Health inspection·August 29, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Review of Resident #41's Face Sheet dated 08/28/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #41's diagnoses included dementia (memory, thinking, difficulty), vitamin D deficiency, abnormality of gait and mobility, lack of coordination, alcohol dependence, stimulant abuse and dependence, insomnia (difficulty sleeping), hypertension (high blood pressure), muscle weakness, and cognitive communication deficit (problems with communication). Residents Affected - Some Record review of Resident #41's Quarterly MDS dated [DATE] revealed that Resident #41's BIMS score was a 5 indicating the resident could understand and make self-understood at times. Review of Resident #45's Face Sheet dated 08/28/2024 revealed he was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #45's diagnoses included hypertensive chronic kidney disease (damage to kidneys due to chronic high blood pressure), nausea, muscle weakness, hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety, and kidney disease and failure. Record review of Resident #45's Quarterly MDS dated [DATE] revealed that Resident #45's BIMS score was a 6 indicating the resident could understand and make self-understood at times. Observation of lunch hall trays being passed on 08/27/2024 at 11:53am revealed that CNA A did not knock on Resident #41's door before entering. CNA B walked into Resident #19's room without knocking. Observation of breakfast hall trays on 08/28/2024 at 7:24am revealed CNA C walked into Resident #35, #45 and Resident #19's rooms without knocking. An interview with the DON on 08/28/2024 at 2:39pm revealed that staff were to knock and wait for a response before entering the resident's room. She said all staff were required to always knock on the resident's door before entering. She said the resident may not feel good if staff just walk into their home without knocking. She said she did not know why staff were not knocking on the residents' doors. An interview with the ADM on 08/28/2024 at 3:01pm revealed that staff had been trained on resident rights and knocking on residents' doors. He said the policy was to knock on the door and ask permission to come in. He said all staff were supposed to knock before entering the resident's room. He said residents could feel different ways about staff not knocking. He said he was not aware staff were not knocking on resident's doors before entering. An interview with Resident #41 on 08/29/2024 at 7:47am revealed that he would like for staff to knock before entering his room. He said that most of the time the staff do knock but had to ask them to knock before. An interview with Resident #35 on 08/29/2024 at 7:51am revealed that staff do not knock on the door often. She also said that she does not get upset but it does startle her at times. An interview with Resident #45 on 08/29/2024 at 7:54am revealed that staff do not knock on the door most of the time. She said she would like the staff to knock but does not get upset. She also said that she would like for the staff to knock depending on what she was doing and if she was expecting them to come. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 2 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with Resident #19 on 08/29/2024 at 7:58am revealed that staff do not knock on his door most of the time. He said it did not matter if he wanted the resident to knock, if they wanted to come in, they would. He said that he would like the staff to knock. Observation of Resident #19's room on 08/29/2024 at 8:00am revealed that Resident #19 had put his call light on, and CNA C walked into Resident #19's room without knocking. An interview with CNA C on 08/29/2024 at 8:33am revealed she had been trained on resident rights. She said that all staff were to knock on the resident's door before entering the room. She said residents may feel like their privacy was being invaded. She said that she went into Resident #19's room because his call light will go off at times and he will be sleeping. She said she thought he was asleep. She said she did not know why she did not knock on the other resident's doors before entering. An interview with CNA D on 08/29/2024 at 8:47am revealed that she had been trained on resident rights. She said staff were to knock and announce themselves to the resident before entering the resident's room. She said if staff did not knock the resident may feel belittled or feel like staff were invading their privacy. She stated the staff may have forgot to knock before entering the resident's room. She also said everyone knows that they were to knock before entering. An interview with RN A on 08/29/2024 at 8:56am revealed that she had been trained on resident rights and knocking on resident's doors. She said that staff were to knock on the resident's door before entering. She said that the resident may feel uncomfortable if staff do not knock on their door before entering. She stated she did not know why she did not knock before entering the resident's room. Record review of Resident Rights Policy dated 11/28/2016 revealed the resident has a right to personal privacy. Policy for personal privacy was requested from the surveyor to the ADM on 09/04/2024 but at time of exit was not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 3 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #33) reviewed for bed positioning. The facility failed to ensure Resident #33's bed was in the lowest position for fall prevention per facility policy and procedure. This failure could place residents at risk of falls, injuries, pain, and hospitalization. Findings included: Record review of an undated Face Sheet for Resident #33 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Paraplegia (paralysis that affects the legs but not arms), and lack of coordination. Record review of the Quarterly MDS dated [DATE] for Resident #33 reflected he had a BIMS score of 15 indicating intact cognitive status. Record review of the Care Plan for Resident #33 dated 11/30/2023 and revised on 03/06/2024 reflected he was at risk for falls related to paraplegic status. An actual fall was noted. In an observation and interview on 08/27/2024 at 11:25 AM Resident #33's bed was not in the low position. There was a fall mat on the floor. RN A came into the room and lowered the bed. She stated his bed should be in low position and she lowered it to the lowest position. In an interview on 08/27/2024 at 2:16 PM RN A stated she had worked at the facility for 13 years. She stated Resident #33's bed should have been in low position because he had a fall in the past. She stated all of the nursing staff was responsible for ensuring the bed was in low position. In an interview on 08/29/2024 at 11:20 AM the DON stated her expectation was for a resident on fall precautions to have their bed in low position to make sure they don't fall again. She further stated the risk of not keeping the bed in low position was a potential fall. In an interview on 08/29/2024 at 11:25 AM the ADM stated his expectations of fall precautions was that their policy should be followed. He stated as far as potential risk, he didn't like to speculate. Record review of a facility policy and procedure dated 2003 and revised on October 5, 2016, reflected Preventive Strategies to Reduce Fall Risk Policy: the goal of fall prevention strategies is to design intervention that minimize fall risk by eliminating or managing contributing factors while maintain or improving the resident's mobility. Procedure: 7. Environment: Keep bed in low position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 4 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 that 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 1 of 1 resident (Resident #18) reviewed for pain management. Residents Affected - Few The facility failed to ensure Resident #18 received her 06:00 -10:00 AM daily scheduled Lidocaine Patch 5% for pain on 08/27/2024. This failure placed the resident at risk of increased pain and decreased quality of life. Findings included: Review of the undated Face Sheet for Resident #18 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pain in right shoulder and pain in unspecified joint. Review of the Quarterly MDS assessment dated [DATE] for Resident #18 reflected a BIMS score of 4, indicating severe cognitive impairment. Section I - Active Diagnoses reflected Resident #18 had pain in right shoulder and primary generalized osteoarthritis (common joint disease that causes pain and stiffness). Review of the Care Plan for Resident #18 dated 05/01/2024 and revised on 05/08/2024 reflected she had a potential for uncontrolled pain related to Arthritis. Her goal was to verbalize adequate relief of pain, and interventions included to administer analgesia as per orders anticipate the need for pain relief and respond immediately to any complaint of pain. Review of a physician's order for Resident #18 dated 09/20/2023 reflected Lidocaine 5% patch apply to right shoulder one time a day at 6:00 AM and remove at bedtime. In an interview on 08/27/2024 at 10:46 AM Resident #18 complained she had not been getting her pain medication on time and she was in pain down both shoulders down to her hands. In an interview on 08/27/2024 at 10:49 AM CNA/MA C stated she had worked at the facility for less than a month. She stated Resident #18 was supposed to get a lidocaine patch 5% to either shoulder. She stated she was getting to Resident #18's room for her medication pass really late . She further stated the risk to the resident was she would be experiencing pain for a longer time. In an interview on 08/29/2024 at 08:43 AM RN A stated her expectation was for residents to get their medications on time. She stated Resident #18 had prn pain medications, but she was not informed the resident was getting her pain patch late. She further stated the risk to the resident was pain and the MA should have let her know she was running late on her medication pass. In an interview on 08/29/2024 at 08:45 AM the DON stated her expectation was that medications ideally would be given an hour before or an hour after they were scheduled but they had a liberalized medication pass, and they could be given from 6:00 AM to 10:00 AM in the morning. She stated the MA should have let the nurse know they were running late on their medication pass. She stated the risk to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 5 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 the resident was that she could be hurting and uncomfortable and their goal was to keep her comfortable. Level of Harm - Minimal harm or potential for actual harm In an interview on 08/29/2024 at 11:25 AM the ADM stated he expected a resident to get their pain medication on time. He stated the risk to the resident would be pain. Residents Affected - Few Record review of an undated facility policy and procedure titled Liberalized Medication Policy reflected AM time code- May be given from 6 AM until 10 AM. If a physician's order specifically states the time of day a medication is to be given, then the facility must administer it at the time specified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 6 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room reviewed for sanitation. 1. The facility failed to ensure Dietary Staff F wore a beard restraint and hair restraint properly while in the kitchen. 2. The facility failed to properly store closed and dated food in the refrigerator. 3. The facility failed to ensure the Nourishment Room was properly cleaned, ice was stored properly, and items were correctly labeled and dated. 4. The facility failed to ensure Dietary [NAME] E properly sanitized her hands between tasks. 5. The facility failed to ensure Dietary [NAME] E referenced recipes while preparing foods. These failures could place residents who were served from the kitchen at risk for health complications and foodborne illnesses, and decreased quality of life. Findings included: Observation in the kitchen on 08/27/24 between 09:32 AM -10:15 AM revealed dietary staff F was standing by the freezer. Dietary Staff F had facial hair on his chin approximately 4 inches long and was not wearing a beard guard to cover all the facial hair. Observation in the kitchen on 08/27/24 between 09:32 AM -10:15 AM revealed Dietary Staff F was standing in the dish washing room with hairnet only covering half his hair. Approximately 6 inches of hair on the back of his head were not covered by the hairnet. Observation of the in kitchen refrigerator on 08/27/24 between 09:32 AM -10:15 AM revealed found that multiple items were missing dates. Observations of open and undated items included a bottle of open and undated Hershey's syrup, a bottle of sweet chili sauce, a jar of bread and butter pickles, and a gallon of vanilla ice cream. Observation of storage shelf above the prep station on 08/27/24 between 09:32 AM -10:15 AM revealed m Multiple shelf stable spices were missing dates including salt, sesame seed, ground all spice, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 7 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 ground cinnamon, and chives. Level of Harm - Minimal harm or potential for actual harm Observation of the in kitchen refrigerator on 08/27/24 between 09:32 AM - 10:15 AM revealed found that multiple items were improperly closed and exposed to air. Findings included a taquitos bag and a chicken nugget bag were undated, improperly closed, and exposed to the air. Residents Affected - Some Observation of in the nourishment room on 8/27/24 at 1:30 PM revealed that there were multiple food items in trays and unlabeled in the refrigerator. There there were cupcakes without a name or date sitting out on the counter uncovered, ice his chest was full of ice with ice scoop remaining in the ice chest. The ice chest had an unknown brown substance in the cracks of the ice chest where the lid fit into the bucket. Observed coffee creamer on a shelf with cleaning chemicals above it. Observed and multiple shelf stable items that were open and undated. Observations of Dietary [NAME] E onat 08/28/24 at 09:14 AM while preparing pureed foods found that she did not reference recipes for pureeing mixed vegetables, dinner rolls, and Salisbury Steak. while preparing foods. Dietary [NAME] E did not perform proper hand hygiene before she moved from processing purees to preparing bread rolls for the lunch meal. While finishing the purees she put on clean gloves, touched an unrelated cart, and grabbed got another pan for the regular mixed vegetables without changing gloves. Observation on 08/28/2024 at 11:45 am revealed found that Dietary [NAME] E was plating food without gloves, then put on gloves without washing hands then continued to plate food. Observed her push the serving cart outside of the kitchen, returned inside and didn't wash hands or put on new gloves. During an interview with Dietary Staff E on 8/29/24 at 12:45 PM he stated that the expectation was to wash hands and wear hairnets and beard Nets while in the kitchen. The company has a policy not to wear gloves while serving but not to touch foods with bare hands and use tongs while playing the roles. For storage they were we are required to put a lid on food label and date it then throw it out within seven days. They were We are required to sweep and mop all visible dirt out of this storage areas. Any condiments need to be labeled and dated. He stated that he had not gone through the nourishment room yet today but would do that later. He stated that any spoiled food could get residents sick and contaminate the food they eat. During an interview with Dietary [NAME] F on 8/29/24 at 12:55 PM she stated that they were when facility we are supposed to wash their our hands and put on gloves. Glove use wasis when we they were are serving food and cooking only. They We change their our gloves when they we do something different or leave the kitchen. She stated that for leftover food they wereare supposed to place in it a container and label it with the date and throw it away after 7 days. She she stateds that she checks for food labels multiple times a day. During an interview with the dietary manager on 8/29/24 at 1:00 PM he stated uh he expects employees to use gloves and hairnets all the time. There wasis a policy that they do not want themus to use gloves while serving. He expected them to grab hairnets and beard nets when they walk in the kitchen immediately. He states that they wereare supposed to go through the refrigerator daily and throw out food that wasis over a week old or wasis undated. He stated that he expected foods that wereare exposed to the air for longer than 12 hours or that have freezer burn to be thrown out. He expected his dietary staff to go through the nourishment room once a day to throw out food that is unlabeled or spoiled. He recognizes that if food spoils or gets contaminated it could lead to bacterial contamination and sickness for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 8 of 9 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 - Some During an interview with the administrator on 8/29/24 at 1:15 PM he stated that he expected his staff to wear hairnet and gloves as appropriate. He expected his staff to throw out food after three days and that all foods should be properly labeled and dated. If food had freezer burn or was exposed to air it should be thrown away. He expects that food should be stored according to facility policy. He expected his DON and ADON to maintain the nourishment room and alert dietary staff if it needs attention. When asked about negative outcomes to the resident for these failures; he stated that he does not want to speculate. During an interview with the DON and ADON at 8/29/24 at 1:33 PM they stated that the kitchen wasis supposed to stock the snacks and look at the dates. They stated that housekeeping wasis supposed to clean out the fridge for open food daily. They believe food should not be in there open for more than three days. Staff should not have any personal items in the nourishment room. They believe that there should be no food uncovered. They they believe that the cupcakes were from the night shift. They stated that the ice coolers should be cleaned daily by the kitchen although they've known it needs to be replaced because the lid does not stay on. The scoop should be in the pouch on the cart and washed daily. It should not stay in the ice cooler. The DON and ADON stated that if any of the food gets contaminated or bad it will hurt the residents. Review of the facility policy titled Sanitation and Food Handling reveals that Guideline #2 states Hairnet or hats (with a hairnet underneath) covering the hairline are always worn. [NAME] guards and required for facial hair. Guideline #4 DO not handle food with bare hands . remember to change gloves after touching anything that should not contact food, including clothing hair doorknobs, etc. Review of the facility policy titled Food Storage and Supplies dated 2012 states that 4. Open Packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Guideline 9 states that Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration or best buy date) , but non perishablenonperishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. Review of the facility policy titled Menu Approval and Honoring Resident Special Requests and Food Brought from the Facility from Unapproved Sources documents Guideline #2 states that if a family member or other visitor or staff brings prepared potentially hazardous time and temperature control for safety food items for a resident these items cannot be stored in the dietary department this poses a problem with potential cross contamination as the facility is unaware of how the food was handled or whether was maintained at an appropriate temperature during transport these items can be stored in the individual resident room or other approved areas depending on the food item. Before exit on 8/29/24 at 3:30 PM there was no policy available from the administrator related to for storage in the nourishment room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 9 of 9