Health inspection·November 30, 2022

F 0689 10/5/2016, reflected in part, The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors and maintain non-slip floor surface. 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: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure that 3 of 4 (Residents #32, #34, and #47 ) residents reviewed for respiratory care were provided care consistent with professional standards of practice in that: Residents Affected - Some Resident #32 did not have her SVN mask bagged when not in use. Resident #34 did not have her CPAP mask bagged when not in use. Resident #47 did not have his nebulizer bagged when not in use. This deficient practice could place residents who received oxygen treatments at risk of respiratory infection. Findings include: Resident #32 Review of Resident #32's admission Record, dated 11/30/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included major depression, single episode and generalized anxiety disorder. Review of Resident #32's quarterly MDS Assessment, dated 11/4/22 revealed she was on oxygen. Review of Resident #32's care plan, updated 7/14/22, revealed Focus: Resident has a Respiratory Infection. Goal: The resident will be free from signs or symptoms of infection by the review date. Interventions/Tasks: Bronchodilators via nebulizer as ordered by physician. Review of Resident #32's Order Summary Report, dated 11/30/22, revealed orders dated 9/15/22 for Albuterol Sulfate Nebulization Solution 0.083% vial inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease . Observation on 11/27/22 at 11:27 a.m. revealed Resident #32 was in her room. She had an SVN mask on her nightstand, that was open to air, not bagged and not in use . Resident #34 Review of Resident #34's admission Record, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included sleep apnea, and chronic obstructive pulmonary disease. Review of Resident #34's quarterly MDS assessment, dated 8/20/22, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 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 She scored a 15 of 15 on her mental status exam with no signs of delirium indicating she was cognitively intact. Level of Harm - Minimal harm or potential for actual harm She received oxygen therapy. BiPAP/CPAP was not checked. Residents Affected - Some Review of Resident #34's care plan, updated 12/06/2020, revealed: Focus: Resident has a history of Chronic Obstructive Pulmonary Disease, Sleep Apnea, and seasonal allergies. She uses oxygen and CPAP. Review of Resident #34's Order Summary, dated 11/30/22, revealed orders for CPAP to be worn at bedtime every night shift dated 7/30/2 2. Observation on 11/28/22 at 11:20 a.m. revealed Resident #34 was in her room. Her CPAP mask was on the made bed, not bagged and not in use. Resident #47 Review of Resident #47's admission Record, dated 11/28/22, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included atherosclerosis of arteries to the right leg; atherosclerotic heart disease ; muscle weakness; muscle wasting; hypertension; chronic kidney disease; and type 2 diabetes mellitus. Review of Resident #47's care plan, updated 10/28/22, revealed, Focus: Resident is at risk of hypertension and hyperlipidemia and is at risk for complications. Goal: The resident will remain free from complications related to hypertension and hyperlipidemia through the review date. Interventions/Tasks: Monitor for signs and symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea, vomiting, difficulty breathing. Observation on 11/29/22 at 08:30 a.m. revealed Resident #47 was not in his room. He had a nebulizer on the bedside table along with a dirty breakfast tray. The mouthpiece was touching the surface of the bedside table. Interview on 11/30/22 at 2:05 PM the Corporation RN stated the expectation was nebulizer tubing be changed weekly and bagged when not in use. She said the same thing for CPAP masks, they were to be bagged when not in use. She said the DON or designees did periodic checks to monitor for compliance. Record review of the facility's policy titled, Oxygen Administration, revised [DATE], reflected in part, the resident will be free from infection; change the tubing (including nasal prongs or mask) when it becomes visibly contaminated; oxygen concentrators should be cleaned according to manufacturer recommendations; change or clean oxygen concentrator filters according to manufacturer recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #32) of 5 residents reviewed for unnecessary medications. Resident #32 was placed on the antipsychotic Olanzapine without an appropriate indication for use. Resident #32's antipsychotic Olanzapine was increased without indicator documented supporting the increased dosage. These failures put residents at increased risk of side effects as a result of being administered an unnecessary antipsychotic. Finding include: Review of Resident #32's admission Record, dated 11/31/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included major depression and single episode and generalized anxiety disorder. She was admitted under hospice services. Review of Resident #32's quarterly MDS Assessment, dated 11/4/22 revealed: She scored a 15 of 15 on her mental status exam indicating she was cognitively intact. She showed no signs of delirium. She scored a 3 of 27 on her depression screening (indicating active depressive symptoms) She had no behaviors such as delusions or hallucinations identified. Her flagged medications included an antipsychotic medication for 7 of 7 days. Review of Resident #32's Care Plan, updated 8/2/22, revealed: Focus: Resident requires anti-psychotic medications. Goal: Resident will remain free of drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Secondary Goal: Resident will reduce the use of psychoactive medication through review date. Interventions included: 1) Administer medications as ordered. Monitor/Document for side effects and effectiveness. 2) Discuss with doctor, family about ongoing need for use of the medications. Review of Resident #32's Order Summary Report, dated 11/30/22, revealed she was on psychotropic medications including antipsychotic Olanzapine 10 mg at bedtime for major depressive disorder, order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 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 0758 date 7/7/22. Level of Harm - Minimal harm or potential for actual harm Review of Resident #32's admission Monthly Pharmacy Review, dated 5/18/22, revealed Resident #32 was on the psychotropic medications of the antianxiety Clonazepam and the antidepressant Mirtazapine only. Residents Affected - Few Review of Resident #32's Progress Notes revealed: Nursing Note on 5/31/2022 at 9:04 a.m. the hospice nurse here to visit resident, she was very upset claiming that a doctor or someone in a gray suit was spraying raid to kill cockroaches outside her room and across the hall. The hospice nurse went and asked around to everyone if they were spraying anything in or around the resident's room and did not find anyone. The hospice nurse also tried to calm the resident down with no effective result. The hospice nurse ordered a one-time, extra dose of Clonazepam and then 1- 5mg tab every day as needed. This additional dose did help calm the resident down but was still insisting they were all in This together and did not believe her. Nursing Note on 6/2/2022 at 1:35 p.m.: Received new order from hospice for Olanzapine 5 mg by mouth at bedtime. The pharmacy and responsible party notified. Social Services Note on 6/13/2022 at 11:32 a.m.: Resident participated in the MDS assessment today. She scored a 15 on her cognition test indicating that her memory was good. She scored a 16 on her mood which was significant for depression. (There was no documentation about significant behaviors, hallucinations, or delusions) Nursing Note on 7/7/22 at 2:01p.m.: New order to increase Olanzapine to 10 mg every night at bedtime. Nursing Note at 11/16/2022 at 1:41 p.m.: Hospice was contacted by this LVN. The resident's family requested a medication review due to insomnia and sleepiness during the day. 8:00 a.m. meds changed to 7:00 p.m. and resident/family made aware. Review of the Resident #32's available hospice notes revealed, in part, dated 07/5/22 (prior to the increase): Female with COPD, comorbidities included depression and anxiety. She was alert and oriented with intermittent confusion and hallucinations. She had increased anxiety requiring an increase in as needed antianxiety. The antipsychotic was added for the hallucinations with improvement. Interview on 11/30/22 at 02:05 p.m. the Corporate RN and the ADON reveled Resident #32 had respiratory symptoms, occasional confusion in the evening and was on hospice. The ADON stated Resident #32 liked to keep to herself. She said Resident #32 was on Olanzapine for depression. She said an antidepressant was not an indication for use of an antipsychotic. The ADON stated the antipsychotic use was probably for her anxiety. She said an antipsychotic was not indicated for the treatment of anxiety. The ADON stated the facility contacted hospice and the hospice agency managed her medication. The Corporate RN stated Resident #32 was admitted to the facility on hospice and on the antipsychotic. She was informed Resident #32 was not on any antipsychotic when she was admitted to the facility. The Corporate RN reviewed the available hospice records and could not find any documentation supporting the increase in the Olanzapine. They did not answer if anyone asked the hospice agency why the antipsychotic was increased . Interview on 11/30/22 at 4:03 p.m. Resident #32 stated her medications made her sleepy, dizzy, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 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 0758 Level of Harm - Minimal harm or potential for actual harm nauseated. She stated she was going to fall again because she fell eight times through 2022. She stated she fell backwards, and it was scary. Resident #32 said she did not know what medications she was on. She stated she just knew she had anxiety and panic attacks. She said she did not see things that other people were not seeing and that things just got strange. Resident #32 said she did not know when the last time it happened was just a while back. Residents Affected - Few Interview on 11/30/22 at 5:17 p.m. Resident #32's doctor stated Resident #32 started having hallucinations in June of 2022. She said the hallucinations were of a man spraying for roaches in her room. The Doctor stated Resident #32 was placed on Olanzapine 5 mg at bedtime which helped but Resident #32 still saw roaches, so she increased the dose to 10mg in July 2022. The Doctor stated Resident #32 seemed to be doing well on the increased dose. The Doctor stated Resident #32 had a history of psychosis prior to admission to facility. She stated they had discussed Resident #32's use of the medication and hallucinations in the interdisciplinary team meetings. The Doctor said it should be documented in her chart. The Doctor said she was certain the hospice chart had documentation of the medication indication, the hallucinations, and the resident's medical history prior to admission. She stated she would have hospice send all records to the facility to add to the resident's chart . Interview on 11/30/22 at 5:50 PM the Administrator stated the nurses should have been documenting on Resident #32 after she began the antipsychotic medication. He confirmed there was no documentation after the progress note about the man spraying for roaches. He said there was no follow-up documentation by facility staff in Resident #32's chart about the Olanzapine or Resident #32's behavior after the medication was started or what happened after the dosage was increase. The Administrator said the facility was aware of Resident #32's history of psychosis when she was admitted . He stated he could not explain why there was no documentation to support the diagnosis in her chart. The Administrator said he was unsure why the ball got dropped on Resident #32 because the staff were typically very good about documenting or monitoring behaviors and the facility worked hard to keep the antipsychotic use in the building low. Review of the facility's policy and procedure on Psychotropic Drugs, revised 10/25/17, revealed: The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. The facility must will ensure that - Resident who have not used psychosocial drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotic Medications - as with all medications, the indication for any prescribed antipsychotic must be thoroughly documented in the medical record. While antipsychotic medications may be prescribed for expressors or indications of distress, the interdisciplinary team must first identify and address any medical, physical, psychological causes, and/or social/environmental triggers. Any prescribed antipsychotic medication must be administered at the lowest possible dosage for the shortest period of time. Diagnoses alone do not necessarily warrant the use of antipsychotic medication. Antipsychotic medications may be indicated if: Expressions or indications of distress that are significant distress to the resident. If antipsychotic medications are prescribed, documentation must clearly show the indication for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 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 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 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 0758 antipsychotic medication, the multiple attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions. 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: 676046 If continuation sheet Page 8 of 8