Inspection·February 5, 2025

F 0677 1/13/25- CNA A indicated activity did not occur at 11:19am. Level of Harm - Minimal harm or potential for actual harm 1/14/25-CNA A indicated activity did not occur at 10:44am. 1/15/25- CNA A indicated activity did not occur at 10:29am. Residents Affected - Few 1/16/25- CNA A indicated activity did not occur at 2:29pm. 1/17/25- CNA A indicated activity did not occur at 2:43pm. 1/19/25- CNA E indicated activity did not occur at 3:05am. 1/20/25- CNA E indicated activity did not occur at 6:29am. 1/21/25- CNA E indicated activity did not occur at 6:29am. 1/22/25- CNA E indicated activity did not occur at 6:29am and CNA F indicated Not Applicable at 2:29pm. 1/23/25-CNA D indicated resident was totally dependent on staff for bathing at 5:57pm. 1/25/25-CNA E indicated activity did not occur at 6:29am. 1/27/25- CNA E indicated activity did not occur at 6:29am, CNA A indicated activity did not occur at 2:29pm, and CNA C indicated Not Applicable at 8:30pm. 1/28/25- CNA E indicated activity did not occur at 6:29am and CNA A indicated activity did not occur at 2:29pm. 1/29/25-CNA D indicated resident was totally dependent on staff for bathing at 5:43pm. 1/31/25- CNA E indicated activity did not occur at 6:29am and CNA A indicated activity did not occur at 11:30am. 2/1/25-CNA A indicated activity did not occur at 11:09am. 2/2/25-CNA E indicated activity did not occur at 6:29am and CNA A indicated activity did not occur at 10:31am. 2/3/25-CNA A indicated activity did not occur at 11:34am. Review of the facility's shower binder reflected 1 shower sheet for Resident #1 dated 1/2/2025. No other shower sheets were found for Resident 1 for the duration of January 2025. Review of the facility's staffing schedule for the past 30 days revealed some call ins listed with a replacement's name written in to float multiple hallways. Observation on 2/5/25 at 11:00 AM revealed Resident #1 in her bed in her room. Her chin had a long grey hair approximately 1 inch long. Her hair was well kempt, and she did not exhibit any strong (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676047 If continuation sheet Page 2 of 4 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 676047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059 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 odors. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/5/25 at 10:50am with Resident #1 revealed that she wishes she could get showers more often because the last time she received a shower was a week ago. She stated that she only gets showers on Tuesdays and Thursdays but an additional shower on Saturday would be nice as well. She stated that there has to be 2 staff help her because they use the Lift to get her out of bed and a lot of the time there are not enough aides to help. She stated that not getting her showers makes her feel dirty. Residents Affected - Few During an interview on 2/5/25 at 12:45pm with the ADON she stated that she has worked here for a couple of years and that CNA's conduct showers for residents by the list of names of people needing showers located in the shower room. The CNA's chart the shower in PCC as well as do a paper skin assessment and turn that into the charge nurse. She stated that it is very important for resident's skin integrity as well as the overall health of the resident to receive their showers according to schedule. Resident #1 has refused showers in the past but is not one that the ADON will generally receive report that resident refused. During an interview on 2/5/2025 at 12:51pm with CNA A she stated that she works the 6am-2pm shift, and that Resident #1 receives showers on the 2pm-10pm shift. The reason her name shows up for the shower tasks multiple times for Resident #1 is because CNA A is documenting that the shower did not occur during her shift because that is not the residents' schedule. During a telephone interview on 2/5/2024 at 2:07pm with CNA B who works the 2-10pm shift, stated that she has worked at the facility since 11/2024. She stated that baths and/or showers are documented on shower sheets and turned into the charge nurse. The shower schedule is posted inside the shower room. Sometimes they are short staffed and sometimes she feels that they (CNA's) just run out of time during their shift to complete all their tasks. She stated that she works with Resident #1 and Resident #1 does not refuse showers. She also stated that Resident #1 must utilize the Lift and that also required needing a second staff to assist with transfers, which makes it harder to bathe her if there are not enough people. During an interview on 2/5/2025 at 2:11pm with CNA C and CNA D with the assistance of a Spanish speaking interpreter revealed that CNA C does not regularly work on the hall where Resident #1 lives. However, she is aware that Resident #1 requires a 2 person assist to use the mechanical lift. CNA C stated that she sometimes must work 1 hallway on 1 side of the building as well as another hallway on the other side on the same night and she is constantly having to go back and forth and tend to a lot of resident needs. CNA C and CNA D both stated that they feel there is not enough staff during the 2-10pm shift to complete all the tasks for all the residents in the facility, they can try to do someone's shower but if a 2nd person is not available to help with a shower for someone who uses the mechanical lift the shower may not get done. During an interview on 2/5/2025 at 2:45pm with the ADM she stated that her expectation is that on the residents' shower day the resident is to receive their shower, if the resident is not available, they should be able to receive their shower at a different time to make up the missed shower. She stated a negative outcome of the resident not receiving showers as ordered could be skin issues, body odor, and loss of dignity. She stated that administrative nurses are ultimately responsible for ensuring showers and documentation get done. When asked if she felt the facility was short staffed, she stated that she does not feel they are shorthanded, but there has been a time or two that staff have felt they are shorthanded, and she had seen administrative nurses help with showers during those (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676047 If continuation sheet Page 3 of 4 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 676047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059 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 times. Level of Harm - Minimal harm or potential for actual harm Review of facility's Bath, Shower/Tub policy dated revised February 2018 reflected, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Residents Affected - Few Under the subheading labeled Documentation it stated: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). Under the subheading labeled Reporting it stated: 1. Notify the supervisor if the resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated. 3. Report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676047 If continuation sheet Page 4 of 4