Health inspection·October 19, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 10/17/23 at 2:56 PM the Maintenance Director said the water temperature should be in the range of 103 to 108 degrees Fahrenheit. The Maintenance Director said if the water got too hot it could scald the residents. The Maintenance Director said he checked the water temperature once a week and had not noticed them being high, he checked them random rooms throughout the facility. The Maintenance Director was made aware of the temperature readings taken by the surveyor. The Maintenance Director checked the water temperatures in room [ROOM NUMBER] with the facility thermometer and it was 122 degrees Fahrenheit. The Maintenance Director said He would turn the temperature down as it was too high and that the same water heater controlled both halls 100, 200 and the main shower room. During an interview on 10/17/23 at 3:12 PM the Administrator said the water temperature should be around 110 degrees Fahrenheit. The Administrator said she was not sure what the temperature of the water was at the facility as she had just started working as the Administrator the day before today. The Administrator was made aware of the observations of the water temperatures being 122 degrees Fahrenheit on halls 100, 200 and the shower room in between the same two halls. The Administrator said they would get that corrected as the temperature was high and it could lead to the residents getting burned. Record review of the facility's titled Hot water systems dated 2003 indicated in part: Water temperatures should be maintained at 100 degrees Fahrenheit at a minimum and 110 degrees Fahrenheit at a maximum. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 2 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #55) of two residents reviewed for pain in that , Residents Affected - Few 1. RN A failed to accurately assess and administer pain medication to Resident #55 when she complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Review of Resident #55's admission Record dated 10/18/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, pain, major depressive disorder, and palliative care (specialized medical care that focuses on providing relief from pain). Review of Resident #55's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed: She scored an 8 on her mental status exam, indicating moderately impaired cognition. She had no signs or symptoms of delirium. She had no reported behaviors and no reported refection of care. She required only supervision or limited assistance for ADLs. She used a walker to ambulate. She did not report any pain at the time of the assessment. She received an antipsychotic medication, anxiety medication, diuretic, and opioid medication. She was on hospice services. Review of Resident #55's Care Plan last revised 10/17/23 revealed: Focus: I have the potential for pain related to end stage disease processes, arthritis, possible colon cancer. I am able to verbally report pain. I have Fentanyl PRN, Lidoderm patches PRN, acetaminophen PRN (date initiated: 8/29/23) Goal: I will not have an interruption in normal activities due to pain through the review date (Date initiated: 8/29/23) Interventions/Tasks: Administer analgesia as per orders. Give ½ hour before treatments or care. (Date initiated: 8/29/23). Anticipate my need for pain relief and respond immediately to any complaint of pain. (Date initiated: 8/29/23). Monitor/record/report to nurse any s/sx of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). (Date initiated: 8/29/23) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 3 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 0697 Level of Harm - Minimal harm or potential for actual harm Focus: I have a terminal prognosis and/or am receiving hospice services for end stage senile degeneration of the brain. I have comfort medications ordered. Fentanyl PRN Pain, Acetaminophen PRN pain/temp (date initiated: 8/29/23) Goal: My comfort will be maintained through the review date. (Date initiated: 8/29/23) Residents Affected - Few Interventions/Tasks: Observe me closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. (Date initiated: 8/29/23); Work with nursing staff to provide maximum comfort. (Date initiated: 8/29/23). Focus: I am resistive to care related to dementia. I will refuse assist from staff. I refuse medications frequently. I refuse to wear shoes. (Date initiated: 10/11/23, Revision date: 10/17/23) Goal: I have the right to refuse treatment through the review date. (Date initiated: 10/11/23) Interventions/Tasks: Allow me to make decisions about treatment regime to provide a sense of control. (Date initiated: 10/11/23). Instruct on potential side effects or possible adverse effects of not taking the medications or treatments. (Date initiated: 10/11/23) Review of Resident #55's Order Summary dated 10/18/23 revealed: Ativan/Benadryl/Haldol 1/25/1mg PLO 1ml/syringe every 6 hours as needed related to palliative care/dementia with agitation/anxiety (order date 9/8/23) Acetaminophen Oral Tablet 500mg give 1 tablet orally every 6 hours as needed for pain/temp (order date 6/6/23) Acetaminophen Rectal Suppository 650mg insert 1 suppository rectally every 6 hours as needed for pain/temp *not to exceed 3 grams in 24 hours (order date 6/13/23) Fentanyl citrate injection solution 250mcg/5ml give 0.2ml sublingually every 2 hours as needed for pain (order date 9/8/23) Fentanyl citrate injection solution 250mcg/5ml give 0.4ml sublingually every 2 hours as needed for pain (order date 9/8/23) Lidocaine external ointment 5% apply topically to bilateral lower extremities two times a day related to pain (order date 10/3/23) Lidocaine external patch 5% apply to proximal left upper extremity one time a day related to pain 12 hours on and 12 hours off (order date 10/18/23) Observation and interview on 10/17/23 at 2:54 PM revealed Resident #55 walking in the hallway in the women's secured unit asking CNA B if she could have a pain patch for her arm. CNA B explained to her that the patch had been discontinued by the doctor but told Resident #55 that she would go speak with the nurse to see if there was something different she could have for the pain. Resident #55 agreed, and CNA B assisted her to her room and into her recliner to wait. When Speaking with Resident #55 in her room, she complained of pain in her left upper arm. The Surveyor asked what happened to cause the pain to her left arm and Resident #55 explained that the footrest on her recliner had become (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 4 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few difficult to put down with her legs due to her leg pain and she had been using her arms to push it down and her left arm had started aching in the last day or so. On inspection of the resident's left arm there did appear to be a small raised area protruding from the location she was rubbing and complaining about the pain. During the interview with Resident #55 in her room, RN A entered the room holding a plastic bag in each hand; one containing pre-filled syringes and one containing a prescription bottle, and offered Resident #55 two different pain creams for her arm, stating they were fentanyl and ABH (ativan-benadryl-haldol) cream. RN A began to tell Resident #55 that one of the creams was the same cream she used on her leg earlier and resident stated that she had a patch on her leg. RN A stated that no she had cream because she refused to wear the patches and so the patches had been discontinued. RN A asked Resident #55 if she wanted the cream or not and resident said yes. RN A asked Resident #55 to rate her pain on scale of 1 to 10 and Resident #55 stated oh honey it is a 20. RN A placed the two bags of medication on the resident's bed, donned gloves and applied the ABH cream to the resident's left upper arm. RN A did not assess Resident #55's left arm for injury or cause of the pain. Further inspection of the bags revealed that the bottle of fentanyl was not a cream rather it was oral liquid fentanyl. In an interview on 10/18/23 at 9:45 AM, the DON stated that she was not aware that Resident #55 had been experiencing arm pain. She stated that RN A had not reported the new complaint of pain to her on 10/17/23. She stated that Resident #55 had constant complaints of leg pain. The DON stated that she recently had her lidocaine patches discontinued because she would refuse to wear them. She stated that Resident #55 was a very difficult resident to give medication to because of her dementia. She stated that Resident #55 often refused to take oral medications because she believed the staff was trying to poison her and keep her drugged up. The DON stated that RN A should have assessed Resident #55's left arm for a source for the pain since she had never complained of pain in that location before. The DON acknowledged that ABH cream was not prescribed for pain but for anxiety and RN A should have attempted to give Resident #55 the fentanyl because it was a pain medication. She stated that Resident #55 did have anxiety and that anxiety could manifest as pain but without properly assessing the resident and administering or attempting to administer the appropriate medication it would be impossible to tell what the cause of the pain (DON used air quotes) was. During the interview, the DON opened Resident #55's EHR and found no documentation of the administration of the ABH cream in the nurse's notes regarding a pain assessment by RN A. The DON stated she would assess Resident #55 herself to follow up. In an interview on 10/18/23 at 5:45 PM, RN A stated that Resident #55 had delusions. She stated that Resident #55's family member put her in the facility due to her not taking her medications, not eating, not going to the bathroom, and generally just not being able to care for herself. RN A stated she believed Resident #55 came in on hospice and if not was admitted to hospice services right after her admission to the facility, five or six months ago. She stated that Resident #55 did not complain of pain when she first came to the facility. When Resident #55 first started complaining of pain, she complained of severe chest pain, which they acted on quickly because she did have a history of heart problems. RN A stated that the majority of pain Resident #55 complained of was in her legs, but she refused most of the meds they had for her and walked up and down the halls as though nothing was wrong. RN A stated 10/17/23 was the first time Resident #55 had ever complained about her arm hurting. RN A stated that she chose to give her the cream instead of the pain medication because historically Resident #55 would not take anything by mouth and she had been refusing the lidocaine patches that had recently been discontinued. She stated the cream was the only thing that she would allow the staff to give her even though it was not for pain. RN A stated she understood that the medication that she gave was not indicated for pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 5 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but that she knew her residents and what would work for them and sometimes that was more important than what the medication was prescribed for. RN A stated that Resident #55 was putting on a show because of the surveyor's presence in the room, that Resident #55 knew what the meds were and what they were for because she used to be a nurse. She stated that Resident #55 had dementia and she understood that caused residents to act out. She stated she did believe that Resident #55 was in some pain but not as much as she was claiming. RN A stated when she went back into Resident #55's room approximately 30 minutes after applying the cream on her left arm to ask how her pain was, Resident #55 told her she felt much better . When asked if she documented the initial complaint of arm pain, administration of the ABH cream, and the follow up with Resident #55 on 10/17/23, RN A stated she got busy and forgot but when she was called in to speak to the surveyor by the DON, she made a late entry progress note but she had to guess at the time because she was unable to remember the exact time she administered the medication to the resident. In an interview on 10/19/23 at 1:23 PM, CNA B stated that Resident #55 gave staff trouble taking medication every day regardless of which staff it was. CNA B stated Resident #55 had good days and bad days when it came to taking medication. She stated Resident #55 would refuse medication and then ask for it later. She stated that Resident #55 was paranoid that people were trying to keep her drugged up. CNA B stated it was not just oral medication, it was every kind of medication. CNA B stated she felt like it was partially attention seeking because of Resident #55's dementia and because her family did not get to visit her as much as she wanted them to. CNA B stated she believed Resident #55 did have pain at times in her legs and feet because she was constantly up and moving. She stated she had never heard Resident #55 complain of having arm pain before 10/17/23. She stated that Resident #55 was showered by hospice aides on Tuesday's and Thursday's. CNA B stated that the hospice aides did not leave notes but she asked about skin issues so she could document on the shower sheets, and no one reported anything unusual to her on Tuesday (10/17/23). CNA B stated that she had not noted any bruising or swelling to Resident #55's left arm but she had seen Resident #55 using a wheelchair to wheel herself around the secured unit on Monday and Tuesday (10/16/23 and 10/17/23), which she stated she did not require, and stated she believed that might be what caused the pain in her left arm since she was not used to propelling herself in the chair. She stated that Resident #55 told her she was using the wheelchair because her legs were hurting when she walked. In a follow up interview on 10/19/23 at 3:32 PM the DON stated she would expect a nurse to offer a pain medication to a resident when they asked for a pain medication, not an antianxiety medication. RN A should have told Resident #55 that the ABH cream was not for pain before she offered it to her and then asked if she still wanted it instead of just applying it. RN A should have assessed Resident #55 better before giving her anything. The DON stated that RN A told her (DON) and Regional Compliance RN that Resident #55 seemed more anxious than in pain and that when she went back to check on her 20-30 minutes later, she was fine and said her pain was gone. The DON stated she went to speak with Resident #55 the next day and assessed her with the Regional Compliance RN and did not find any abnormalities to her left arm. The DON stated they asked her how her arm was doing, and she told them it felt better, not as sore and that the cream worked well. The DON stated they advised Resident #55 that the cream was not prescribed for pain and that it was an anxiety medication and she (Resident #55) told them that was ok because it did help, and then asked if she could have the pain patch back. The DON stated an x-ray was obtained of Resident #55's left arm as ordered by her physician which showed no fracture or mass. The DON stated the Lidocaine patch was reordered as Resident #55 requested and they were waiting for an order to be approved for voltaren gel for pain since she did better with topical medication. The DON reiterated that Resident #55 was very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 6 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 0697 Level of Harm - Minimal harm or potential for actual harm difficult to give medication to due to her dementia and all staff had the same problem getting her to take medication. The DON stated that RN A had been written up for giving the ABH cream when she should have given pain meds and for not explaining to the resident the difference. The DON also stated that the Regional Compliance RN had started an in-service for all nurses regarding pain. Residents Affected - Few Review of facility in-service Subject: Pain, dated 10/18/23, revealed: Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability need to be asked. If a resident is non-verbal, the questions will be a PAINAD assessment. When new acute pain is identified staff will complete a pain SBAR. Administer pain medication as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. Regardless of the resident cognition staff must address any c/o signs of pain and administer medication that is appropriate for the symptoms. Do not administer behavioral medication when it comes to addressing pain issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 7 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 observation, interview and record review, the facility failed to ensure, based on a comprehensive assessment, residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition for one (Resident #55) of two residents reviewed for pain. 1. RN A administered ABH cream which was prescribed for agitation or anxiety when Resident #55 complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Review of Resident #55's admission Record dated 10/18/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, pain, major depressive disorder, and palliative care (specialized medical care that focuses on providing relief from pain). Review of Resident #55's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed: She scored an 8 on her mental status exam, indicating moderately impaired cognition. She had no signs or symptoms of delirium. She had no reported behaviors and no reported refection of care. She required only supervision or limited assistance for ADLs. She used a walker to ambulate. She did not report any pain at the time of the assessment. She received an antipsychotic medication, anxiety medication, diuretic, and opioid medication. She was on hospice services. Review of Resident #55's Care Plan last revised 10/17/23 revealed: Focus: I have the potential for pain related to end stage disease processes, arthritis, possible colon cancer. I am able to verbally report pain. I have Fentanyl PRN, Lidoderm patches PRN, acetaminophen PRN (date initiated: 8/29/23) Goal: I will not have an interruption in normal activities due to pain through the review date (Date initiated: 8/29/23) Interventions/Tasks: Administer analgesia as per orders. Give ½ hour before treatments or care. (Date initiated: 8/29/23). Anticipate my need for pain relief and respond immediately to any complaint of pain. (Date initiated: 8/29/23). Monitor/record/report to nurse any s/sx of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). (Date initiated: 8/29/23) Focus: I have a terminal prognosis and/or am receiving hospice services for end stage senile (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 8 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 degeneration of the brain. I have comfort medications ordered. Fentanyl PRN Pain, Acetaminophen PRN pain/temp (date initiated: 8/29/23) Goal: My comfort will be maintained through the review date. (Date initiated: 8/29/23) Interventions/Tasks: Observe me closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. (Date initiated: 8/29/23); Work with nursing staff to provide maximum comfort. (Date initiated: 8/29/23). Focus: I am resistive to care related to dementia. I will refuse assist from staff. I refuse medications frequently. I refuse to wear shoes. (Date initiated: 10/11/23, Revision date: 10/17/23) Goal: I have the right to refuse treatment through the review date. (Date initiated: 10/11/23) Interventions/Tasks: Allow me to make decisions about treatment regime to provide a sense of control. (Date initiated: 10/11/23). Instruct on potential side effects or possible adverse effects of not taking the medications or treatments. (Date initiated: 10/11/23) Review of Resident #55's Order Summary dated 10/18/23 revealed: Ativan/Benadryl/Haldol 1/25/1mg PLO 1ml/syringe every 6 hours as needed related to palliative care/dementia with agitation/anxiety (order date 9/8/23) Acetaminophen Oral Tablet 500mg give 1 tablet orally every 6 hours as needed for pain/temp (order date 6/6/23) Acetaminophen Rectal Suppository 650mg insert 1 suppository rectally every 6 hours as needed for pain/temp *not to exceed 3 grams in 24 hours (order date 6/13/23) Fentanyl citrate injection solution 250mcg/5ml give 0.2ml sublingually every 2 hours as needed for pain (order date 9/8/23) Fentanyl citrate injection solution 250mcg/5ml give 0.4ml sublingually every 2 hours as needed for pain (order date 9/8/23) Lidocaine external ointment 5% apply topically to bilateral lower extremities two times a day related to pain (order date 10/3/23) Lidocaine external patch 5% apply to proximal left upper extremity one time a day related to pain 12 hours on and 12 hours off (order date 10/18/23) Observation and interview on 10/17/23 at 2:54 PM revealed Resident #55 walking in the hallway in the women's secured unit asking CNA B if she could have a pain patch for her arm. CNA B explained to her that the patch had been discontinued by the doctor but told Resident #55 that she would go speak with the nurse to see if there was something different she could have for the pain. Resident #55 agreed, and CNA B assisted her to her room and into her recliner to wait. When Speaking with Resident #55 in her room, she complained of pain in her left upper arm. The Surveyor asked what happened to cause the pain to her left arm and Resident #55 explained that the footrest on her recliner had become difficult to put down with her legs due to her leg pain and she had been using her arms to push it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 9 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 down and her left arm had started aching in the last day or so. On inspection of the resident's left arm there did appear to be a small raised area protruding from the location she was rubbing and complaining about the pain. During the interview with Resident #55 in her room, RN A entered the room holding a plastic bag in each hand; one containing pre-filled syringes and one containing a prescription bottle, and offered Resident #55 two different pain creams for her arm, stating they were fentanyl and ABH (ativan-benadryl-haldol) cream. RN A began to tell Resident #55 that one of the creams was the same cream she used on her leg earlier and resident stated that she had a patch on her leg. RN A stated that no she had cream because she refused to wear the patches and so the patches had been discontinued. RN A asked Resident #55 if she wanted the cream or not and resident said yes. RN A asked Resident #55 to rate her pain on scale of 1 to 10 and Resident #55 stated oh honey it is a 20. RN A placed the two bags of medication on the resident's bed, donned gloves and applied the ABH cream to the resident's left upper arm. RN A did not assess Resident #55's left arm for injury or cause of the pain. Further inspection of the bags revealed that the bottle of fentanyl was not a cream rather it was oral liquid fentanyl. In an interview on 10/18/23 at 9:45 AM, the DON stated that she was not aware that Resident #55 had been experiencing arm pain. She stated that RN A had not reported the new complaint of pain to her on 10/17/23. She stated that Resident #55 had constant complaints of leg pain. The DON stated that she recently had her lidocaine patches discontinued because she would refuse to wear them. She stated that Resident #55 was a very difficult resident to give medication to because of her dementia. She stated that Resident #55 often refused to take oral medications because she believed the staff was trying to poison her and keep her drugged up. The DON stated that RN A should have assessed Resident #55's left arm for a source for the pain since she had never complained of pain in that location before. The DON acknowledged that ABH cream was not prescribed for pain but for anxiety and RN A should have attempted to give Resident #55 the fentanyl because it was a pain medication. She stated that Resident #55 did have anxiety and that anxiety could manifest as pain but without properly assessing the resident and administering or attempting to administer the appropriate medication it would be impossible to tell what the cause of the pain (DON used air quotes) was. During the interview, the DON opened Resident #55's EHR and found no documentation of the administration of the ABH cream in the nurse's notes regarding a pain assessment by RN A. The DON stated she would assess Resident #55 herself to follow up. In an interview on 10/18/23 at 5:45 PM, RN A stated that Resident #55 had delusions. She stated that Resident #55's family member put her in the facility due to her not taking her medications, not eating, not going to the bathroom, and generally just not being able to care for herself. RN A stated she believed Resident #55 came in on hospice and if not was admitted to hospice services right after her admission to the facility, five or six months ago. She stated that Resident #55 did not complain of pain when she first came to the facility. When Resident #55 first started complaining of pain, she complained of severe chest pain, which they acted on quickly because she did have a history of heart problems. RN A stated that the majority of pain Resident #55 complained of was in her legs, but she refused most of the meds they had for her and walked up and down the halls as though nothing was wrong. RN A stated 10/17/23 was the first time Resident #55 had ever complained about her arm hurting. RN A stated that she chose to give her the cream instead of the pain medication because historically Resident #55 would not take anything by mouth and she had been refusing the lidocaine patches that had recently been discontinued. She stated the cream was the only thing that she would allow the staff to give her even though it was not for pain. RN A stated she understood that the medication that she gave was not indicated for pain but that she knew her residents and what would work for them and sometimes that was more important (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 10 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 than what the medication was prescribed for. RN A stated that Resident #55 was putting on a show because of the surveyor's presence in the room, that Resident #55 knew what the meds were and what they were for because she used to be a nurse. She stated that Resident #55 had dementia and she understood that caused residents to act out. She stated she did believe that Resident #55 was in some pain but not as much as she was claiming. RN A stated when she went back into Resident #55's room approximately 30 minutes after applying the cream on her left arm to ask how her pain was, Resident #55 told her she felt much better . When asked if she documented the initial complaint of arm pain, administration of the ABH cream, and the follow up with Resident #55 on 10/17/23, RN A stated she got busy and forgot but when she was called in to speak to the surveyor by the DON, she made a late entry progress note but she had to guess at the time because she was unable to remember the exact time she administered the medication to the resident. In an interview on 10/19/23 at 1:23 PM, CNA B stated she had never heard Resident #55 complain of having arm pain before 10/17/23. She stated that Resident #55 was showered by hospice aides on Tuesday's and Thursday's. CNA B stated that the hospice aides did not leave notes but she asked about skin issues so she could document on the shower sheets, and no one reported anything unusual to her on Tuesday (10/17/23). CNA B stated that she had not noted any bruising or swelling to Resident #55's left arm but she had seen Resident #55 using a wheelchair to wheel herself around the secured unit on Monday and Tuesday (10/16/23 and 10/17/23), which she stated she did not require, and stated she believed that might be what caused the pain in her left arm since she was not used to propelling herself in the chair. She stated that Resident #55 told her she was using the wheelchair because her legs were hurting when she walked. In a follow up interview on 10/19/23 at 3:32 PM the DON stated she would expect a nurse to offer a pain medication to a resident when they asked for a pain medication, not an antianxiety medication. RN A should have told Resident #55 that the ABH cream was not for pain before she offered it to her and then asked if she still wanted it instead of just applying it. RN A should have assessed Resident #55 better before giving her anything. The DON stated that RN A told her (DON) and Regional Compliance RN that Resident #55 seemed more anxious than in pain and that when she went back to check on her 20-30 minutes later, she was fine and said her pain was gone. The DON stated she went to speak with Resident #55 the next day and assessed her with the Regional Compliance RN and did not find any abnormalities to her left arm. The DON stated they asked her how her arm was doing, and she told them it felt better, not as sore and that the cream worked well. The DON stated they advised Resident #55 that the cream was not prescribed for pain and that it was an anxiety medication and she (Resident #55) told them that was ok because it did help, and then asked if she could have the pain patch back. The DON stated an x-ray was obtained of Resident #55's left arm as ordered by her physician which showed no fracture or mass. The DON stated the Lidocaine patch was reordered as Resident #55 requested and they were waiting for an order to be approved for voltaren gel for pain since she did better with topical medication. The DON reiterated that Resident #55 was very difficult to give medication to due to her dementia and all staff had the same problem getting her to take medication. The DON stated that RN A had been written up for giving the ABH cream when she should have given pain meds and for not explaining to the resident the difference. The DON also stated that the Regional Compliance RN had started an in-service for all nurses regarding pain. Review of facility in-service Subject: Pain, dated 10/18/23, revealed: Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676068 If continuation sheet Page 11 of 12 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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 FORM CMS-2567 (02/99) Previous Versions Obsolete measures, and all available resources of the facility. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability need to be asked. If a resident is non-verbal, the questions will be a PAINAD assessment. When new acute pain is identified staff will complete a pain SBAR. Administer pain medication as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. Regardless of the resident cognition staff must address any c/o signs of pain and administer medication that is appropriate for the symptoms. Do not administer behavioral medication when it comes to addressing pain issues. Event ID: Facility ID: 676068 If continuation sheet Page 12 of 12