quarterly MDS, dated [DATE], indicated Resident #3 understood others and usually made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 2 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #3's comprehensive care plan, revised 12/09/2023, indicated Resident #3 had potential to demonstrate physical behaviors related to dementia. The care plan interventions included provide physician and verbal cues to alleviate anxiety, give positive feedback, and assist verbalization of source of agitation. Record review of Resident #4's face sheet, dated 02/07/2024, indicated Resident #4 was an [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's quarterly MDS, dated [DATE], indicated Resident #4 usually understood others and made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #4's comprehensive care plan, revised 01/22/2024, indicated Resident #4 had impaired cognitive function/dementia or impaired though processes possibly related to dementia. The care plan interventions included, administer medications as ordered, use the resident preferred name, and identify yourself at each interaction. Record review of the Provider Investigation Report dated on 11/26/2023 indicted an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 11/25/2023 at 9:00 p.m. Resident #3 went into Resident #4's room while he was asleep and swung Resident #4 legs back and forth off the bed. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 11/26/2023 at 9:28 a.m. Record review of the Event Nurses' note dated 11/25/2023 at 9:00 p.m., by LVN F indicated Resident #3 went into Resident #4's room and grabbed Resident #4 legs and swung them back and forth off the bed. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated LVN F contacted her shortly after the incident around 9:11 p.m. via phone. Administrator G stated she should have reported the incident within 2 hours of the allegation. Administrator G stated the only thing she could think of why she did not report within 2 hours was to verify if the incident was considered abuse or not. Administrator G stated it was important to report allegations to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 3 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 20 residents (Residents #1, #2, #3 and #4) reviewed for abuse and neglect. 1. The facility did not report the resident-to-resident altercation between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified. 2. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of being notified. These failures to report could place the residents at risk for abuse. Findings included: 1. Record review of Resident #1's face sheet, dated 02/07/2024, indicated Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (problems with metabolism cause brain dysfunction). Record review of Resident #1's quarterly MDS, dated [DATE], indicated Resident #1 understood others and made herself understood. Resident #1 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #1's comprehensive care plan, revised 06/19/2023, indicated Resident #1 had impaired cognitive function related to the late effects of a CVA. The care plan interventions included, use the preferred name, identify yourself ay each interaction and use task segmentation to support shirt term memory deficits. Record review of Resident #2's face sheet, dated 02/07/2024, indicated Resident #2 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included encephalopathy (brain disease that alters brain function or structure). Record review of Resident #2's quarterly MDS, dated [DATE], indicated Resident #2 understood others and made himself understood. Resident #2 had a BIMS score of 10, which indicated his cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, revised 12/11/2023, indicated Resident #2 had impaired cognitive function/dementia or impaired though processes possibly related to CVA (stroke). The care plan interventions included, administer medications as ordered, communicate with resident/family regarding capabilities and needs. Record review of the Provider Investigation Report dated on 01/14/2024 indicted an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 01/12/2024 at 6:00 p.m. Resident #1 reported to the nurse Resident #2 yelled at her across from the hall during the evening of 01/12/2024. Resident #1 stated Resident #2 was singing too loud and she told him to shut up, then he told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 4 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her to shut up. Resident #1 stated she mumbled something back and Resident #2 stated he would kill her motherfucker. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 01/14/2024 at 3:13 a.m. The provider investigation report stated the facility found the incident to be unconfirmed for abuse or neglect. Record review of the Event Nurse's Note dated 01/13/2024 at 9:40 a.m., by LVN E indicated Resident #1 stated to her that last night (01/12/2024) that man (Resident #2) was singing too loud, and she hollered and told him to shut up. Resident #1 stated he told her to shut up and she mumbled something back and then stated, I'll kill you motherfucker. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated she was notified by LVN E via phone on 01/13/2024 regarding the incident that occurred between Resident #1 and Resident #2. Administrator G stated after hearing the details about the incident between Resident #1 and Resident #2, she contacted the Area Director of Operations and was instructed to report in 24 hours. Administrator G stated she should have reported within 2 hours. Administrator G stated it was important to report an allegation of abuse to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. During an interview on 02/07/2024 at 11:03 a.m., the Area Director of Operations stated she was notified by Administrator G regarding the incident between Resident #1 and Resident #2. The Area Director of Operations stated she never told her to report within 24 hours. The Area Director of Operations stated Administrator G was instructed that the incident was reportable and to see if Resident 1's family member witnessed the incident. The Area Director of Operations stated it was important to report allegations to ensure resident safety. 2. Record review of Resident #3's face sheet, dated 02/07/2024, indicated Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #3's quarterly MDS, dated [DATE], indicated Resident #3 understood others and usually made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #3's comprehensive care plan, revised 12/09/2023, indicated Resident #3 had potential to demonstrate physical behaviors related to dementia. The care plan interventions included provide physician and verbal cues to alleviate anxiety, give positive feedback, and assist verbalization of source of agitation. Record review of Resident #4's face sheet, dated 02/07/2024, indicated Resident #4 was an [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's quarterly MDS, dated [DATE], indicated Resident #4 usually understood others and made himself understood. The assessment indicated the BIMS score was not completed due to the resident unable to complete the interview. Record review of Resident #4's comprehensive care plan, revised 01/22/2024, indicated Resident #4 had impaired cognitive function/dementia or impaired though processes possibly related to dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 5 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The care plan interventions included, administer medications as ordered, use the resident preferred name, and identify yourself at each interaction. Record review of the Provider Investigation Report dated on 11/26/2023 indicted an allegation of resident-to-resident incident on Resident #3 and #4 that occurred on 11/25/2023 at 9:00 p.m. Resident #3 went into Resident #4's room while he was asleep and swung Resident #4 legs back and forth off the bed. The report indicated no staff witnessed the incident. The incident was reported to the state agency on 11/26/2023 at 9:28 a.m. Record review of the Event Nurses' note dated 11/25/2023 at 9:00 p.m., by LVN F indicated Resident #3 went into Resident #4's room and grabbed Resident #4 legs and swung them back and forth off the bed. During an interview on 02/07/2024 at 9:57 a.m., the previous Administrator G stated LVN F contacted her shortly after the incident around 9:11 p.m. via phone. Administrator G stated she should have reported the incident within 2 hours of the allegation. Administrator G stated the only thing she could think of why she did not report within 2 hours was to verify if the incident was considered abuse or not. Administrator G stated it was important to report allegations to verify if anyone was connected to the abuse or the perpetrator was separated from everyone else. Record review of the facility policy for Abuse/Neglect revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms the facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/2019 . a. If the allegations involve abuse or result in serios bodily injury, the report is to be made within 2 hours of the allegation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 6 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 4 (NA A, NA B, NA C, and Hospitality Aide D) of 4 staff reviewed for demonstration of skills and techniques necessary for residents' needs. The facility failed to conduct competency assessments for NA A, NA B, NA C, and Hospitality Aide D. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Findings included: Record review of personnel file for NA A with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA B with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA C with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for Hospitality Aide D with hire date [DATE] indicated no evidence of skill competency checkoffs. During an interview on [DATE] at 5:57 PM, Hospitality Aide D said she was no longer employed at the facility. Hospitality Aide D said her CNA license was expired. Hospitality Aide D said she was not supposed to perform the job duties of a CNA, but she had worked on the secured unit multiple occasions and provided ADL care, such as incontinent care, to the residents on her own. Hospitality Aide D said she had performed the job duties of a CNA because the facility was sometimes short staffed. Hospitality Aide D said she did not know if a competency check off had been performed on her. During an interview on [DATE] 9:58 AM, the Unit Manager said the ADON and herself were responsible for completing the staff competencies. The Unit Manager said CNA A, CNA B, and CNA C were currently employed at the facility, and they had completed the student nurse aide class and were waiting to test to obtain their certification. The Unit Manager said CNA A, CNA B, and CNA C were able to work on the floor as nurse aides. The Unit Manager said she did not complete competency check offs for the nurse aides. The Unit Manager said it was important for the competency check offs to be completed for the safety and well being of the residents. During an interview on [DATE] at 12:01 PM, the Regional Clinical Consultant said nurse management (DON, ADON, Unit Manager) was responsible for completing the competency check offs. The Regional Clinical Consultant said she did not know if the competencies were completed because they had changes in DON and administrators. The Regional Clinical Consultant said the competencies were completed to ensure the staff were trained and knew how to perform the skills necessary to complete their job. The Regional Clinical Consultant said Hospitality Aide D was taking the nurse aide class, but she had not made it to the end of the class because she was terminated. The Regional Clinical Consultant said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 7 of 8 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 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 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 0726 Hospitality Aide D received enough training so she could work on the floor. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 1:51 PM, the Administrator said her first day at the facility was Monday ([DATE]), and her expectations were for the nurse aides' competencies to be completed per the policy. The Administrator said typically the DON was responsible for ensuring the competencies were completed. The Administrator said it was important for the competencies to be completed for quality of care. Residents Affected - Some During an interview on [DATE] at 1:55 PM, the DON said it was her third day in the building. The DON said the nurse aide competency check offs should be done on hire. The DON said the Unit Manager was responsible for completing the nursing staffs' competencies. The DON said it was important for the competencies to be completed to ensure they knew the policies, what they were doing and were not abusing the residents, and to correct the staff if they were doing something wrong. During an interview on [DATE] at 2:39 PM, the ADON said the Unit Manager normally did the competency check offs, but she had not been working and just returned to the facility in January. The ADON said the competency check offs should be completed while the nurse aides trained within the first three days of hire. The ADON said the nurse aides' competency check offs were not completed because she must have overlooked it upon the other tasks she had to perform in the facility. The ADON said Hospitality Aide D was only supposed to be passing ice and working alongside other CNAs in the facility. The ADON said to her knowledge Hospitality Aide D did not perform any patient care on her own. The ADON said it was important for the competency check offs to be completed to ensure all skill sets were met, and they knew what they were doing. During an interview on [DATE] at 2:11 PM, the Human Resource Coordinator said she did not collect the competency check offs that nursing was responsible for completing them. The Human Resource Coordinator said it was important for the competency check offs to be completed to ensure the staff understood their duties. Record review of the facility's Facility Assessment, Staff Competencies indicated Person-centered care All staff - on hire, annually and as needed, Activities of Daily Living Nursing staff - on hire, annually and as needed, Infection Control-Hand Hygiene All staff- on hire, annually and as needed, Infection Control Universal Precautions All staff- on hire, annually and as needed, Infection Control-Protective Equipment All staff- on hire, annually and as needed, Caring for People with Dementia. Alzheimer's and Cognitive Impairments All staff- on hire, annually and as needed, Caring for Residents with Mental and Psychosocial disorders All staff- on hire, annually and as needed, Non-Pharmacological management of Responsible Behaviors All staff- on hire, annually and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 8 of 8