Inspection·March 7, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #1's Face Sheet reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Acute Respiratory Failure (sudden disease or injury that interferes with the ability of the lungs to deliver oxygen), unspecified Dementia (a group of thinking and social symptoms that interfere with daily functioning, impairment of at least two brain functions, such as memory loss and judgment), blindness right eye, and weakness. Residents Affected - Some Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating intact cognitive status. Her functional status reflected she required supervision or touching assistance for personal hygiene. Record review of Resident #1's Care Plan dated 03/16/2023 reflected she had an ADL self-performance including personal hygiene related to blindness. Interventions: Personal Hygiene: The resident requires extensive assistance with personal hygiene. Provide assistance as needed to complete tasks. Record review of Resident #1's Weekly Skin assessment dated [DATE] reflected her fingernails were clean, neat and trimmed. Observation and interview on 03/05/2024 at 10:52 AM in the bedroom of Resident #1 revealed she had 1-inch-long jagged fingernails past her fingertips on both hands. She stated she wanted them trimmed as they bent over because they were too long. Observation on 03/07/2024 at 7:45 AM in the dining room revealed Resident #1's fingernails had been trimmed short and were clean. 3. Record review of Resident 59's Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of unspecified Dementia (a group of thinking and social symptoms that interfere with daily functioning, impairment of at least two brain functions, such as memory loss and judgment) mild, with other behavioral disturbance and muscle weakness (generalized). Record review of Resident # 59's Quarterly MDS dated [DATE] reflected he had a BIMS score of 3 indicating severe cognitive impairment. His functional status reflected he required substantial/maximal assistance for personal hygiene. Record review of Resident #59's Care Plan dated 09/22/2022 reflected he had an ADL self-performance including personal hygiene due to deficits related to COVID-19 and dementia. Interventions: Showering/Bathing: Resident requires physical assistance with part of bathing/showering, provide assistance as needed to complete. Observation on 03/07/2024 at 7:46 AM of Resident #59 in the dining room revealed he had ¾-inch-long fingernails past his fingertips with brown debris under them. In an interview on 03/07/2024 at 7:50 AM, TNA C stated she had worked at the facility for almost eight months and stated she was responsible for making sure residents' nails were clean, but Resident #59 was scheduled for night shift bathing and those aides would trim his nails. She stated the potential risk of dirty nails was infection. In an interview on 03/07/2024 at 8:00 AM in the dining room CNA D stated she had worked for the company for 15 years. CNA D looked at Resident #59's nails, noting they were long with brown debris (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 2 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some underneath. She stated all staff were responsible for ensuring his nails were clean and trimmed but the night shift aides were responsible for giving him a bath and were supposed to trim his nails. She stated he could scratch himself and get an infection from the dirty nails. In an interview on 03/07/2024 at 9:05 AM the ADON stated she had worked at the facility since October 2021. She stated the facility had recently instituted a procedure where each Nurse Manager took responsibility for a hall and the Staff Development Nurse had the 400 Hall. She stated they oversaw everything on their assigned hall including the resident's appearance, hair, nails, and showers. She stated she and the Nurse Managers met with the DON, the Administrator and wound care nurse weekly to discuss issues regarding the residents. She stated her expectation was that the resident could refuse personal hygiene, however, they were offered showers and nail care two to three times a week per their preference. She further stated the potential risk to the resident of not receiving nail care was they could scratch themselves and the scratch could get infected. She stated they could get bacteria in their mouth from eating with dirty fingernails. In an interview on 03/07/2024 at 9:14 AM, the Staff Development Nurse stated she had worked for the company five years in June 2023. She stated the Nurse Managers recently decided to split the halls and check rooms for any maintenance issues, check residents for grooming, hair, nails, and oral care. She stated they would follow-up if a resident refused personal hygiene and there was no daily checklist. She stated they checked the residents three times a week on Mondays, Wednesdays, and Fridays for personal hygiene. She further stated the evening CNAs did bathing and showers. She stated if a resident had long nails there could be skin concerns as they could scratch themselves and cause an infection. She stated it was everyone's responsibility to look at the residents to ensure they were groomed properly. In an interview on 03/07/2024 at 9:48 AM, LVN E stated she had worked at the facility for three years and worked on the 100 and 400 halls. She stated she tried to keep up with the residents' nails and she had trimmed Resident #59's nails but he would get angry and curse. She stated they left him alone and did not like to get him upset as he hollered and called for mother dearest. She stated he could be really loud. She stated the risk to the resident was he could scratch himself and he had done that before and hurt his palms. She stated she was sure he could get an infection. In an interview on 03/07/2024 at 11:24 AM, the DON stated her expectations were that residents should have weekly skin assessments and then be checked by the nurse managers to catch anything that falls between the cracks. She stated she had communicated her expectations to staff that nails should be trimmed and cleaned. She stated if a resident refused nail care, staff should have documented the refusal and tried again. She stated the potential risk to a resident was they could scratch themselves and get an infection or cause injuries to other people. In an interview on 03/07/2024 at 11:44 AM, the Administrator stated his expectation was that residents would have their nails trimmed and cleaned on a consistent basis. He stated if their nails were untrimmed and unclean, the resident could get scratch themselves, get skin tears, and potentially get an infection or scratch someone else. He stated he would expect CNAs to check the residents' nails, then the treatment nurse and the nurse managers. Record review of the facility' Policy and Procedure titled Activities of Daily Living and dated 05/30/2023 reflected Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 3 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 maintain good nutrition, grooming, and personal and oral hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 4 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Provide activities to meet all resident's needs. 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 provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 3 of 5 residents (Resident #43, Resident #46 and Resident #59) reviewed for quality of life. Residents Affected - Few The facility failed to ensure one-on- one activities for Residents #43, Resident #46 and Resident #59 was provided according to the one-on-one activity schedule. This failure could place residents at risk for a decline in social, mental, psychosocial well-being, and a diminished quality of life. Findings included: 1. Record review of Resident #43's face sheet, dated 03/06/2024, reflected Resident #43 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: major depressive disorder ( a mental health condition that causes a loss of interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, and/or appetite changes), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (the loss of cognitive functioning such as: thinking, remembering, reasoning- to the extent that it interferes with a person's life and activities. No signs of behaviors disturbances), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), cognitive communication disorder (difficulty with processes include attention, memory, organization, problem solving/reasoning, and executive functions). Record Review of Resident #43's Significant Change MDS (activity staff does not document on quarterly MDS only significant change, annuals, or admission MDS's) dated, 02/23/2023, reflected Resident #43 had a BIMS score of three, which indicated the residents' cognition was severely impaired. According to the MDS it was very important for Resident #43 to be involved in the following activities: listening to music, go outside for fresh air and participate in religious activities. Resident #43 was not assessed to have any mood or behavior concerns. Record review of Resident #43's Quarterly assessment dated , 02/02/2204, reflected Resident #43 had a BIMS score of 3, which indicated the residents' cognition was severely impaired. Resident #43 did not respond to the questions about her mood. Resident #43 was assessed to have a diagnosis of the following: depression (a mental health condition that causes a loss of interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, and/or appetite changes), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and non-Alzheimer's dementia ( a progressive decline in behavior, language skills, or both, distinguishing if conditions like Alzheimer's disease- affects memory, thinking and behavior). Record review of Resident #43's Comprehensive Care Plan dated, last review was on 02/19/2024, reflected Resident #43 had impaired cognition/thought process. Resident #43 had short- and long-term (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 5 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few memory deficits and needed assistance with decisions. Interventions: engage resident in simple, structured activities that avoid demanding tasks. Resident preferred music, television, bingo, and one on one's. Record review of the facility's Group and One-on-One (in room activities) Participation Record Manual for the months of January 2024, February 2024, and March 2024 reflected Resident #43 did not have a participation record in the manual. Observation on 03/04/2024 at 10:52 AM, Resident #43 was in her room. There was a radio in her room and it was not on for resident to listen to music. Resident was in bed staring toward the ceiling. During an attempted interview on 03.04.2024 at 10:54 AM, Resident #43 did not communicate verbally or with gestures. Interview on 03/07/2024 at 8:43 AM, the Activity Director stated Resident #43 began one-on-one (in room activities) in February 2024. She stated she did not recall the date she changed Resident #43 from group activities to in room activities. She also stated Resident #43 was to receive one-on-one activities three times per week. The Activity Director stated Resident #43 had begun increasing time in her room due to decline in physical condition. She stated Resident #43 had a radio in her room. She also stated there was not a group or one-on-one (in room activities) participation record for Resident #43 during the months of January 2024, February 2024, and March 2024. She stated it was expected for her to document on the participation records anytime a resident participated in any type of activity program including one-on-ones. She stated she was busy and forgot to complete any type of documentation. The Activity Director stated if a resident with dementia (the loss of cognitive functioning such as: thinking, remembering, reasoning- to the extent that it interferes with a person's life and activities), depression and/or anxiety and did not receive any social visits or activities there was a possibility the resident cognition may decline, become more depressed, increase in anxiety and have a decline in quality of life. She stated it was very important for Resident #43 to have one-on-one activities due to her current physical condition and decline of coming out of her room over the past month. Interview on 03/07/2024 at 11:26 AM, TNA A stated she worked on the Secure Unit where Resident #43 resided. She stated she had not witnessed anyone including the Activity Director visiting Resident #43 and doing any type of activities with her. She also stated no one informed her of what type of music Resident #43 preferred. She stated the staff sometimes turned on the radio for Resident #43. She stated Resident #43 had declined coming out of the room over the past month due to her physical decline. She stated there Resident #43 did not have any documentation of receiving one-on-one activities or attending any group activities for the months of January 2024, February 2024, or March 2024. She stated it was expected of her to document on the participation records when a resident attended a group activity or received one-on-one activities. 2. Record review of Resident #46's face sheet, dated 03/06/2024, reflected Resident #46 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (it causes problems with reasoning, planning, judgement, and memory), frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage ( a symptom that happens with conditions that disrupt your brain's ability to control thoughts, emotions and behavior), Bipolar disorder ( a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns and behavior), lack of coordination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 6 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), and muscle wasting ( the thinning or loss of muscle tissue). Record Review of Resident #46's Annual MDS (activity staff does not document on quarterly MDS only significant change, annuals, or admission MDS's) dated, 11/01/2023, reflected Resident #46 had a BIMS score of zero, which indicated the residents' cognition was severely impaired. According to section F (preferences for customary routine and activities) reflected the Resident #46 did not respond to any of the activity preference questions. The staff completed section F and reflected Resident #46's activity preference was listening to music. Resident #46 was assessed to have non-Alzheimer's dementia (a progressive decline in behavior, language skills, or both, distinguishing if conditions like Alzheimer's disease- affects memory, thinking and behavior), bi-polar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns and behavior), muscle wasting (the thinning or loss of muscle tissue) and lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Record review of Resident #46's Quarterly MDS (activity staff does not document on quarterly MDS only significant change, annuals, or admission MDS's) dated, 02/01/2024, reflected Resident #46 had a BIMS score of zero, which indicated the residents' cognition was severely impaired. Resident #46 was assessed to have lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), bi-polar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns and behavior), muscle wasting (the thinning or loss of muscle tissue) and non-Alzheimer's dementia (a progressive decline in behavior, language skills, or both, distinguishing if conditions like Alzheimer's disease- affects memory, thinking and behavior). Record review of Resident #46's Comprehensive Care Plan dated, last review was on 01/10/2024, reflected Resident #46 was at risk for pain. Intervention provides diversional activities. Resident #46 had a diagnosis of Alzheimer/Dementia (affects the part of the brain associated with learning, symptoms include: changes in memory, thinking and reasoning skills). Resident #46 required assistance with decisions. Interventions: when Resident #46 was attempting to communicate allow resident time to complete thoughts, provide wording as able, encouragement of gestures such as pointing. Resident #46 was also assessed to be at risk for decline in cognition. Intervention: encourage and assist with physical activities as able. Resident #46 had long and short-term memory problems. He required verbal redirection and supervision for decisions. Intervention: encourage resident to attend activities of interest. Resident #46 had impaired cognition/ thought process related to short- and long-term memory deficits and needed assistance with decisions. Intervention: Engage Resident #46 in simple, structured activities that avoid overly demanding tasks. Use task segmentation (divides a demonstrated task into a sequence of skills). Record review of the facility's Group and One-on-One (in room activities) Participation Record Manual on 03/06/2024 for the months of January 2024, February 2024, and March 2024 reflected Resident #46 did not have a participation record in the manual. Observation on 03/06/2024 at 1:30 PM reflected Resident #46 was in room lying in bed without his television on for stimulation. His eyes were opened and he was staring toward the wall in front of him. The curtains were opened; however, the lights were off in his room. During an attempted interview and observation on 03/06/2024 at 1:33 PM, Resident #46 did not speak (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 7 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when he was asked questioned and he did not communicate with gestures. He continued to stare toward the wall in front of him and he would move his eyes and mouth. Interview on 03/07/2024 at 8:43 AM the Activity Director stated Resident #46 did not prefer to attend group activities and he was added to the one-on-one activity program (in room activities). She stated she did not remember when he was added to the one-on-one program but she did know Resident #46 was on the program during the months of January 2024, February 2024, and March 2024. She also stated Resident #46 was expected to receive one-on-one activities three times per week. She stated Resident #46 did not have a participation record during these months (January, February, and March 2024). The Activity Director also stated Resident #46 did not prefer being out of room very often and did not prefer group activities. She stated he did need one-on-one activities/visits. She stated he did not want any activity items. He preferred watching television and she did not know if he had a radio in his room. The Activity Director also stated Resident #46 liked to sleep a lot and he was not receiving mental or physical stimulation very often. She stated Resident #46 required one-on-one visits to promote interaction with others and to prevent a decline in his quality of life, his cognition and develop depression symptoms. She stated Resident #46 did not have any documentation of receiving one-on-one activities or attending any group activities for the months of January 2024, February 2024, or March 2024. She stated it was required for her to document all activity attendance on the participation record including one-on- one visits. Interview on 03/07/2024 CNA B at 10:30 AM stated she worked on the same hall where Resident #46 resided numerous times per week. She stated she did not witness the Activity Director entering Resident #46's room and doing any type of activities with him. She stated she had given care to Resident #46 and he did need someone to sit and talk with him and do some type of activity with him. CNA B stated she believed he would benefit from activities and they would help him mentally. 3. Record review of Resident #59's face sheet, dated 03/06/2024, reflected Resident #59 was a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, mild, with other behavioral disturbance ( affect memory, reasoning, and problem solving abilities and has behaviors such as agitation, anxiety, and /or psychosis) cerebral ischemia ( acute brain injury that results from impaired blood flow to the brain), disorientation ( a condition of having lost one's sense of direction), and muscle weakness (a lack of muscle strength). Record review of Resident #59's Annual MDS (activity staff does not document on quarterly MDS only significant change, annuals, or admission MDS's) dated, 05/15/2023, reflected Resident #59 had a BIMS score of three, which indicated the resident's cognition was severely impaired. According to section F (Preferences for Customary Routine and Activities) it was very important for Resident #59 to do his favorite activities and to go outside to get fresh air when the weather was good. It was somewhat important for Resident #59 to participate in religious activities, do things with groups of people, and to listen to music. Resident #59 was assessed to have the following diagnosis: disorientation (a condition of having lost one's sense of direction), cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), and muscle weakness (a lack of muscle strength). Record review of Resident #59's Quarterly MDS (activity staff does not document on quarterly MDS only significant change, annuals, or admission MDS's) dated, 12/06/2023, reflected Resident # 59 had a BIMS score of three, which indicated the residents' cognition was severely impaired. Resident #59 was assessed to have the following diagnosis: Non-Alzheimer's Dementia (a progressive decline in behavior, language skills, or both, distinguishing if conditions like Alzheimer's disease- affects memory, thinking and behavior), cerebral ischemia (acute brain injury that results from impaired blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 8 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few flow to the brain), and muscle weakness (a lack of muscle strength), and muscle weakness (a lack of muscle strength). Record review of Resident #59's Comprehensive Care Plan dated, last revised was on 03/05/2024, reflected Resident #59 was at risk for wandering. Intervention: Provide structured activities walking inside and outside and reorientation strategies (the determination of one's heading and location relative to that reference frame). Resident #59 was also assessed to have Dementia (a progressive decline in behavior, language skills, or both, distinguishing if conditions like Alzheimer's disease- affects memory, thinking and behavior). Intervention: Encourage and allow resident involvement in daily decision making and activity limit choices and use cueing. Record review of the facility's Group and One-on-One (in room activities) Participation Record Manual on 03/06/2024 for the months of January 2024, February 2024, and March 2024 reflected Resident #59 did have an Activity Participation Record for the month of January 2024. The participation record reflected Resident #59 had four one-on-one visits. He attended one music program, one social, and one church service. Resident #59 did not have an Activity Participation Record for the months of February 2024 and March 2024. Observation on 03/06/2024 at 3:30 PM Resident #59 was in his room lying in bed. He was watching television. During an attempted interview on 03/06/2024 at 3:33 PM, Resident #59 did not communicate verbally or with gestures. Interview on 03/07/2024 at 8:43 AM, the Activity Director stated Resident #59 was expected to receive one-on-one activities (in room activities) three times per week. She stated Resident #59 did not enjoy group activities very often. The Activity Director stated he needed more sensory type activities such as music. She also stated Resident #59 needed one-on-one activities to prevent further decline in his cognition and to enhance his overall quality of life. She stated he watched television but he needed the social interaction he would receive during one-on-one activity visits. The Activity Director stated receiving one-on-one activities four times per month was not enough for Resident #59. She stated there was no excuse why he was not receiving the activities he needed. She also stated there was no documentation of Resident #59's activity level for the months of February 2024 and March 2024. The Activity Director stated it was in the policy for her to document all activity participation including activities performed in residents' rooms. Interview on 03/07/2024 CNA B at 10:50 AM stated she had worked on the hall where Resident #59 resided, numerous times per month. She stated she had been working at the facility over 3 months. She also stated she had not witnessed the Activity Director enter Resident #59's room and do any type of activities with him. CNA B stated she believed if he received visits from the staff that had time to sit and talk to him and do some activities with him there was a possibility it may help him be happier. Interview on 03/07/2024 at 10:11 AM, the Administrator stated if the Activity Director did not document the in-room activities (one-on-one activities) on the activity record, then the activity did not occur. He stated all activities were expected to be documented on the appropriate form every time a resident attended a group activity or received in room activity visits. He stated he was the Activity Directors supervisor, and he would be monitoring the activity documentation more closely. He also stated it was highly important for the residents to receive one-on-one activities. He stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 9 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a possibility a resident may become depressed, have a decline in their cognitive status and a decline in their overall quality of life if they are not receiving enough socialization or a designed activity program to meet their individual needs and preferences. Record review of the Facility's Policy on Individual Activities and Room Visit Program, dated 2001, reflected Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. Policy Interpretation and Implementation: 1. Individual activities are provided for individuals who have a conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities program provides individualized activities consistent with the overall goals of an effective activities program. 3. It is recommended that residents with in-room activity programs receive, at a minimum, three in-room visits per week. A typical in-room visit is ten to fifteen minutes in length but may be longer if appropriate for the resident. Record review of the Facility's Policy on Activities, dated 2024, reflected It is the policy of this facility to provide an ongoing program to support residents in their choices of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activities refer to any endeavor, other than ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. Activities will be designed with the intent to: create opportunities for each resident to have a meaningful life. 1. Activities may be conducted in different ways: a. One-to-One Programs. b. Person appropriate- activities relevant to the specific needs, interests, culture, background, etc. c. Program of Activities- to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. 2. Activities will include individual, small, and large group activities as well as: a. In-room activities (the facility calls in room activities one-to-one activities). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 10 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0679 Level of Harm - Minimal harm or potential for actual harm Record review of the Facility's Policy on Documentation, Activity, dated 2001 reflected The Activity Director/Coordinator is responsible for maintaining, appropriate departmental documentation. Record keeping is a vital part of the activity programs. The following records, at a minimum, are maintained by Activity Department personnel: Residents Affected - Few a. Attendance records. b. Individualized Activities Care Plan or activities portion of the Comprehensive Care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 11 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. A. The facility failed to ensure Dietary Manager wore a hair net when standing by clean plates in the kitchen. B. The facility failed to maintain sanitary all 3 ovens and the only fryer in the kitchen. C. The facility failed to ensure the Dietary Manager properly used proper hand sanitation during food preparation. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illness, and decreased quality of life. Findings included: A. Observation on 03/05/21 at 9:05 AM, Dietary Manager exited the dining room and entered the dishwashing room area without wearing a hair net. She stood by clean plates and cups in the dishwashing room. The Dietary Manager continued to walk in the kitchen and stood by the sink where she donned her hair net. Observation on 03/05/2024 at 9:07 AM revealed there were hair nets available by the two kitchen doors (including the dishwasher room door) prior to entering the kitchen. In an interview on 03/05/2024 at 9:09 AM, Dietary Manager stated she entered the kitchen dish washing room without wearing a hair net and she was standing by the clean dishes. She stated she expected all staff, including herself, before they enter the kitchen, to place hair net on their head prior to entering the kitchen. She also stated she did not care if someone had one foot in the door of the kitchen, all staff including all departments, were expected to place a hair net on their head. She stated there was no exception for this policy/protocol. She stated there was a possibility hair may fall onto the plates and if no one saw the hair and it was on the resident's food there was a potential a resident may become ill with food borne illness from ingesting the hair such as vomiting and diarrhea. She also stated it depended on what chemicals was on the hair and how long it had been since a person had washed their hair. B. Observation on 03/05/2024 at 9:15 AM revealed in the kitchen three ovens each oven had approximately 1-2-inch-thick of black and brownish substance on the sides of the ovens. There were approximately ¼- ½ inch thick brownish/blackish substance on the racks in all three ovens. Observation on 03/05/2024 at 9:26 AM revealed the kitchen's deep fryer had crumbs in the two baskets attached to the back of the fryer. There was oil in the middle and back of the silver section of the fryer covering the oil. There were meal crumbs coated on the side of the deep fryer in the crevice (a small crack in something that forms an opening into the thing's surface). In an interview on 03/05/2024 at 9:33 AM, Dietary Manager stated the three ovens was dirty and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 12 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many needed to be cleaned. She stated there was blackish/ brownish substance built up on the bottom of the ovens, sides and on the oven racks in all three ovens. Dietary Manager stated she did not recall the last time the ovens had been cleaned. She also stated she thought it had been approximately two months and the ovens were required to be cleaned once a week. Dietary Manager stated the cook used the deep fryer on Friday (03/01/2024) to fry fish for lunch. She stated the cook was expected to clean the fryer on 03/10/2024 after she finished the lunch meal. Dietary Manager stated the fryer was also used on 03/04/2024 to prepare tater tots and the cook did not clean the fryer after cooking the tater tots. She stated she was responsible to manage the dietary staff and ensure they were properly cleaning the kitchen equipment. She also stated if the ovens were not cleaned weekly, food can build up in the ovens and in all three ovens and the deep fryer was not considered sanitary. The Dietary Manager stated there was a possibility room temperature particles of fish cooked on 03/01/2024, could fall onto the tater tots cooked on 03/04/2024. She stated if a resident ingested the particles of fish left in the fryer and the particles of tater tots, there was a possibility a resident that ingested the fish may have become physically ill with food poisoning. Record review of cleaning schedule for the months in November 2023, December 2023, January 2024, February 2024, and March 2024 on 03/06/2024 with the Dietary Manager reflected the ovens were only cleaned one time per month from November 2023 to March 2024. The Dietary Manager stated this was unacceptable and it was her responsibility to check the schedules to ensure the staff was cleaning the equipment per protocol . She stated the facility protocol was the fryer was expected to be cleaned after each use and she did not have the cleaning schedule of the fryer but had in-serviced all the staff in dietary to clean the fryer after each use. She stated it was assigned who was responsible for cleaning the ovens each week. She stated she did not know why the ovens were not cleaned week and she stated the fryer was to be cleaned by the cook after each use. Record review of Dietary Department in-service on Food Preparation, Food Safety Requirements, Dietary Employee Personal Hygiene, Handwashing Guidelines for Dietary Employees, Sanitation Inspection, Temperature for Safe Food Handling and Dietary Sanitation dated, 08/30/2024, reflected kitchen sanitation was discussed during the in-service including cleaning the kitchen equipment. The in-service records do not reflect who was responsible for in serving the dietary staff on 08/30/2024. C. Observation on 03/07/2024 at 11:15 AM, Dietary Manager was slicing and dicing onions on the food prep area beside the steam table. She walked away from the food prep table and entered the dishwashing room. Dietary Manager was looking at something on a shelf and touched some type of container. She doffed her gloves, sanitized her hands, donned new gloves, and exited the area where the sink was located and entered the kitchen area. She walked pass another person and touched this person shirt (left upper portion of the sleeve) with the palm and fingers on her left hand. The Dietary Manger continued with her task of touching the onions with both hands and she continued to cut/dice the onions and place the onions in a silver container. In an interview on 03/07/2024 at 11:23 AM, Dietary Manager stated she touched another person's sleeve with her left hand. She stated she did not think about removing her gloves, washing her hands, and placing new gloves on her hands. Dietary Manager stated anyone's clothing was considered contaminated. She stated when she touched a person's clothes and proceeded to touch the onions with both of her hands, the onions were considered contaminated. She also stated if some bacteria from another person's clothes transferred from her gloves to the onions, there was a possibility if a resident ingested the onion, they may become sick with some type of food borne illness such as vomiting, diarrhea. She stated it was a possibility the resident may become severely dehydrated and require to be assessed at the emergency room by a physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 13 of 14 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In an interview on 03/07/2024 at 10:11 AM, the Administrator stated any staff entered the kitchen was expected to place hair nets over their hair. He stated it was a possibility if the Dietary Manager was standing near clean plates, hair may have fallen off onto plates. He stated if the hair remained on the plates and a resident ingested the hair, there was a potential a resident may become ill such as diarrhea/ vomiting. He also stated it depended on what type of bacteria was on the hair. The Administrator stated when the Dietary Manger touched someone else's shirt, she was expected to remove her gloves, wash hands and place new gloves on her hands. He stated the shirt had a potential of being contaminated. He also stated if the Dietary Manager touched the onions with the same gloves, she touched someone else's shirt with, there was a possibility the Dietary Manager cross contaminated the onions. The Administrator stated if a resident ingested the onion, there was a low-risk potential a resident may become physically ill. He also stated he expected the fryer to be cleaned after each use and the ovens to be cleaned weekly. He stated if the dietary staff were not cleaning the ovens and deep fryer very often, the ovens and deep fryer would be considered not sanitary. Record review of the Facility's Food Safety Requirements, dated 2023, reflected It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 1. Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. 2. Food Service Safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. 3. Food Safety Practice includes equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. 4. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent cross contamination. Record review of the Facility's Handwashing Guidelines for Dietary Employees, dated 2023, reflected dietary staff are expected to sanitize hands after engaging in any activity that may contaminate the hands. Record review of the Facility's Dietary Employee Personal Hygiene, dated 2023, reflected It is the policy of this facility to utilize the following as guidelines for employee's personal hygiene to prevent contamination of food by food service employees. 1. Gloves are to be worn and changed appropriately to reduce the spread of infection. All staff must wear hair restraints (hair net, hat, and or beard restraint to prevent hair from contacting food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 14 of 14