Health inspection·May 10, 2023

F 0580 notified. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/10/23 at 2:16 p.m., CNA F said she was the aide who took Resident #17 the coffee. CNA F said Resident #17 was sitting in his wheelchair when she brought in the coffee. CNA F said before she could tell Resident #17 where his coffee was located on the table, he knocked it over spilling it on himself and the floor. CNA F said Resident #17 was wearing grey sweatpants when the coffee spilled. CNA F said she assisted Resident #17 to change his clothes but she did not see any marks because he covered himself up. CNA F said she notified the nurse and then left the room. Residents Affected - Few During an interview on 05/09/23 at 8:34 a.m., LVN E said she was the nurse on duty when Resident #17 spilled coffee on himself. LVN E said she assessed his left leg and noted a small, reddened area to his left inner thigh. LVN E said she did not think much about the reddened area because it was small and Resident #17 said it was fine and he did not complain of pain. LVN E said she made a note about the coffee spill in the physicians' book at the nurse's station. LVN E said the physician would check the book on his next rounds. LVN E said she did not report Resident #17's reddened area to the physician because his skin was not opened; he had no pain and it was a minor change. LVN E said it was important to notify the physicians of changes, but she did not feel this was anything major, so she did not notify the doctor. LVN E said she did not report the coffee spill on 05/05/23 to the DON or administrator because it was a redden area, it was not serious and she knew what happened. LVN E said she did not realize the redden area from the coffee spill was considered a first-degree burn (affects the epidermis, or outer layer of skin). During an observation and interview on 05/09/23 at 08:25 a.m., Resident #17 was sitting up in a wheelchair in his room. Resident #17 said his left leg/thigh was fine. Resident #17 did not recall what happened 05/05/23 on the evening of the coffee spill. During an interview on 05/10/23 at 2:36 p.m., the ADON said the physician should have been notified of the redness to Resident #17's leg from the coffee spill. The ADON said she expected the nurses to pick up the phone and notify the physician of any changes. She said it was important to notify the physician of any resident's changes so they would be aware and in case they wanted to order something new or stop something. During an interview on 05/10/23 at 2:53 p.m., the DON said she expected nurses to notify the physician of all changes whether minor or major. The DON said the charge nurses were responsible to notify the physician of any changes and her and the ADON were to follow up. The DON said without notification, the physician would not know if a resident had a change. During an interview on 05/10/23 at 3:26 p.m., the Administrator said she expected nursing staff to notify the physicians of any changes to the residents. The Administrator said administration nurses were to follow up on notifications. The Administrator said failure to notify the physician could impede the resident's care. Record review of facility policy change of condition, observing, reporting and recording dated May 2017 indicated, It is the policy of this home to inform the resident, the resident's physician and if indicated the residents responsible party of the following: #1 an accident or incident involving the resident which results in injury as it has the potential for requiring physician intervention. #2 a significant change in the residence physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, and life-threatening conditions or clinical complication. #4 A need to alter treatment significantly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 2 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 2 resident (Resident #3) reviewed for discharge MDS assessments. Residents Affected - Many The facility did not ensure Resident #3's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of a face sheet dated [DATE] indicated, Resident #3 was initially admitted on [DATE], and readmitted on [DATE] with the diagnoses of memory loss and high blood pressure. Record review of a discharge note dated [DATE] indicated Resident #3 expired in the facility. During interview with the ADON/MDS coordinator on [DATE] at 3:30 p.m., she said while reviewing the electronic medical record for Resident #3's MDS submissions the discharge MDS dated [DATE] was completed but was not transmitted. The ADON/MDS coordinator said she was unaware she failed to transmit Resident #3's discharge MDS. The ADON said she missed transmitting the discharge MDS for Resident #3 by mistake. The ADON/MDS coordinator said she was responsible for ensuring the MDS was transmitted correctly and timely. During an interview on [DATE] at 2:18 p.m., the DON said the ADON/MDS coordinator was responsible for submitting the MDS' timely and accurately. The DON said the ADON/MDS coordinator used a calendar to monitor the submissions. The DON said she was not auditing the MDS process. During an interview on [DATE] at 2:30 p.m., the Administrator said she expected the MDS' to be submitted timely and accurately. The Administrator said the ADON/MDS coordinator was responsible for ensuring timely submissions of the MDS data. The Administrator said the comptroller monitors the MDS process and advises them how to proceed. The Administrator said transmitting the MDS' late could affect entity payments on behalf of Resident #3. Record review of an Electronic Transmission of the MDS policy dated [DATE] indicated, all MDS assessments and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Record review of the MDS Completion and Submission Timeframes policy dated [DATE] indicated, our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 3 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents reviewed for care plans. (Resident #30) The facility failed to develop a care plan for Resident #30's right wrist and hand contractures. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 12/30/2022, indicated Resident #30 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified fracture of upper end of right humerus (break in the lower end of the upper arm), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #30 usually made self-understood and sometimes understood others. The MDS assessment indicated Resident #30 had a BIMS score of 11, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #30 required supervision for bed mobility, transfer, toilet use, and eating, limited assistance for dressing, walking, and personal hygiene. The MDS assessment indicated Resident #30 had a range of motion limitation in the upper extremity on one side. Record review of the Comprehensive Plan of Care and the Interdisciplinary Care Plan both dated 01/19/2023, indicated Resident #30 did not have a plan of care for her right hand and wrist contractures. Record review of Resident #30's physician's order dated 3/1/23, indicated OT (occupational therapy) consult diagnosis right wrist drop due to post-surgical please evaluate for splint and assist patient with splint application. Record review Resident #30's physician's order dated 04/12/23, indicated to discontinue carrot splint to right hand and continue previous hand splint to right hand as needed due to resident takes off per self. During an observation on 05/07/23 at 10:05 AM, Resident #30's right hand was with a downward contracture of her wrist. Resident #30's fingers were contracted to her palm with minimal movement. Resident #30 did not have a splint in place to her right hand. During an interview on 05/10/23 at 1:36 PM, LVN B said the care plans were updated by the ADON. LVN B said Resident #30's right wrist drop (contracture) should have been care planned so Resident #30 could maintain some movement to her right hand. LVN B said the care plan would therefore indicate the interventions being provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 4 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/10/23 at 01:55 PM, the ADON said she was responsible of updating the care plan. The ADON said she updated the care plan as soon as she received an order or when she completed an MDS. The ADON said Resident #30's right wrist drop (contracture) should have been care planned and was somehow missed. The ADON said by not having it care planned the staff would be not know that Resident #30 had limited movement to her right hand. Residents Affected - Few During an interview on 05/10/23 at 02:29, the DON said the ADON was responsible for updating the care plans. The DON said Resident #30's limited range of motion to right hand should have been care planned because she had a physical limitation and could not use her right hand. The DON said by Resident #30 not having her right wrist drop (contracture) care planned could cause staff to be unaware of her limitation to her right hand. During an interview on 05/10/23 at 3:02 PM, the Administrator said she expected the care plans to be person centered and more detailed. The Administrator said the ADON was responsible of updating the care plans. The Administrator said by not care planning Resident #30's right wrist drop (contracture), new staff would be unaware of Resident #30's limitation to right hand. Record review of the facility's policy last revised December 2016, titled, Care plans, Comprehensive Person-Centered, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 5 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 3 residents reviewed for pressure ulcers. (Resident #20) Residents Affected - Few LVN A failed to change his gloves while providing wound care for Resident #20. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 04/29/2022, indicated Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified sequalae of cerebral infarction (stroke), essential (primary) hypertension (high blood pressure), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #20 usually made self-understood and sometimes understood others. The MDS assessment indicated Resident #20 had a BIMS score of 5, indicating his cognition was severely impaired. The MDS assessment indicated Resident #20 required extensive assistance with bed mobility, transfer, and toilet use, and total dependence with dressing, personal hygiene, and bathing. The MDS assessment indicated Resident #20 did not have any unhealed pressure ulcers. Record review of the Comprehensive Plan of Care dated 05/10/2022, indicated Resident #20 had a Stage 2 (skin breakdown resulting in an opened wound) pressure ulcer and an approach to give medications as ordered, monitor labs, and report abnormal symptoms to the medical director. Record review of Resident #20's physician's order dated 05/08/23, indicated she had an order to apply Aquaphor to two stage 2 areas to buttocks every shift until resolved and to clean areas with normal saline before applying Aquaphor. During an observation and interview on 05/09/23 at 3:18 PM, LVN A entered Resident #20's room to provide treatment to her coccyx wounds. During the procedure LVN A failed to change his gloves after cleaning Resident #20's wound and before applying the Aquaphor ointment. LVN A said he was responsible for providing wound care as ordered and per policy. LVN A said he should have changed his gloves after cleaning Resident #20's wounds but did not. LVN A said failure to change his gloves placed Resident #20 at risk for infection. During an interview on 05/10/23 at 11:16 AM, the ADON said they could not find LVN A's wound care competency skill evaluation. During an interview on 05/10/23 at 1:55 PM, the ADON said she expected LVN A to change his gloves after cleaning Resident #20's wounds. The ADON said when going from dirty to clean gloves should be changed and hand hygiene performed. The ADON said if they were not changed the resident was at risk for cross contamination. The ADON said LVN A was responsible for ensuring he performed proper wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 6 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0686 care. The ADON said wound care competency skill evaluations were done annually. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/10/23 at 2:29 PM, the DON said she expected gloves to be changed when going from dirty to clean areas. The DON said she expected wound care to be done per policy and procedure and for the infection control guidelines to be followed. The DON said LVN A was responsible for ensuring he followed infection control policy and procedure. The DON said LVN A not changing his gloves after cleaning Resident #20's wound placed her at risk for infection. The DON said she had not completed the wound care evaluations for the nurses. Residents Affected - Few During an interview on 05/10/23 at 3:02 PM, the Administrator said she expected wound care to be done appropriately and expected LVN A to have changed his gloves after cleaning Resident #20's wounds. The Administrator said LVN A not changing his gloves placed Resident #20 at risk for infection. The Administrator said wound care competency evaluations should be completed upon hire and annually. The Administrator said the DON and ADON were responsible for ensuring those evaluations were completed. The Administrator said LVN A was responsible for ensuring he followed infection control policy and procedure. Record review of the facility's policy last revised October 2018, titled, Standard Precautions, indicated, . 2. a. Gloves (clean, non-sterile) are worn when in contact with bloody, body fluids, mucous membranes, non-intact skin, and other potentially infected material . e. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one .). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 7 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 - Immediate jeopardy to resident health or safety 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 an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. The IJ template was provided to the facility on [DATE] at 11:14 a.m., While the IJ was removed on 05/10/23 at 4:14 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for serious burns, infection and even death. Findings included: 1.Record review of Resident 184's face sheet dated 12/02/20 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including transverse radius fracture (wrist break), cerebrovascular accident (stroke - when blood flow to the brain is blocked), Dementia (impaired ability to remember), and depression (feeling sad). Record review of Resident #184's significant change in status MDS assessment dated [DATE] indicated she was usually understood and usually understood others. The MDS indicated Resident #184 was severely impaired (BIMS score was 02). The MDS indicated Resident 184 required total assist with transfers, dressing, bathing, extensive assist with bed mobility and supervision with eating. The MDS indicated Resident #184 had other skin problems requiring treatment. Record review of Resident #184's physician order summary report dated for the month of November 2022 did not indicate a treatment order for right upper leg. Record review of Resident #184's comprehensive care plan dated 12/01/22 indicated she was at risk for skin breakdown as evidenced by incontinence, impaired bed mobility and cognitive impairment. The interventions were to assist with repositioning as needed, give medication as ordered, assess skin weekly and report any changes to the physician. Record review of an incident report dated 11/19/22 at 7:00 a.m., indicated Resident #184 obtained three reddened areas to right upper leg from coffee spill. Area #1 measured approximately 3cmx2cm, area #2 measured approximately 5cmX1cm, and area #3 measured approximately 8cmX2cm. Resident #184 did complain of pain and received Morphine (pain medication) 0.25ml for pain. Resident #184 received a new order to apply Silvadene cream (medication to help heal burns) to affected areas twice daily for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 8 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 seven days. The incident report indicated the DON was notified on 11/19/23 at 8:10 a.m. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 05/10/23 at 2:09 p.m., LVN B said she was the nurse who assessed Resident #184 after staff reported she had spilled coffee on herself. LVN B said Resident #184 originally had three reddened areas but after reassessing after breakfast she developed a blister to area #3. LVN B said she notified the physician and received new treatment orders. LVN B said she did not know this was a reportable incident, but she reported the incident to the DON on 11/19/22. Residents Affected - Few During an interview and observation on 05/07/23 at 9:40 a.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher BB tested temperature on both coffee pots. The first coffee pot temperature was 147-degree Fahrenheit and second coffee pot temperature was 140-degree Fahrenheit. Dishwasher BB said she did not test the temperature of the coffee before pouring into the coffee pots. During an observation and interview on 05/08/23 at 1:41 p.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher CC tested temperature on both coffee pots. The first coffee pot temperature was 149- degree Fahrenheit and second coffee pot temperature was 142-degree. Dishwasher CC said she had never tested the temperature of the coffee. During an interview on 05/08/23 at 1:42 p.m., the dietary manager said coffee pots were assessable to everyone on the side table. He said the coffee temperature was not checked prior to leaving the kitchen. The dietary manager said he was aware a resident received a coffee burn sometime last year but could not remember who. He said he was unaware of Resident #17's hot coffee spill on 05/05/23. He said they did not implement any changes in the kitchen after the Resident #184 received burns from the hot coffee. The dietary manager said he was not aware the coffee should have been checked prior to leaving the kitchen. The dietary manager said he tested the coffee periodically but did not have a log. The dietary manager said he would start a temperature log for the coffee. During an interview on 05/08/23 at 4:22 p.m., the DON said she was aware Resident #184 obtained a coffee burn but did not realize it needed to be reported to HHS. The DON said she thought if they knew what happen it was not reportable. The DON said they put a plan in place for Resident #184 which included supervision for meals and a two handled cup for safety after the coffee spill. The DON said they did not do any in-services or implement a plan for other residents who might be at risk of coffee burns because she had implemented a plan for Resident #184 and did not think about any other residents who might had been at risk. During an interview on 05/08/23 at 4:28 p.m., the ADON said she was aware Resident #184 received a coffee burn the following Monday, 11/21/22 after the incident occurred. The ADON said she was not aware this type of incident needed to be reported since they were aware of how the incident occurred. The ADON said she did not look at any other residents who could have been at risk because they implemented a plan for Resident #189 During an interview on 05/08/23 at 4:39 p.m., the Administrator said initially she was not aware Resident #184 had a burn from the coffee. The Administrator said at some point later she became aware Resident #184 had a burn. She said she did not report to HHS because they had implemented a plan to protect Resident #184 from further burns and when they tested the coffee shortly after Resident #184 spilled the coffee on herself, the temperature was within their policy range of 133-degree Fahrenheit. The ADM said she did not think about the risk of other residents after she learned about Resident #184 because it was an isolated event and they had implemented a plan for Resident #184. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 9 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #184 had a second degree burn from the spilled hot coffee. 2. Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, and difficulty with balance and coordination). Record review of Resident #17's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. The MDS indicated Resident #17 was moderately impaired (BIMS score was 08). The MDS indicated Resident 17 required limited assistance with personal hygiene, dressing and supervision with bed mobility, transfers, toileting, and eating. The MDS indicated Resident #17 was continent of bowel and bladder. Record review of Resident #17's comprehensive care plan dated 02/16/23 indicated he had cognitive impairment as evidenced by memory problems and impaired ability to make daily decisions. The interventions were to explain all procedures, allow time for task, and reorient as needed. Resident #17 was on a regular diet and needed supervision for eating. The interventions were to assist with setup, explain to Resident #17 where his food was using the clock method due to his blindness. Record review of Resident #17's incident report dated 05/05/23 at 8:15 p.m., revealed Resident #17 spilled his coffee on his left thigh and obtained a 3-inch X 1-inch reddened area to his left thigh area. During an observation on 05/09/23 at 7:21 a.m., several residents in dining room for breakfast and observed Resident #12 spilling coffee on his shirt while drinking. Resident #12 noted with tremors and had to have his other hand to help with mobility while drinking coffee. During an observation and interview on 05/09/23 at 08:25 a.m., Resident #17 was sitting up in a wheelchair in his room. Resident #17's left upper leg assessed with no injuries noted. Resident #17 said his left leg/thigh was fine. Resident #17 did not recall what happened 05/05/23 on the evening of the coffee spill. During an interview on 05/10/23 at 2:16 p.m., CNA F said she was the aide who took Resident #17 the coffee. CNA F said Resident #17 was sitting in his wheelchair when she brought in the coffee. CNA F said she was supposed to tell Resident #17 where his coffee was located because he was blind CNA F said before she could tell Resident #17 where his coffee was located on the table, he knocked it over spilling it on himself and the floor. CNA F said Resident #17 was wearing grey sweatpants when the coffee spilled. CNA F said she assisted Resident #17 to change his clothes, but she did not see any marks because he covered himself up. CNA F said she notified the nurse and then left the room. During an interview on 05/09/23 at 8:34 a.m., LVN E said she was the nurse on duty when Resident #17 spilled coffee on himself. LVN E said she assessed his left leg and noted a small, reddened area to his left inner thigh. LVN E said she did not think much about the reddened area because it was small, and Resident #17 said it was fine and he did not complain of pain. LVN E said she made a note about the coffee spill in the physicians' book at the nurse's station. LVN E said the physician would check the book on his next rounds. LVN E said she did not report Resident #17's reddened area to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 10 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 - Immediate jeopardy to resident health or safety Residents Affected - Few physician because he did not have any visual openings to his skin; he had no pain, and it was a minor change. LVN E said it was important to notify the physicians of changes, but she did not feel this was anything major, so she did not notify the doctor. LVN E said she did not report the coffee spill on 05/05/23 to the DON or administrator because it was a redden area, it was not serious, and she knew what happened. LVN E said she did not realize the redden area from the coffee spill was considered a first-degree burn. During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #17 had a first degree burn from spilled hot coffee. Record review of Resident #17's nurses note charted by LVNE dated 05/05/23 at 9:00 p.m., revealed Resident #17 spilled coffee on his left thigh. Denied pain. Red area 3-inchX1-inch noted to front of left thigh. Record review of Resident #17's nurses note dated 05/05/23 at 9:00 p.m., did not indicate any notification to physician, nurse managers or administrator. During an interview on 05/10/23 at 2:36 p.m., the ADON said she was not aware of hot coffee spilling on Resident #17's left thigh until Monday 05/08/23. The ADON said she was not aware this type of incident needed to be reported to HHS since they were aware of how the incidents occurred. The ADON said she now knows this was a reportable event. The ADON said because they initiated the hot liquid safety assessment on 05/09/23 she did identify some residents who would benefit from some added safety such as: assist with hot liquids, drink hot liquids only at the table or drink hot liquids in a cup with a lid. During an interview on 05/10/23 at 2:53 p.m., the DON said when any abnormal incidents occur such as a burn the nurses were supposed to call her or the administrator. The DON said she was not aware of Resident #17's coffee burn on 05/05/23 but identified it on 05/08/23. The DON said she did not know it needed to be reported to HHS. The DON said she after reading the reporting letter she was aware of the criteria of what to report to HHS. The DON said failure to investigate incidents properly could delay safety for others. During an interview on 05/10/23 at 3:26 p.m., the administrator said she became aware on 5/8/23 of Resident #17's coffee burn that occurred on 05/05/23. The administrator said she was not aware why staff had not reported the incident on 05/05/23. The administrator said she was the abuse coordinator and should have been notified when Resident #17 obtained the coffee burn. The administrator said she reread the guidelines for reporting to HHS on 05/09/23 and realized she should have reported Resident #184's and Resident #17's coffee burn within 2 hours after learning about them both. Record review of the facility policy titled, Accidents, Incidents, investigating and reporting, dated July 2017, indicated All incidents or accidents involving residents .occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor or charge nurse shall promptly initiate and document investigations of the or accident. The nurse supervisor or charge nurse shall complete a report of incident/accident form and submit the original to the director of nurse's services within 24 hours of the incident or accident. The director of nurse's shall ensure the administrator receives a copy of the report of incident/ accidents for each occurrence. Record review of the facility policy titled, Abuse prevention, dated May 2017, indicated The facility will assure that all residents are free from verbal, sexual, physical, and mental abuse, corporal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 11 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 - Immediate jeopardy to resident health or safety Residents Affected - Few punishment, involuntary seclusion, neglect, and misappropriation of property. #4 E all injuries to a resident will have an incident report completed. Injuries of unknown origin will be investigated. Administrator and director of nursing will determine what injuries are to be reported to HHS per regulation. #7 the administrator will report all abuse, neglect, misappropriation of resident property allegations to HHS per regulation. This was determined to be an Immediate Jeopardy (IJ) situation on 05/09/23 at 10:33 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/09/23 at 11:04 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 05/10/23 at 2:14 p.m. and indicated the following: Immediate action: Implement measures to prevent other coffee spills with burns. Immediate removal of coffee from dining room coffee will be kept in the kitchen completed 5/9/23 at 10:45 AM. Coffee temperature immediately lowered to 110 degrees by adding ice. Coffee temperature will be maintained in a thermos. All hot liquids will be served at a safe temperature from our kitchen, per our policy for the safety of all residents. Completed 5/9/23 at 10:45 AM. Kitchen staff will check temperature of all hot/warm liquids before it leaves the kitchen. Resident #17 was screened by physical therapy and a recommendation of a cup with lid, screen completed 5/9/23 at 11:00 AM. In service all staff on setting up meals/drinks for all residents started on 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. All staff in-serviced on safety procedures for serving hot liquids/coffee completed 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. Added in-service on safety procedures for serving hot liquids to hire pack for all new employees to complete prior to working. Completed by business office 5/9/23. Hot liquid assessments to be done today for all residents 5/9/23. Completed on 5/9/23. Hot liquid assessments to be completed quarterly and on all admission done by a licensed nurse. Monitor temperature of hot liquid served to resident. All hot liquids will have temperature checked in kitchen prior to being served. Completed by kitchen staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 12 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 All kitchen staff will be in-serviced on new hot/warm beverage requirement. Completed 5/9/23 at 11:00 AM. Level of Harm - Immediate jeopardy to resident health or safety Identify at risk residents: Residents Affected - Few -amended 5/10/2023 coffee temperature per facility hot beverage policy. 15 residents at risk, all residents accessed for hot liquid safety done by nurse management 5/9/23. In-services: Coffee/hot liquid safety Safety procedures for serving hot liquids/coffee Assisting the impaired with in room meals Assistance with meals/snacks Monitoring: Interviews on 05/10/23 from 1:30 p.m. until 4:00 p.m. revealed the following: Interviews with 2 RNs: DON and RN L (6am-6pm); 1 LVN PRN nurses, (6a-2p),1 LVN B(6a-2p), 2 nurses (2a-10p), LVN B and LVN E (2p-10p), LVN K and LVN G (10p-6a), 3 CNA's (6a-2p) CNA N, CNA P and CNA Q,3 CNA's (2p-10p) CNA O CNA R and CNA F and 2 (10-6p) CNA AA and CNA S, 1 laundry T, 3 Housekeepers (8a-4p) Housekeeper U, housekeeper V and housekeeper W, 4 dietary (1p-7p) Dietary X Dietary Y, Dietary Z and cook D, Dietary Manager, Activity Director, ADON, and Adm in-serviced on hot liquid process. All coffee will come from the kitchen. Kitchen staff must test coffee temperature before serving to the residents. All hot liquids must be below 140 degrees Fahrenheit. Residents who need lids will be provided a cup with a lid. Record review of the facility policy titled, Hot beverage, dated 05/09/23, indicated Our long-term nursing care facility is committed to providing a safe and comfortable environment for all our residents, including their enjoyment of hot beverages such as coffee and tea. In accordance with state regulations, we have established the following policy regarding the temperature of hot beverages served in our facility. #1 hot beverages served will be cooled to a temperature below 140 degrees Fahrenheit. #2 residents that have been assessed to need hot beverages with a lid will receive their beverages in one. It will be delivered on their tray. #3 the temperature of hot beverages must be checked using a calibrated thermometer to ensure compliance with company policy before being served. #4 the kitchen staff will log the temperature of hot beverages on a hot temperature log once the beverage it is below 140 degrees Fahrenheit. #5 all hot beverages will go out on trays from the kitchen. #6 hot beverages that are not 140 or below must be cooled to 140 degrees Fahrenheit before being served to the resident. #7 all staff members involved in preparing and serving hot beverages must receive training on the proper temperature requirement for coffee and the importance of maintaining these standards. #9 residents who request hot beverages must be served promptly, but only with hot beverages that meet the temperature requirements outlined in this policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 13 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 - Immediate jeopardy to resident health or safety On 05/10/2023 at 4:14 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 14 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care (Residents #24). Residents Affected - Few The facility failed to ensure Resident #24 had an oxygen concentrator filter in place. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #24's face sheet dated 01/10/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses Alzheimer's Disease (a neurodegenerative disease that slowly and progressively worsens), fracture of right hip, chronic obstructive pulmonary disease (a progressive lung disease with log-term respiratory symptoms and airflow limitations), high blood pressure, and high cholesterol. Record review of Resident #24's most recent quarterly MDS dated [DATE] indicated she had a BIMS score of 9 which indicated moderate cognitive impairment. The MDS indicated Resident #24 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, toilet use, personal hygiene, and bathing. The MDS in section O did not indicate resident had oxygen. Record review of the care plan revised on 04/13/23 indicated Resident #24 had a condition called Chronic Obstructive Pulmonary Disease and she was at risk for symptoms such as cough, mucous, shortness of breath, and/or wheezing. Interventions included Resident #24 was to be administered oxygen therapy as needed. The care plan interventions also included, monitor for respiratory symptoms, and notify physician of unrelieved symptoms. Record review of Resident #24's Physician orders dated May 2023 indicated she had an order: May have O2 (Oxygen) at 2-4liters/minute via nasal cannula to keep saturations above 90% or shortness of breath with a start date of 01/19/23. During an observation and interview on 05/07/23 at 09:42AM, an oxygen concentrator was to the right side of Resident 24's bed. There was no filter in the oxygen concentrator filter slot. Resident #24 had oxygen on via nasal canula and it connected to the concentrator. The concentrator was set at 3 liters/minute. Resident #24 said she was not aware of the staff changing her filter. During an observation on 05/08/23 at 09:13AM, Resident #24 was in her bed. She wore her nasal cannula, and it was connected to the oxygen concentrator to the right of her bed. The oxygen was set at 3L/min. There was no filter in the oxygen concentrator. During an observation on 05/09/23 at 10:15AM, Resident #24 was in her bed. She wore her nasal cannula, and it was connected to the oxygen concentrator to the right of her bed. The oxygen was set at 3L/min. There was no filter in the oxygen concentrator. During an observation and interview on 05/10/23 at 01:50PM, Resident #24's oxygen concentrator sat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 15 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the right side of her bed. There was no filter in the oxygen concentrator. LVN B said there should always be a filter in Resident #24's oxygen concentrator and was not sure how it was missing. LVN B said filters on the oxygen concentrators were important because they filtered dust and debris and bacteria away from the resident. LVN B said the 10-6 nurses were responsible to ensure oxygen concentrator filters were cleaned and replaced weekly on Wednesday nights. LVN B said if she would have noticed there was no oxygen filter in place in Resident #24's oxygen concentrator she would have replaced it. During an interview on 05/10/23 at 02:23PM, the DON said it was the night shift's nurse responsibility to ensure oxygen concentrator filters were cleaned and replaced weekly (every Wednesday night). The DON said she expected all nurses to ensure the filters were in place and to replace filters if they noticed one was missing from a concentrator. The DON said there was not currently a system in place, other than the scheduled Wednesday night care related to oxygen filters. The DON explained the medication administration record or treatment administration record did not have a sign off area. The DON said it was important for oxygen filters to be in place/clean in the concentrators because the lack of the filter or a filter covered in dust could increase residents' risk for respiratory infections and respiratory complications. During an interview on 05/10/23 at 02:51PM, the administrator said she expected residents' oxygen concentrator filters to be clean and in place. The administrator said the 10-6 shift charge nurses were responsible for changing the filters and tubing out weekly, but she expected all staff to be observant of the concentrators during rounds on the halls. The administrator said it was important for the filters to clean and in place to prevent residents from having breathing, or lung problems. The facility policy Oxygen Administration dated October 2010 did not include information about the oxygen concentrator filter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 16 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #26) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #26's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of Resident #26's face sheet dated 03/02/2023 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of senile degeneration of the brain (mental loss related to aging, dementia), edema (swelling related to fluid retention), hypertension (high blood pressure), and atrial fibrillation (increased and irregular heart rate). Record review of Resident #26's admission MDS dated [DATE] indicated Resident #26 did not have a BIMS assessment because he was rarely/never understood related to severely impaired cognition. The MDS indicated Resident #26 had a 0 score which indicated he had no signs and symptoms of depression or mood disorder. The MDS indicated Resident #26 had behaviors of wandering daily. The MDS indicated Resident #26 required supervision for transfers, bed mobility, walking, and eating, and limited assistance of one person for dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #26 had 7 days of antipsychotic medications given over the 7-day look back period and on a routine basis. Record review of Resident #26's comprehensive care plan dated 03/09/23 indicated he had a diagnosis of depression and was at risk for an altered mood. The care plan indicated an intervention for Resident #26 was to take his medication, Seroquel 25mg tablet daily. Record review of Resident #26's physician orders dated April 2023 indicated Resident #26 had an order for Seroquel (Quetiapine) 25mg tablet by mouth twice daily for the diagnosis senile degeneration of the brain that started on 03/01/23. Record review of the Consent for Antipsychotic and Neuroleptic Medication Treatment dated 03/01/23 indicated that Resident #26 was taking Seroquel 25mg tablet 1 by mouth twice daily for Alzheimer's Disease and dementia with behavior disturbances and depression. During an observation on 05/07/23 at 10:33AM Resident #26 was sitting in his recliner sleeping with visible unlabored respirations. Resident had his call light within reach, walker and water. He had no extrapyramidal symptoms noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 17 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 During an observation on 05/10/23 at 1:35PM Resident #26 was walking with his walker, with an unsteady gait and posture, in the front lobby talking with another male resident. During an interview on 05/10/23 at 11:08AM the medical director said dementia with agitation was a standard use with the antipsychotic medication Seroquel. He said other interventions should have been placed for Resident #26 prior to using it. The medical director said Resident #26 admitted with the medication and the family was resistant to allowing him to discontinue or reduce the Seroquel dosage. During an interview on 05/10/23 at 02:00PM, LVN A said the medication Seroquel was an antipsychotic and it was not supposed to be used for residents with Alzheimer's Disease or dementia. He said he was accustomed to other medications being used such as Namenda or Aricept. LVN A said he was not aware of Resident #26 having a psychosis diagnosis so he could understand why Seroquel would be considered an unnecessary medication. LVN A said the potential outcome of giving Resident #26 a medication with no relevant indication or diagnosis could cause increase in falls or other adverse side effects of the medication. He said they completed behavior monitoring every shift. During an interview on 05/10/23 at 02:20PM, the DON said Alzheimer's Disease, dementia, nor depression were acceptable diagnosis for residents to take Seroquel. She said Resident #26 had the medication on his orders upon admit. She said she was responsible for talking with the medical director to ensure residents had appropriate diagnosis for medications but overall, the medical director would have to change any diagnosis. The DON said she had talked to the medical director about Resident #26's medication list when he had admitted so that he would review them and provide other alternatives, but the medications were never changed. The DON said the pharmacy consultant had also reviewed the medications and no changes were suggested. The DON said the failure of prescribing Seroquel without having an acceptable diagnosis could have caused Resident #26 to have a decline as well as extrapyramidal symptoms or increased confusion. During an interview on 05/10/23 at 02:55PM, the Administrator said Resident #26 should not have been taking Seroquel for Alzheimer's Disease, dementia, or depression. She said overall the medical director and the DON are responsible for ensuring residents have appropriate diagnosis for medications. She said the failure of not having a proper diagnosis for the antipsychotic medication could cause Resident #26 to have a decline as well as other issues with his care. During an interview on 05/10/23 at 03:15PM the pharmacy consultant said he was unsure about Resident #26's medication without having his file. He said Resident #26 could possibly have an order for Seroquel for adjunct therapy or if resident had failures with other medication trials. During an interview on 05/10/23 at 03:49PM Resident #26's responsible party said she was open to changes with Resident #26 and medications. She said she lived out of town and did not attend care plans, but the facility would call her. She said Resident #26 was prescribed the Seroquel by his neurologist and had been taking the medication for a long time. She was unsure of the date. Record review of the facility policy for Antipsychotic Medication Use revised December 2016 indicated Policy Statement Antipsychotic medications may be considered for residents with dementia but only after medical, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 18 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents Affected - Few Policy and Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated effective. 2. The attending Physician and other staff with gather and document information to clarify a resident's conditions for which they are indicated and effective . 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following condition/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g., bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in absence of dementia; . 11. Antipsychotic medications will not be used if only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 19 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 f. Insomnia; Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 20 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2. During an observation and interview on 05/07/23 at 11:27 a.m., nurses' cart #1 revealed Resident #7's Lispro insulin was not dated when opened. LVN A said the insulin bottle should have been dated when it was opened. LVN A said he administered Resident #7 12 units of Lispro for her 6:30 a.m. medication pass on 05/07/23. LVN A said he did not notice the bottle was not dated during his 6:30 a.m. morning medication pass. LVN A said all medication should be dated when open. LVN A said without knowing when the insulin was opened it could cause residents to not receive effective medication. During an observation and interview on 05/08/23 at 10:10 a.m., medication cart #2 revealed Fluticasone Propionate 50mg (nasal spray) filled on 3/27/23 with no date when opened for Resident #24, Fluticasone Propionate (nasal spray) 50mg filled 2/1/23 with no date when opened for Resident #8, Debrox ear drops with no date when opened for Resident #27 and quadrivalent influenza (flu) vaccine in fridge with no date when opened. LVN B said she was not aware these medications did not have an opened date on them. LVN B said the nurse or medication aide who opened the medication should have dated them. LVN B said the night nurses usually checked for expired medication on the medication carts and or medication room but it was all nurse's responsibility. LVN B indicated expired medications given to a resident could affect the efficacy of the medication. During an interview on 05/08/23 at 2:08 p.m., the ADON said she expected all medication to be dated when opened. The ADON said the nurse who opens the medication were responsible for dating it. The ADON said by not dating the insulin or other medications when opened the staff will be unaware of when the medication expires. The ADON said residents were at risk for the medications not to work properly. During an interview on 05/08/23 at 4:22 p.m., the DON said she expected all medication to be dated when opened. The DON said the person who first opened the medication was responsible for dating it. The DON said the carts were to be checked daily by the night nurses, but it was her responsibility to oversee the process. The DON said the residents were at risk for ineffective medications. During an interview on 05/10/23 at 3:26 p.m., the Administrator said she expected all medication to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Administrator said the carts were checked by the nurses and the nurse managers were to follow up. The Administrator said failure to date medication could lead to ineffective medication being received. Record review of the facility's policy titled Administering Medications revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility's policy last revised April 2019, titled, Storage of Medications, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended . Based on observation, interview, and record review the facility failed to provide pharmaceutical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 21 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0761 Level of Harm - Minimal harm or potential for actual harm services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 of 1 nurse's cart and 1 of 2 medication carts (#2 medication cart) reviewed for pharmacy services. The facility failed to ensure the nurse's cart was locked when left unattended in the hallway. Residents Affected - Some The facility failed to ensure all medications on the nurses' cart and the #2 medication cart were labeled when opened. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1. During an observation and interview on 05/09/23 at 09:28 AM, the nurse's cart was on the 100 hall and was unlocked. There was no staff present. LVN B came out of a resident's room, and she said she was the one responsible for leaving the cart unlocked. LVN B said it was her responsibility to lock the cart when left unattended. LVN B said by leaving the cart unlocked and unattended, residents could open the cart and take medications. During an interview on 05/10/23 at 1:55 p.m., the ADON said she expected all carts to be locked when left unattended. The ADON said by not locking the cart, residents could be at risk for getting into the cart and obtaining anything they want or overdosing on medications. The ADON said the person who had the keys for the cart was responsible for ensuring the cart remained locked when unattended. During an interview on 05/10/23 at 2:29 PM, the DON said she expected the carts to be always locked unless the nurse was getting something from it. The DON said the nurse who had the keys was responsible for ensuring the cart remained locked when leaving unattended. The DON said leaving the cart unlocked the resident was at risk for getting into the cart and taking medications they were not supposed to. During an interview on 05/10/23 at 3:02 PM, the Administrator said she expected the carts to be locked when not in use. The Administrator said the nurse was responsible for ensuring the cart stays locked when not in use. The Administrator said by leaving the cart unlocked, the residents were at risk of getting ahold of something unsafe for them to have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 22 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 14 residents reviewed for laboratory services (Residents #25). Residents Affected - Few The facility failed to obtain ordered CBC and BMP levels for Resident #25. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. Findings included: 1. Record review of Resident #25's face sheet dated 10/11/22, indicated a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included anemia (a condition in which the body does not have enough healthy red blood cells), congestive heart failure (condition in which the heart does not pump blood as well as it should), cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe). Record review of Resident #25's comprehensive care plan dated 10/20/22, indicated he had a history of congestive heart failure and was at risk for shortness of breath, chest pain, increased swelling, and blood pressure. The care plan interventions included to give medications as ordered, monitor labs, and report any abnormal labs to the medical director. Record review of Resident #25's MDS assessment dated [DATE], indicated he was usually understood and usually understood others. Resident #25's had a BIMS (Brief Interview for Mental Status) score of 10, indicating he had moderately impaired cognition. Resident #25 required supervision with bed mobility, transfers, walking, locomotion, and eating. Record review of Resident #25's physician orders for the month of April 2023, indicated he had an order for CBC and BMP every 2 weeks. Record review of Resident #25's medical record indicated CBC results obtained on 04/06/23 and BMP results obtained on 04/05/23.There were no results found for Resident's #25's CBC or BMP for the week of 04/19/23 or the week of 05/03/23. During an interview on 05/08/23 at 1:49 PM, the DON said Resident #25's CBC and BMP had not been collected since 04/06/23. The DON said the lab order must have fallen off the system for the lab to collect. The DON said the lab did not send any notification the order was about to expire and needed to be reinstated. During an interview on 05/10/23 at 11:05 AM, the Medical Director said he expected the lab to be drawn as ordered. The Medical Director said failure to do so could place the resident at risk for not having the proper follow up on specific medical problems. During an interview on 05/10/23 at 1:36 PM, LVN B said when she received a lab order she would write the order and then call the ADON or DON. LVN B said the DON and ADON were the only ones with access to place the lab order in the system for the lab company to obtain. LVN B said she had not seen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 23 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any notification on lab orders that were about to expire. LVN B said it was important for labs to be drawn as ordered as resident could be anemic and require changes in medication. During an interview on 05/10/23 at 01:55 PM, the ADON said she expected labs to be drawn as ordered. The ADON said the DON and herself were responsible for ensuring the routine labs were placed in the system. The DON said they do not print a lab requisition. The DON said the order was electronically sent to the lab once transcribed. The ADON said lab orders received on the weekend or after hours, the nurse was required to call her so she could therefore place the order in the lab system. The ADON said by not obtaining the labs as ordered placed residents at risk for their health status to decline. During an interview on 05/10/23 at 2:29 PM, the DON said she expected labs to be obtained as ordered. The DON said they do not have a lab monitoring system in place. The DON said it was her responsibility to ensure the labs were being drawn and the orders were up to date. The DON said the ADON and herself placed the lab orders in the system. The DON said the nurses do not have access to the lab system at this time. The DON said after hours, or weekend lab orders were called to the ADON and she placed the orders through her phone. The DON said the lab company obtained the labs according to what was ordered. The DON said Resident #25 had a history of gastrointestinal bleed and anemia, failure to obtain his labs placed him at risk for his hemoglobin (is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) and hematocrit (the percentage by volume of red cells in your blood) to drop and staff to be unaware. During an interview on 05/10/23 at 3:02 PM, the Administrator said she expected labs to be drawn as ordered. The Administrator said Resident #25 was anemic and it was important for his labs to be drawn as ordered to monitor his blood levels. Record review of the facility's policy last revised November 2018, titled, Lab and Diagnostic Test ResultsClinical Protocol, indicated, Assessment and Recognition 1. The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process the test requisitions and arrange for tests . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 24 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by Dietary [NAME] C and [NAME] D while they prepared and served residents' food. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 05/07/23 at 11:49 a.m., [NAME] C was not wearing a hair restraint appropriately while serving the lunch meal. [NAME] C's hair was visible outside of the hairnet at the ears and neck. During an observation on 05/08/23 at 11:23 a.m., [NAME] D was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] D's hair was visible outside of the hairnet at the base of her neck. During an interview on 05/08/23 at 1:45 p.m., [NAME] D said she wore a hair restraint to cover her hair and to prevent hair from falling into the food. [NAME] D touched her hair by the base of her neck and verbalized her hair was not appropriately in the hair restraint. [NAME] D said she had a lot of hair, and it was hard to keep all her hair in the hair restraint. [NAME] D said not having all her hair in the hair restraint could potentially cause food borne illness/contamination. During an interview on 05/08/23 at 1:48 p.m., the dietary manager said he saw [NAME] C and [NAME] D with partial hair out of their hair restraints. The Dietary Manager stated he was the overseer of the kitchen and he did daily spot checks and addressed any issues as needed. The dietary manager said he would do an in-service on the importance of wearing hair restraints and how to properly wear a hair restraint. The dietary manager said it was important to wear hair restraints to prevent hair from contaminating the food. During an interview on 05/10/23 at 11:30a.m., [NAME] C said the hair restraint should cover her whole head. [NAME] C was unable to say why her hair restraint was not covering her whole head. She said the dietary manager had talked with her on 05/09/23 and explained the importance of always keeping her hair in the hair restraint while in the kitchen. [NAME] C said there was a possibility for hair to get into the resident's food if all hair was not completely covered. Record review of in-service dated 05/09/23 revealed, [NAME] C and [NAME] D signed the in-service on hair restraints. Record review of policy hair restraint in food service kitchen indicated, The purpose of this policy was to establish guidelines for employees to follow when it comes to hair restraint in food service kitchens. Hair restraint was an essential component of maintaining a safe and sanitary environment in a food service kitchen and is necessary to prevent contamination of food. The policy applies to all employees who work in the kitchen or food preparation areas of the facility including cooks and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 25 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 dishwasher. #1 all employees working in the kitchen or food preparation areas must always wear a hair restraint. #2 hair restraints must be clean and in good condition. Hair restraints that are dirty torn or frail must be replaced immediately. #3 hair restraints must completely cover all hair on the head, including bangs and sideburns. #8 employees who fail to comply with a hair restraint policy may be subject to disciplinary action up to and including termination. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 26 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the first quarter October 1, 2022, to December 31, 2022). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met. Findings included: Review of the facility's undated staff roster indicated the following: 1 Administrator 3 RN's (included DON) 1 Maintenance person 1 Social Worker 1 Activity Director assistant 11 Licensed vocational nurses (included 1 ADON/MDS Coordinator) 12 CNAs/Medication aide 6 Housekeeping/Laundry Personnel 6 Dietary Personnel (included one Dietary Manager) Record review of the CMS 672 form dated and signed by the ADON on 05/07/2023 that was provided by the Administrator indicated a total of 31 residents in the facility. Record review of the CMS PBJ Staffing Data Report (payroll based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 1 2023 (October 1- December 31), dated 03/22/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. During an interview on 05/10/2023 at 2:18 p.m., the DON said she was not familiar with the payroll-based journal. The DON said she was unable to find a policy. During an interview on 05/10/2023 at 2:30 p.m., the Administrator said she thought the Comptroller was entering the payroll-based journal data. The Administrator said she was not familiar with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 27 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0851 payroll-based journal data. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 28 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify residents and/or the residents' Responsible Party (RP) or families by 5:00 p.m. the following day, after 2 of 2 residents (Resident #'s 14 and 84) test positive for Covid-19. Residents Affected - Few The facility failed to inform residents and/or the residents' RPs/family of Resident #'s 14 and 84's confirmed infections of Covid-19 by the 5:00 p.m. on 12/08/2022 and 03/02/2023. This failure could place residents, families, and responsible parties at risk of not being kept informed on the Covid-19 status in the facility. Findings included: 1. Record review of Resident #84 face sheet dated 12/08/2022 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of heart disease, diabetes, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath. Record review of a nurse note dated 12/07/2022 at 8:00 a.m., LVN A wrote Resident #84 was sent to the local emergency room with shortness of breath, decreased mental status, and a cough. Record review of a self-report 12/08/2022 indicated Resident #84 tested positive at the local hospital emergency room for Covid-19 infection. 2. Record review of a face sheet dated 03/07/2023 indicated Resident #14 admitted to the facility on [DATE] with the diagnosis of urinary tract infection, diabetes, and dementia (memory loss). Record review of a SARS COV2 (the virus causing Covid 19) lab results dated 02/28/2023 indicated Resident #14 was positive for the respiratory virus Covid-19. 3.Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, and difficulty with balance and coordination). Record review of Resident #17's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. The MDS indicated Resident #17's cognition was moderately impaired (BIMS score was 08). The MDS indicated Resident 17 required limited assistance with personal hygiene, dressing and supervision with bed mobility, transfers, toileting, and eating. The MDS indicated Resident #17 was continent of bowel and bladder. Record review of Resident #17's nursing notes for 12/08/2022 and 2/28/2023 did not reveal Resident #17 nor his family was notified of the facility's Covid-19 outbreak. During an interview on 05/08/2023 at 2:04 p.m., the ADON said the notification consists of calling the family/RP of the resident with confirmed Covid-19 and calling the roommate of the resident with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 29 of 30 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 676142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory Health and Rehab 983 N Texas Street Emory, TX 75440 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 0885 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed Covid-19. The ADON said then a note was posted on the front door notifying all other family members as they enter to visit. During an interview on 05/10/2023 at 2:18 p.m., the DON said she usually used a resident roster calling the RP/family then checking them off. The DON said she did not chart the calls in the resident's medical record. The DON said she was responsible for ensuring the residents and their RP/family were aware of Covid-19 infections in the facility. The DON said she did not notify the family members. During an interview on 05/10/2023 at 2:30 p.m., the Administrator said she expected the DON to notify the RP/family of the Covid-19 infections since she was the infection preventionist. The Administrator said the RP/family should know so they could decide for themselves if visiting was an option. Record review of a Coronavirus Disease (Covid-19)-Education and Training dated July 2020 indicated residents, visitors, family, and staff are provided educational material and updated information on Covid -19, including signs and symptoms, infection prevention and control, and testing. 4. New suspected or confirmed Covid-19 infections and deaths in the facility are reported to residents and their representatives and families within 24 hours, with a cumulative number reported at least weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676142 If continuation sheet Page 30 of 30