Health inspection·June 29, 2023

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or when it should have been transmitted. The Corporate MDS Consultant stated Resident #58's MDS assessment was overdue to transmit but had been transmitted on 06/28/2023. She was not able to identify any risks to residents due to the late submission of MDS data. In an interview on 06/29/23 at 02:40 PM the Administrator, he said that people at the corporate level monitored the timeliness of MDS submission and would follow up with facility staff regarding the submission of MDS data according to required timelines. He was not able to identify any risks to residents because of the late submission of MDS data. Record review of the facility policy MDS Completion and Submission Timeframes dated 09/2020 documented that the facility would conduct and submit resident assessments in accordance with current federal and state submission time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 2 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0641 Ensure each resident receives an accurate assessment. 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 each resident received an accurate assessment, that reflects the resident's status at the time of the assessment for 1 (Resident #41) out of 1 resident reviewed in accordance with professional standards. Residents Affected - Few The facility failed to document MDS assessment that accurately reflected the resident's current status for Resident #41. This failure could affect the resident by placing them at risk of not receiving adequate care due to the assessment not reflecting the resident's status at the time of the assessment. Findings included: Record review of Resident # 41's face sheet dated 06/28/23 revealed a [AGE] year-old female with an initial admission date of 11/17/19, and an readmission date of 05/09/23 to the facility. Record review of Resident #41's History and Physical dated 05/05/23 revealed a diagnosis of Alzheimer's (disease that affects memory slowly leading to people not being able carry out simple task). Record review of Resident #41's Quarterly MDS dated [DATE], in section B documented resident speech was unclear, had difficulty making herself understood and had difficulty understanding others. Section C documented Resident #41 was able to maintain focus during conversation however, Resident #41 had difficulty understanding and would lose focus easily. Section C indicated Resident #41 had a BIMS score of 8 indicating Resident #41 was cognitively mildly impaired. Resident #41 was coded as nonverbal, however Section C indicated she responded to questions. Resident #41 was coded as non-ambulatory, had left side weakness and a Hoyer lift was utilized for transfers and requires total assistance. However, section G indicated Resident #41 needed extensive assistance and 2 people assistance even for transfers. MDS assessment documented Resident #41 had no impairment to lower extremities . Finally, Section I documented active diagnosis of respiratory failure with hypoxia. Resident #41 is on a Puree consistent carbohydrate diet that is not documented in section K indicating no swallowing difficulties or altered texture. Record Review of Resident #41's care plan did not reflect the current status of Resident #41. Observation and interview on 6/27/23 at 01:45 PM with Resident #41 revealed resident was non-verbal, resident appeared unengaged with conversation. Interview on 6/27/23 at 01:47 PM with LVN G revealed that Resident #41 was nonverbal, other than facial expressions there wereis no other form of communication with Resident. LVN G stated if the MDS assessment does not accurately reflect the status of the resident it can affect the care provided. Interview with MDS Nurse B on 6/29/23 at 4:30PM revealed MDS assessments should reflect residents' status. MDS Nurse B stated, Resident #41 was verbal and able to communicate. MDS Nurse B stated MDS assessments were done incorrectly, it can affect the care provided to the residents. Interview on 06/29/23 at 03:45pm with CNA C, revealed Resident #41 had been non-ambulatory for a while unable to give exact dated confirmation over 6months. CNA C stated he always used a Hoyer lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 3 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when transferring Resident #41. CNA C stated Resident #41 was nonverbal, and she makes sound but never words. CNA C revealed Resident #41 required total care and feeding assistance as she was unable to feed herself. Policy for MDS Accuracy requested on 06/29/23 at 12:30pm, second request on 6/29/23 at 4:50pm, 3rd request prior to exit Administrator verbalized he would email policy, no policy for MDS Accuracy provided . Event ID: Facility ID: 676185 If continuation sheet Page 4 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for 2 (Resident #41 and Resident #50) of 19 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure the person-centered comprehensive care plan for Resident #41 accurately reflect the resident's current status. The facility failed to have a care plan for pain for Resident #50. These failures could place residents at risk of decreased quality of life due to pain control needs not being met and increased risk of skin-related issues due to not having their positioning needs met. Findings included: Record review of Resident # 41's face sheet dated 06/28/23 revealed a [AGE] year-old female with an initial admission date of 11/17/19, and an readmission date of 05/09/23 to the facility. Record review of Resident #41's History and Physical dated 05/05/23 revealed a diagnosis of Alzheimer's (disease that affects memory slowly leading to people not being able carry out simple task). Record review of Resident #41's quarterly MDS dated [DATE], in section B documented resident speech was unclear, had difficulty making herself understood and had difficulty understanding others. Section C documented Resident #41 was able to maintain focus during conversation. Section C also indicated Resident #41 had a BIMS score of 8 indicating Resident #41 was cognitively mildly impaired. Section G documented Resident # 41 needing maximum assistance with two people assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of Resident #41's comprehensive care plan dated 5/23/23 did not accurately reflect Resident #41's current status. Resident # 41 was nonverbal and did not have a care plan to address her impaired communication. Resident #41 also had a care plan documenting ADL deficit related to cognitive impairment dated 05/23/23 with the goal to improve level of function, and with interventions such as transfers with 1 person assistance. This care plan did not reflect the current care provided to Resident #41 since she was Hoyer lift transfer. Observation and interview on 6/27/23 at 01:45 PM with Resident #41 revealed resident was non-verbal, resident appeared unengaged with conversation unable to complete interview. Resident #41 was about to be placed in bed for nap as stated LVN G, as staff brought in the Hoyer lift to transfer Resident #41. Interview on 6/27/23 at 01:47 PM with LVN G revealed that Resident #41 was nonverbal, she communicates with facial expressions, groans, grading or pulling away for pain and discomfort. LVN G stated when Resident #41 was admitted she was able to speak and ambulated with assistance but has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 5 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 progressively deteriorated. LVN G stated Resident #41 cannot no longer ambulate and will only make sounds not words. Interview with MDS Nurse B on 6/29/23 at 4:30PM revealed MDS assessments were required to reflect residents 'status and then were utilized to create a comprehensive care plan. MDS Nurse B stated, the nurses working with Resident #41 should know what care is required for the resident, the nurses don't go read care plans they read doctor orders. MDS Nurse B stated MDS assessments and comprehensive care plans were done to determine the care needed for the residents and if it was not done correctly, it can affect the care provided to the residents. Resident #50 Record review of Resident #50's face sheet dated 06/29/2023 documented he was [AGE] years old and admitted to the facility on [DATE]. Record review of Resident #50's History and Physical dated 03/07/2023 documented he had diagnoses including type 2 diabetes and borderline intellectual disability. He had decreased leg strength in both legs, swelling and varicose veins. His cognitive impairment was evident. Record review of Resident #50's annual MDS dated [DATE] documented he had a BIMS of 7 (Severe cognitive impairment).? He required supervision from one person for all ADLs except eating (Limited assistance from one person) and personal hygiene (limited supervision with help to set up). He stated he rarely had pain, and in the last five days had pain at a level of 6 out of 10, with 10 being the worst. He had received PRN pain medication over the past five days. Record review of Resident #50's quarterly MDS dated [DATE] documented he had received PRN pain medication over the five days. In the last five days the resident had pain at a level 5 out of 10, with 10 being the worst. Record review of Resident #50's Care Plan dated 03/22/2022 documented no care plan specific to pain control. Pain was mentioned three times in his care plan: as a potential symptom of coronary artery disease, as a potential result of diabetes mellitus, and as a potential symptom of urinary tract infection. Record review of Resident #50's pain assessment dated [DATE] documented he rarely had pain which he rated at a 2 out of 10. Record review of Resident #50's physician orders documented the following orders: Order dated 03/04/2022, monitor pain every shift; order dated 04/01/2022, Acetaminophen-Codeine #3 (pain medication) Tablet 300-30 MG 1 tablet every 4 hours PRN for moderate pain; order dated 04/01/2022, Acetaminophen-Codeine #3 300-30 MG 2 tablets every 4 hours PRN for moderate pain; order dated 03/14/2022, tramadol HCl (medication for moderate to severe pain) 50 MG 1 tablet every 6 hours PRN for pain; order dated 03/14/2022 tramadol HCl 50 MG 2 tablets every 6 hours PRN for pain; order dated 03/04/2022, Tylenol Tablet 325 MG (Acetaminophen) 2 tablets every 4 hours PRN for pain or fever. Record review of Resident #50's MAR for June 2023 dated 06/28/2023 documented he reported pain on 06/02/2023 (pain level not documented).? The MAR did not document the administration of any pain medication at that time. On 06/24/2023 the resident received two Acetaminophen-Codeine #3 300-30 MG tablets for pain he rated at a level 4 out of 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 6 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 In an interview on 06/27/23 at 04:07 PM, Resident #50 said he had pain in his feet from diabetes and it hurt him whenever he tried to stand or walk. He did not remember if he received medication for pain. In an interview on 06/29/23 at 09:17 AM, RN A said Resident #50 had told her he had foot pain when he walked. She said the facility had become aware of this issue the morning of 06/29/2023. She said she assessed the resident for pain every shift and the resident rarely asked for pain medication. She said this the morning of 06/29/2023 was the first time Resident #50 had asked her for pain medications. RN A said that based on doctor's orders she was supposed assess for pain and that the resident would ask for pain medication of needed. The nurse said she did not know if physician's orders for monitoring for pain or orders for pain medication appearing on the resident's MAR should trigger inclusion of pain monitoring on the resident's care plan. She said if a resident said he has pain, it should be on the resident's care plan. In an interview on 06/29/23 10:30 AM the DON said that pain management should be on Resident #50's care plan. She said that since monitoring for pain and pain medications appeared in his doctor's orders and on the MAR, he should have pain management on his care plan. She did not know why pain management did not appear on his care plan. She said that if a resident had pain and did not have a care plan for pain management it could pose a risk if the resident complained and there was nothing in place to address the pain. She said that there was a risk of the resident's pain not being controlled. Record review of the facility policy Care Plans, Comprehensive Person-Centered dated 12/2016 documented that a comprehensive person-centered care plan included measurable objectives and timetables to meet resident's physical needs. The care plan would describe services to be furnished to attain or maintain the resident's highest practicable physical wellbeing, would incorporate identified problem areas, and aid in preventing or reducing decline in the resident's functional status and/or functional levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 7 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have an established system in place for accurate reconciliation for 4 (Hall 100, 200, 300 and 400) of 4 halls that had residents with orders for controlled substances. Licensed Staff were not signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy The facility failed to monitor expiration dates on the over-the-counter medication. These failures could affect residents by placing them at risk of drug diversion and receiving medication that will not provide the same result. Findings included: Controlled Drugs - Count Records: Record Review [DATE] of Controlled Drugs Shift Count Record for 8 out of 8 Medication Carts Revealed the following: Hall 100: Medication Aide Carts: Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 8 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 and off-going nurse at change of shift on [DATE],[DATE],[DATE],[DATE],[DATE],[DATE],[DATE] and [DATE] Level of Harm - Minimal harm or potential for actual harm Nurse Medication Cart : Residents Affected - Some Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] 200 Hall: Medication Aide Cart: Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) & (7AM -7PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 9 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 on-coming, and off-going nurse at change of shift on [DATE] Level of Harm - Minimal harm or potential for actual harm Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE], [DATE] Residents Affected - Some Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) & (7AM -7PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Nurse Medication Cart: Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE],[DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse on-coming at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 10 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 300 Hall: Level of Harm - Minimal harm or potential for actual harm Medication Aide Cart: Residents Affected - Some Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) (7:00AM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift from [DATE] to [DATE] No Controlled Drugs Count Record Sheets provided for March & April Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Nurse Medication Cart: Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) (7:00AM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift from [DATE] to [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse on-coming at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 11 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview and record review with LVN L on [DATE] at 09:51 AM, confirmed Controlled Drug Shift Count Record sheet for the month of [DATE] on the 300 hall had 15 blanks to include [DATE] nurse signature and the medication cart keys were inside the binder on top of medication cart. LVN L, stated they had been trained when hired to count at the beginning of the shift before signing to ensure narcotic counts were correct and to sign the Controlled Drug Shift Count Record sheet. LVN L, stated staff need to hand over the keys to the other nurse after narcotic count is complete and the person with the keys assumes responsibility to avoid drug diversion. 400 Hall: Medication Aide Cart: Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming at change of shift on [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Nurse Medication Cart: Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for off-going nurse at change of shift on [DATE], [DATE], [DATE], [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 12 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 Level of Harm - Minimal harm or potential for actual harm Controlled Drugs - Count Record dated [DATE] (7:00PM- 7:00AM) no signatures for off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) (7:00AM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift from [DATE] Residents Affected - Some Controlled Drugs - Count Record dated February 2023 (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated February 2023 (7:00PM- 7:00AM) no signatures for off-going nurse at change of shift on [DATE], [DATE], [DATE] Controlled Drugs - Count Record dated [DATE] (7:00AM- 7:00PM) no signatures for nurse on-coming, and off-going nurse at change of shift on [DATE] Interview and record review on [DATE] at 09:04 AM with Medication Aide M, revealed Controlled Drug Shift Count Record sheet for the month of [DATE] on 400 hall was missing a on-coming nurse signature for 7am-7pm shift on [DATE]. Medication Aide M stated, she was unsure what license staff member did not sign on that day. Medication Aide M stated, she was trained when hired to sign Controlled Drug Shift Count Record sheet after counting narcotics and ensuring the count was correct at the beginning or end of every shift. Medication Aide M also verbalize anytime you hand over the keys to your medication cart or take keys from any staff member to their medication cart, a medication count needs to occur since you are assuming responsibility for the controlled substances in that cart. Interview with the ADON on [DATE] at 02:05 PM revealed staff should be signing after they have counted narcotics and at the change of every shift. ADON stated the key to medication carts should never be left in the narcotic count binder and should be handed over after counting to the on-coming nurse and/or Med Aide. ADON stated nurses and med aides were trained upon hire, counting narcotic at change of shift. ADON stated accurate record of the Controlled Drug Shift Count Records was to ensure there were no discrepancies and diversion of narcotics. Observation and interview on [DATE] at 03:45 PM with the DON revealed 5 bottles of chlorhexidine gluconate solution 4.0% with expiration date of 09/2020 inside the cabinet in the medication room. The DON stated staff usually dispose of any over-the-counter medication or supply they find in the medication storage room and notify her or any ADON if it needs to be replaced. The DON stated all nursing staff is responsible for medication storage room. The DON stated expired over the counter medication should not be utilized since it does not have the same effect. Record review of the facility Controlled Substances policy dated [DATE] revealed nursing staff must count controlled medication at the end of every shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the director of nursing. Record review of the facility Storage of medication policy dated [DATE] revealed facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The nursing staff shall be responsible for maintaining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 13 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 0755 medication storage area clean, safe and sanitary. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 14 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety in that: The following were observed: -1 dented 105 oz. can of peaches found in same rack as other cans. -1 unlabeled container of green beans was found in refrigerator. -1 partly covered container of tuna salad was found in the refrigerator. -1 partly covered tray of watermelon was found in the walk-in refrigerator. -Missing refrigerator temperature entry for 6/26/23. These failures could place residents at risk of food-borne illness. Findings included: Observation of kitchen area on 06/27/23 at 8:20 AM revealed one 105 oz. dented can of sliced peaches was located on rack with other cans. The dented can was not separated and placed with the other dented cans. Observation of the refrigerator in the kitchen on 06/27/23 at 8:25 AM revealed a partly covered container of tuna salad dated 6/24 stored on one of the racks. Part of the plastic wrap was sunken into the container and did not cover it completely. There was also a container of green beans that was not labeled or dated stored on the top rack of the refrigerator. The temperature log for the refrigerator was posted on the refrigerator doors. The log was missing an entry for 06/26/2023 for morning and evening shift. Observation of walk-in refrigerator on 06/27/23 at 8:30 AM revealed a tray of watermelon slices that were partly covered. The plastic wrap did not cover the watermelon entirely. In an interview on 06/27/23 at 8:39 AM with Dietary Manager , she revealed food had to be labeled with date and time as soon as it was prepared to ensure it was?fresh and because it was part of the state regulations. She said the food also had to be completely covered to keep it from developing bacteria. She stated dented cans could not be used because she did not know?what could be under the dent and did not want to risk it being bacteria. She revealed?the temperature log had to be completed daily by checking the temperatures twice daily to ensure the refrigerator was?maintaining its' correct temperature in order for food to stay fresh. She stated if the temperature was not maintained then they would be able to call the maintenance worker. Review of the facility policy titled Food Receiving and Storage dated December 2008 read in part .All foods stored in the refrigerator or freezer will be covered, labeled and dated .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 15 of 16 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 676185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Lakes Nursing and Rehabilitation Center 1300 2nd St Granbury, TX 76048 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 .and documented according to state-specific requirements . Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Refrigerators and Freezers dated December 2014 read in part .Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures .Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily .all food shall be appropriately dated . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676185 If continuation sheet Page 16 of 16