Inspection·January 25, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #49's order summary report, dated 01/25/2023, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cerebral infarction (stroke), and dysphagia (difficulty swallowing). Record review of the MDS assessment, dated 11/30/2022, revealed Resident #49 had clear speech and was usually understood by staff. The MDS revealed Resident #49 was usually able to understand others. The MDS revealed no behaviors or refusal of care. The MDS revealed Resident #49 required extensive assistance with a one-person assistance with eating. Record review of the comprehensive care plan, last revised on 2/18/2022, revealed Resident #49 had an ADL self-care performance deficit and swallowing problem related to coughing during meals. The interventions did not address assistance required with eating. During an observation on 01/22/2023 at 12:49 PM, CMA L referred to Resident #49 as a feeder directly in front of Resident #49's room in the hallway. During on observation and resident interview on 01/22/2023 at 12:53 PM, NA K loudly referred to Resident #49 as a feeder approximately 30 feet from Resident #49's room in the hallway. Resident #15 was non-verbal during an attempted interview. During an interview on 01/25/2023 at 11:47 AM, NA K stated she was responsible for providing incontinent care to Resident #15. NA K stated she did provide incontinent care to Resident #15 with the door open. NA K stated she was in a hurry and the door popped back open. NA K stated it was not okay to provide incontinent care to residents without providing privacy. NA K stated the failure to Resident #15 for not providing privacy during incontinent care was the resident feeling exposed, a decrease in self-esteem, and lack of dignity and respect. NA K stated staff should not refer to residents as a feeder. NA K stated she referred to Resident #49 as a feeder during mealtime in the hallway. NA K stated she called Resident #49 a feeder without thinking. NA K stated the failure to Resident #49 for being referred to as a feeder was lack of privacy and lack of respect and dignity. During an interview on 01/22/2023 at 12:14 PM, CMA L stated she referred to Resident #49 as a feeder. CMA L stated she referred to Resident #49 as a feeder during mealtime in the hallway in front of her room. CMA L stated she should not have referred to Resident #49 as a feeder. CMA L stated it just slipped out without registering in her head. CMA L stated calling Resident #49 a feeder would have hurt her feelings and provided a lack of privacy for the amount of assistance she required with eating. During an interview on 01/25/2023 at 12:13 PM, LVN M stated NAs and CNAs were responsible for providing incontinent care to residents. LVN M stated she helped NAs and CNAs with incontinent care at times. LVN M stated NAs or CNAs were supposed to provide privacy during incontinent care. LVN M stated the door should have been closed prior to providing incontinent care for Resident #15. LVN M stated the failure to Resident #15 for not providing privacy during incontinent care was the resident being seen or exposed and lack of dignity and respect. LVN M stated staff should not use the term feeder. LVN M stated staff should word it another way, such as a resident who needs to be fed. LVN M stated the failure to Resident #49 for being referred to as a feeder was lack of dignity and respect. During an interview on 01/25/2023 at 2:57 PM, the DON stated privacy should have been provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 2 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few while providing incontinent care. The DON stated she expected staff to close the privacy curtain or the door while providing incontinent care. The DON stated she monitored this by performing random checks on direct care staff. The DON stated the failure to Resident #49 for not providing privacy during incontinent care was lack of privacy to the resident. The DON stated the staff should not refer to residents as feeder. The DON stated she expected staff to use terms like the resident needs to be fed. The DON stated the failure to Resident #49 for being referred to as a feeder was unknown because she would have to ask the resident. During an interview on 01/25/2023 at 3:15 PM, the Operational Manager stated he expected staff to provide privacy during incontinent care. The Operational Manager stated the failure to Resident #15 for not providing privacy during incontinent care was lack of dignity and respect. The Operational Manger stated he expected staff to not use the term feeder when referring to residents. The Operational Manager stated the failure to Resident #49 for referring to her as a feeder was lack of dignity and respect. Record review of the Resident Rights document, last revised October 4, 2016, revealed You [the resident] have the right to be treated with respect and dignity . The document also revealed You [the resident] have the right to personal privacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 3 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 22 residents (Resident #43) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately document Resident #43's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: Record review of Resident #43's order summary report, dated 01/25/2023, indicated Resident #43 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included muscle wasting and atrophy (thinning or loss of muscle tissue), essential hypertension (high blood pressure), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #43's admission MDS assessment, dated 09/16/2022, indicated Resident #43 usually understood others and made himself understood. The assessment indicated Resident #43 was moderately cognitive impaired with a BIMS score of 8. The assessment indicated Resident #43 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment did not indicate Resident #43 used tobacco. Record review of Resident #43's care plan, dated 09/13/2022, indicated Resident #43 was potentially at risk for injury related to smoking. The care plan interventions included, complete smoking assessment, explain smoking policy and maintain smoking material at nurse's station or other designated area. Record review of a smoking evaluation dated 12/18/2022 indicated Resident #43 smoked four times a day. During an interview on 01/22/2023 at 10:58 a.m., Resident #43 stated he had been a smoker since he was [AGE] years old. During an interview on 01/25/2023 at 10:51 a.m., RN N stated her responsibility was to ensure Resident #43 MDS was coded accurately. RN N stated Resident #43 MDS should have been coded for tobacco use. RN N stated she must have missed it at that time the assessment was completed. RN N stated audits were done at least once a month to ensure the MDS was coded accurately. RN N stated audits were done by her and she has not noticed any issues in the past month. RN N stated the risk of not coding the MDS correctly could potentially place residents at risk for not having their needs met. During an interview on 01/25/2023 at 2:01 p.m., the DON stated Resident #43 MDS should have been coded for tobacco use. The DON stated she was not aware until surveyor's intervention that Resident #43 was not coded for tobacco use. The DON stated RN N was responsible for monitoring the accuracy of residents MDS. The DON stated after RN N changed positions, she would be responsible for monitoring the accuracy. The DON stated Resident #43's tobacco uses not being coded on the MDS did not result in a failure because it was identified on the admission and a smoking assessment was completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 4 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 During an interview on 01/25/2023 at 2:27 p.m., the Administrator stated he expected the MDS assessments to be completed accurately. The Administrator stated RN N was responsible for ensuring Resident #43 MDS was coded accurately. The Administrator stated not completing the MDS assessments accurately placed the residents at risk for not having their needs met. The Administrator stated there was no policy related to MDS assessments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 5 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 - Some 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, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 22 residents reviewed for care plans. (Resident #18, Resident #49, and Resident #51). 1. The facility failed to ensure Resident #18 had a person-centered care plan to accurately reflect Resident #18's actual pressure wound. 2. The facility failed to ensure Resident #49 had a person-centered care plan to accurately reflect Resident #49's required one on one activities. 3. The facility failed to ensure Resident #51 had a person-centered care plan to accurately reflect refusal of care for ADLs. These failures could place the residents at increased risk of injury or infection and not having their individual needs met. The findings included: 1. Record review of Resident #18's order summary report, dated 01/24/2023, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of wedge compression fracture of the T11-T12 vertebra (fracture in the thoracic spine), gram-negative sepsis (infection in the blood stream caused by a gram-negative bacteria), and mild cognitive impairment (condition characterized by problems with language, memory and thinking). The order summary report further revealed an order for buttocks/coccyx, cleanse area with NS, pat dry, apply collagen and dry dressing every day that started on 01/06/2023. Record review of the MDS assessment, dated 11/09/2022, revealed Resident #18 had clear speech and was understood by staff. The MDS revealed Resident #18 was able to understand others. The MDS revealed Resident #18 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #18 required extensive assistant with one person staff assistance with bed mobility, toilet use, and personal hygiene. The MDS revealed Resident #18 had no wounds at the time of assessment and was not at risk of developing pressure ulcers/injuries. Record review of the comprehensive care plan, last revised on 01/20/2023, revealed Resident #18 had potential/actual impairment to skin integrity related to fragile skin. The goal was Skin injury of the buttock/coccyx will be healed by review date (04/16/2023). The only intervention was Educate resident/family/caregivers of causative factors and measures to prevent skin injury. The care plan did not address Resident #18's actual pressure wound, or interventions needed. Record review of the wound care progress note, dated 01/23/2023, revealed Resident #18 was seen for follow up on wound to the sacrum. The progress note revealed the wound has improved as evidence by smaller, increased epithelial tissue. The progress note revealed Wound #1 status is Open. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 1.0 cm in length, 1.4 cm in width, and 0.1 cm in depth. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 6 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 progress note revealed a diagnosis for Pressure ulcer of sacral region, stage 3. The progress note revealed a plan of: May shower/bathe as preferred; Change dressing every other day - clean with saline and gauze, apply collagen to wound bed, cover with dry dressing; Follow facility pressure ulcer prevention policy/protocol; Pressure redistribution mattress per facility policy/protocol; offload heels per facility policy/protocol. Residents Affected - Some 2. Record review of Resident #49's order summary report, dated 01/25/2023, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cerebral infarction (stroke), and dysphagia (difficulty swallowing). Record review of the MDS assessment, dated 11/30/2022, revealed Resident #49 had clear speech and was usually understood by staff. The MDS revealed Resident #49 was usually able to understand others. Record review of the comprehensive care plan, last revised on 2/18/2022, revealed Resident #49 preferred to watch TV in her room and she liked food related activities. The goal was Resident will attend/participate in activities of choice through next review date. The interventions included: Invite to scheduled activities; provide with activities calendar and notify resident of any changes to the calendar of activities. The care plan did not address Resident #49's required one on one activities. Record review of the Monthly List of One-On-One, undated, provided by Activity Director, revealed Resident #49 received one-on-one activities in room. Record review of the Activities, One-to-One Visits log, dated January 2023, revealed Resident #49 received in room activities on 01/03/2023, 01/09/2023, and 01/16/2023 that included: visit with staff, manicure, and reading. 3. Record review of Resident #51's order summary report, dated 01/25/2022, revealed Resident #51 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of the MDS assessment, dated 12/26/2022, revealed Resident #51 had clear speech and was understood by staff. The MDS revealed Resident #51 was able to understand others. The MDS revealed Resident #51 had a BIMS score of 5, which indicated moderately impaired cognition. The MDS revealed Resident #51 had no behavioral problems or refusal of care during the look-back period. The MDS revealed Resident #51 required extensive assistance with dressing, toilet use, and personal hygiene. The MDS revealed Resident #51 required total dependence with bathing. Record review of the comprehensive care plan, last revised on 05/23/2022, revealed Resident #51 had an ADL self-care performance deficit. The interventions included: Bathing: Requires extensive to total 1-2 staff participation with bathing. The care plan revealed no refusal of care with ADLs. Record review of the ADL documentation for December 2022, revealed Resident #51 refused bathing on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 7 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 12/02/2022, 12/12/2022, 12/13/2022, 12/16/2022, 12/19/2022, and 12/28/2022. Level of Harm - Minimal harm or potential for actual harm Record review of the ADL documentation for January 2023, revealed Resident #51 refused bathing on 01/02/2023, 01/06/2023, 01/11/2023, 01/18/2023, and 01/20/2023. Residents Affected - Some Record review of the Skin Check - Shower sheets, dated 01/16/2023 and 01/20/2023, revealed Resident #51 refused bathing and was signed by the resident. During an observation and resident interview on 01/22/2023 at 2:40 PM, Resident #51 was sitting up in her wheelchair outside her room. Resident #51 had un-kempt hair that looked oily. Resident #51 had several approximately 0.5 - 1-inch hairs on her chin. Attempted interview with Resident #51 was unsuccessful related to confused conversation. During an interview on 01/25/2023 at 11:47 AM, NA K stated she had worked full time on Resident #18, Resident #49, and Resident #51's hall for about 1 year. NA K stated Resident #18 had a wound to his bottom. NA K stated NAs and CNAs were responsible for turning and repositioning Resident #18 every 2 hours. NA K stated Resident #18 had been turned and repositioned every 2 hours, but he almost immediately repositions himself back on his back. NA K stated Resident #18 refused at times to be turned. NA K stated she has reported refusal of care to the nurse. NA K stated Resident #51 refused assistance with most ADLs. NA K stated Resident #51 liked to do things for herself and refused help most of the time. NA K stated she reported Resident #51's refusal of care to the nurse. NA K stated the Activity Director was responsible for performing in-room activities for Resident #49. NA K stated residents who refused help with showers or other ADLs should have been found in the [NAME] (electronical charting system that pulls interventions from the care plan to provide easy access for CNAs). NA K stated the failure to place interventions on the care plan, so it pulled over to the [NAME], for wounds or refusal of care with ADLs would cause direct care staff to not have been fully informed of the needed care of each resident. During an interview on 01/25/2023 at 12:13 PM, LVN M stated the treatment nurse was responsible for ensuring wounds were care planned. LVN M stated Resident #18 had a wound to his coccyx. LVN M stated interventions provided for Resident #18 were encouraging him to stay off his back as much as possible, dietary supplements, keep a pillow under his feet or heels to offload pressure, and monitoring intake. LVN M stated Resident #18 turned and repositioned himself. LVN M stated CNAs or NAs would turn and reposition Resident #18, but he would almost immediately reposition himself to lay on his back. LVN M stated Resident #49 was provided in-room activities. LVN M stated the Activity Director was responsible for providing in-room activities. LVN M stated Resident #51 refused ADL care and showers. LVN M stated refusal of care should have been care planned. LVN M stated MDS or the ADON was responsible for ensuring behavioral care plans were in the computer. LVN M stated the failure to Resident #18 and Resident #51 for not having an accurate, person-centered care plan was lack of consistency of care. During an interview on 01/25/2023 at 2:16 PM, the Activity Director stated she was responsible for ensuring activity care plans were updated and accurate. The Activity Director stated care plan meeting were conducted every 3 months and activity care plans were updated during the care plan meetings. The Activity Director stated care plans should have been personalized and patient centered. The Activity Director stated one-on-one, in-room activities should have been on the activity care plan. The Activity Director stated she was unaware why Resident #51 was not care-planned for in-room activities. The Activity Director stated Resident #51 had received in-room, one-on-one activities. The Activity Director stated the failure to Resident #51 for not having an accurate, person-centered care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 8 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 plan was staff not proving the correct activities for her. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2023 at 2:29 PM, LVN O stated she was the wound care nurse for the facility. LVN O stated she was responsible for ensuring wounds were on the care plan. LVN O stated wound care plans should have been patient centered. LVN O stated she felt like Resident #18's care plan accurately reflected the interventions that were provided by the facility. LVN O stated Resident #18 refused the low air loss mattress and repositioned himself back to his back after staff turned and repositioned him. LVN O stated all she was able to do is educate the staff and resident. LVN O stated she thought the care plan stated he refused care but was unable to find it on his care plan. LVN O stated the failure to Resident #18 for not having an accurate, person-centered care plan for his wounds was potential decline to wound status. Residents Affected - Some During an interview on 01/25/2023 at 2:57 PM, the DON stated the wound care nurse was responsible for ensuring wounds were accurately care planned. The DON stated she expected the care plan to accurately reflect the wound status and interventions provided by staff. The DON stated the interventions were being completed by staff, they just were not reflected in the care plan. The DON stated the failure to Resident #18 for not accurately care planning his wound status was potential decline in wound status. The DON stated she was aware Resident #51 refuses ADL care at times. The DON stated she was responsible for ensuring behaviors and refusal of care were reflected in the care plan. The DON stated refusal of care should have been reflected in the care plan. The DON stated the failure to Resident #51 for not accurately care planning her refusal of care would have been technical error and consistency of care. During an interview on 01/25/2023 at 3:15, the Operational Manger stated he expected staff to develop and implement care plans to accurately reflect resident status. The Operational Manager stated the failure to residents for not providing an accurate plan of care was inconsistent care and potential decline or risk for injury. Record review of the Skin and Wound Monitoring and Management policy, revised on January 2022, revealed This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care. The policy further revealed Procedure a. Resident Assessment e. Develop an individualized person-centered care plan based on the assessment and designed to minimize the possibility of skin breakdown. Record review of the Resident Rights document, dated October 4, 2016, revealed Planning and Implementing Care. You [the resident] have the right to be informed of, and participate in, your treatment, including the right to: request, refuse, and/or discontinue treatment . Record review of the Nursing Administration policy and procedure with the Subject: Care Planning, last revised on May 2007, revealed Procedures: 2. The care plan is developed by the IDT which includes but is not limited to the following professionals: E. Activity staff member responsible for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 9 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 22 residents (Resident #52 and Resident #70) reviewed for accident hazards. 1. The facility failed to ensure Resident #52's oxygen cylinder was securely stored. 2. The facility failed to ensure Resident #70 was free from an antiseptic agent containing alcohol. These failures could place residents at risk of injury. Findings included: Resident #52 Record review of the face sheet, dated 01/25/23, revealed, Resident #52 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (colon cancer), malignant neoplasm of upper lobe, left bronchus or lung (lung cancer), and chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order recap report, dated 01/25/23, indicated Resident #52 had an order for O2 (oxygen) at 1.5 L/MIN continuous per nc (nasal cannula) as needed with start date of 01/24/23. Record review of the MDS assessment dated , 12/23/22, indicated Resident #52 understood others and made himself understood. The MDS assessment indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Resident #52's MDS assessment indicated he required extensive assistance with bed mobility, dressing, toileting, and personal hygiene, and supervision for eating. The MDS assessment indicated Resident #52 did not have shortness of breath or trouble breathing. The MDS assessment indicated Resident #52 did not receive oxygen therapy while a resident at the facility. Record review of the care plan, last revised 01/08/23, did not indicate Resident #52 received oxygen therapy. During an observation on 01/23/23 at 03:02 PM, an oxygen cylinder was in upright position on the floor leaned against the wall in Resident #52's room. During an observation on 01/24/23 at 08:20 AM, an oxygen cylinder was in upright position on the floor leaned against the wall in Resident #52's room. During an observation on 01/24/23 at 11:51 AM, an oxygen cylinder was in upright position on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 10 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 floor leaned against the wall in Resident #52's room. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 01/24/23 at 03:20 PM, Nurse A said she was the nurse for Resident #52 and confirmed Resident #52 required the use of oxygen via nasal cannula. Nurse A said she did not know why the oxygen cylinder was on the floor leaned against the wall. Nurse A said the oxygen cylinders were stored in the oxygen room, off the floor, on a rack. Nurse A said Resident #52's oxygen cylinder should not be on the floor. It should be secured on the back of the wheelchair. Nurse A said the nurses were responsible for making sure the oxygen cylinders were stored properly. Nurse A said it was important to make sure the oxygen cylinders were stored properly because if it fell over it could release a harmful substance and if the oxygen cylinders were hit the wrong way they would blow up. Residents Affected - Few During an interview on 01/25/23 at 1:32 PM, the DON said oxygen cylinders should have been stored in a carrier, on the back of the chair in a sleeve, or in the oxygen room in a case. The DON said the oxygen cylinders should not have been left leaned against the wall in a resident's room. The DON said she was not aware there was an oxygen cylinder leaned against the wall in Resident #52's room. The DON said the nurses and management making rounds were responsible for ensuring the oxygen cylinders were stored properly. The DON said she made rounds twice a shift on each hall to ensure the oxygen cylinders were stored properly. The DON said it was important to properly store the oxygen cylinders because the oxygen cylinders could fall over and shoot off and cause injury. Record review of Resident #70's order summary report, dated 01/25/2023, revealed he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). Record review of the MDS assessment, dated 12/27/2022, revealed Resident #70 had clear speech and was understood by staff. The MDS revealed he was able to understand others. The MDS revealed no behaviors during the look-back period. The MDS revealed Resident #70 required supervision assistance with eating and personal hygiene. The MDS revealed Resident #70 had an active diagnosis of non-Alzheimer's dementia. Record review of the comprehensive care plan, last revised 01/04/2023, revealed Resident #70 was at risk for impaired cognitive function/dementia or impaired thought processes related to dementia. During an observation on 01/22/2023 at 10:25 AM, Resident #70 had a bottle of aftershave, containing alcohol, on his dresser. During an observation on 01/22/2023 at 03:29 PM, Resident #70 had a bottle of aftershave, containing alcohol, on his dresser. During an observation on 01/23/2023 at 08:58 AM, Resident #70 had a bottle of aftershave, containing alcohol, on his dresser. During an interview on 01/23/2023 at 10:27 AM, the DON stated the facility did not have a policy on personal products kept at bedside. The DON stated if a resident had a diagnosis of dementia personal products needed to be kept in a drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 11 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2023 at 11:47 AM, NA K stated antiseptic agents, such as aftershave, were allowed to be on the dresser in residents' room if it was a personal item. NA K stated if a resident had dementia, personal items were still allowed at bedside if the residents name was on it. NA K stated Resident #70 kept his aftershave on his dresser. NA K stated the failure to Resident #70 for keeping aftershave on his dresser was an increased risk of injury. Residents Affected - Few During an interview on 01/25/2023 at 12:13 PM, LVN M stated personal items, such as aftershave, were allowed at bedside if the resident was in their right mind. LVN M stated use of personal items at bedside should have been included in the care plan. LVN M stated a resident with a diagnosis of dementia should have aftershave placed in a bag and stored inside a drawer. LVN M stated Resident #70 had a diagnosis of dementia, and his aftershave should have been kept inside a drawer. LVN M stated the failure to Resident #70 for keeping his aftershave on his dresser was potential for poisoning and GI upset. During an interview on 01/25/2023 at 2:57 PM, the DON stated personal care items could have been kept at bedside. The DON stated if a resident had a diagnosis of dementia, aftershave could still have been kept at bedside. The DON stated the facility had no residents currently, who wandered into other residents' rooms. The DON stated Resident #70 would not have ingested his aftershave that was kept at bedside. The DON stated the failure to residents with dementia for keeping aftershave on the dresser was dependent on how bad the dementia was. During an interview on 01/25/2023 at 3:15 PM, the Operational Manager stated personal care items, such as aftershave, should not be kept at resident's bedside. The Operational Manager stated he expected staff to store aftershave appropriately when it was found at bedside. The Operational Manager stated the failure to residents with dementia for keeping aftershave on the dresser was increased risk for harm by ingestion. Record review of the Nursing Administration policy and procedure with subject of Accident Interventions, last revised May 2007, revealed The purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. Further review of the policy revealed 8. Oxygen tanks are to be secured when stored and when in use.; and 34. Any other unsafe condition or potential hazard should be reported to the Administrator or DNS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 12 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 respiratory care was provided with professional standards of practice for 3 of 6 residents (Residents #36, #40, and #3) reviewed for respiratory care and services. Residents Affected - Some 1. The facility failed to ensure Residents #36 and #40's oxygen concentrator filters were free of grey, fuzzy material. 2. The facility failed to administer oxygen at 2 via nasal cannula as prescribed by the physician for Resident #3. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings include: 1. Record review of Resident #36's order summary report, dated 01/25/2023, indicated Resident #36 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), essential hypertension (force of the blood against the artery walls is too high). Record review of Resident #36's order summary report, dated 01/25/2023, indicated Resident #36 received oxygen between 3-4 liters per minute via nasal cannula continuously every shift with a start date 07/13/2022. Record review of Resident #36's admission MDS assessment, dated 03/10/2022, indicated Resident #36 understood others and made himself understood. The assessment indicated Resident #36 was cognitively intact with a BIMS score of 15. The assessment indicated Resident #36 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #36 had SOB with lying flat. The assessment indicated Resident #36 was receiving oxygen therapy. Record review of Resident #36's care plan, with an initiated date of 03/08/2022, indicated Resident #36 had a dx of COPD with exacerbation noted related to history of smoking. The care plan interventions included, give oxygen therapy as ordered by the physician, monitor for difficulty breathing on exertion, and monitor for s/sx of acute respiratory insufficiency. Record review of Resident #36's oxygen concentrator service manual indicated the air filter should be removed and cleaned as needed. During an observation and interview on 01/22/2023 at 10:44 a.m., Resident #36 was sitting in his wheelchair wearing oxygen via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. Resident #36 stated he wore oxygen continuously due to SOB. During an observation on 01/23/2023 at 10:30 a.m., Resident #36 was sitting in his wheelchair wearing oxygen via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 13 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 - Some During an observation on 01/23/2023 at 3:00 p.m., Resident #36's filter on the oxygen concentrator was grey with fuzzy material. 2. Record review of Resident #40's order summary report, dated 01/25/2023, indicated Resident #40 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), generalized anxiety, and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #40's order summary report, dated 01/25/2023, indicated Resident #40 received oxygen at 2 liters per minute via nasal cannula continuously every shift with a start date 09/13/2022. Record review of Resident #40's annual MDS, dated [DATE], indicated Resident #40 understood others and made herself understood. The assessment does not address Resident #40 cognitive status. The assessment indicated Resident #36 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #36 was receiving oxygen therapy. Record review of Resident #40's care plan, with a revision date of 09/09/2021, indicated Resident #40 had a dx of COPD related to lifestyle and history of smoking. The care plan interventions included, give oxygen therapy as ordered by the physician, monitor for difficulty breathing on exertion, and monitor for s/sx of acute respiratory insufficiency. Record review of Resident #40's oxygen concentrator service manual indicated the air filter should be removed and cleaned as needed. During an observation and interview on 01/22/2023 at 10:39 a.m., Resident #40 was sitting on the side of the bed watching television wearing oxygen via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. Resident #40 stated she wore oxygen continuously due to SOB. During an observation on 01/23/2023 at 9:30 a.m., Resident #40's was lying in bed wearing oxygen via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. During an observation on 01/23/2023 at 2:55 p.m., Resident #36's filter on the oxygen concentrator was grey with fuzzy material. During a telephone interview on 01/25/2022 at 1:34 p.m., RN T stated she was Resident #36 and Resident #40's 10p-6a charge nurse. RN T stated she was responsible for cleaning the oxygen concentrator filters. RN T stated she was unable to clean/change their filters on 01/22/2023. When asked why she was not able to clean their filters, she stated I don't have a reason why they weren't clean. RN T stated this failure could place residents at risk for respiratory infection. During an interview on 01/25/2023 at 9:38 a.m., the ADON stated every Monday morning her and the DON did rounds for oxygen and nebulizers to ensure the tubing/humidifier was dated and filters were clean. The DON stated she believed she looked at Resident #36 and Resident #40's filter on 01/23/2023 but overlooked it. The ADON stated this failure could place residents at risk for respiratory infection. During an interview on 01/25/2023 at 2:01 p.m., the DON stated she expected Resident #36 and #40's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 14 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 - Some oxygen concentrator filters to be clean or changed on Sunday nights. The DON stated rounds were made twice a week by her and the ADON to ensure filters were clean and free from dust particles. The DON stated due to state in the building, her and the ADON got off their normal task. The DON stated the risk associated with not cleaning/changing the filters could place resident's respiratory health at risk. During an interview on 01/25/2023 at 2:27 p.m., the Operational Manager stated he expected Resident #36 and Resident #40's oxygen concentrator filters to be cleaned when scheduled. The Operational Manager stated this was monitored by the DON. The Operational Manager stated this failure could place residents at risk for respiratory infection. 3. Record Review of Resident #3's order summary report dated 01/25/2023, indicated Resident #3 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis of dementia (memory loss and confusion), hypertension (force of the blood against the artery walls is too high) and COPD (Chronic inflammatory lung disease that causes obstructed airflow from the lungs). Resident #3's order summary report indicated Resident #3 received oxygen at 2 liters per minute via nasal cannula continuously. Record review of Resident #3's annual MDS, dated [DATE], indicated Resident #3's mental status was rarely or never understood and unable to determine the BIMS score. The assessment indicated Resident #3 was receiving oxygen therapy. Record review of Resident #3's care plan with a revision date of 12/30/2022, indicated Resident #3 received oxygen therapy. The care plan interventions included oxygen setting: 2-3L via nasal cannula PRN (as needed). During an observation on 01/22/23 at 11:13 a.m., resident #3 was lying in bed wearing oxygen set on 3 liters per minute via nasal cannula. During an observation on 01/22/23 at 03:04 p.m., resident #3 was lying in bed wearing oxygen at 3 liters per minute via nasal cannula. During an observation and interview on 01/24/23 at 10:01 a.m. with RN F, Resident #3 was lying in bed wearing oxygen set at 3 liters per minute via nasal cannula. RN F stated she was responsible for the C hall residents and Resident #3 should have had his oxygen on 2 liters per minute per the physician order. RN F did not know why the oxygen was set on 3 liters per minute but stated she should have called the physician and got the order changed. RN F stated if the oxygen setting was wrong, Resident #3 would not have received the correct dose ordered from the physician. RN F stated if the oxygen setting was too low, the resident could have gotten short of breath and if the oxygen setting was too high, the resident could have received too much oxygen. During an interview on 01/25/23 at 11:16 a.m. with the DON, the DON stated the charge nurse was responsible for making sure the oxygen setting was correct on the halls. The DON stated any staff member could look at the oxygen setting to have checked it and she expected the oxygen to be on the correct setting. The DON stated nurses should have made rounds every 2 hours throughout the day and should have been monitoring the oxygen settings. The DON stated if the oxygen level was not correct, the resident could have gotten short of breath or could have received too much oxygen. During an Interview with the Administrator on 01/25/23 at 11:36 a.m., the Administrator stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 15 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete expected the nurses to follow the physician orders and they should have checked resident rooms every two hours to make sure the oxygen settings were correct. The Administrator stated the oxygen should have been set at 2 liters per minute if that was what the physician ordered. The Administrator stated nurses were responsible for making sure the oxygen settings were correct. Record review of the policy on Oxygen Administration, revised on 05/2007 indicated oxygen therapy was administered as ordered by the physician. Event ID: Facility ID: 676190 If continuation sheet Page 16 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 - Few 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #45) of 22 residents reviewed for pharmacy services. The facility did not ensure Resident #45 received her Lantus Solostar Solution (diabetic medication) and blood sugar checks as ordered by the physician. This failure could place the residents at risk of not receiving the intended therapeutic benefit of their medications and accidental exposure or drug diversion. Findings include: Record review of Resident #45's order summary report, dated 01/25/2023, indicated Resident #45 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus with diabetic nephropathy (chronic condition that affects the way the body processes blood sugar, progressive death of nerve fibers, which leads to deterioration of kidney function), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). Record review of the order summary report, dated 01/25/2023, indicated Resident #45 was prescribed Lantus Solostar Solution Pen 100 unit/ml, 20 units subcutaneously at bedtime for diabetes with a start date 11/16/2021. Record review of the order summary report, dated 01/25/2023, indicated Resident #45 was prescribed Lantus Solostar Solution Pen 100 unit/ml, 30 units subcutaneously one time a day for diabetes with a start date 11/17/2021. Record review of Resident #45's annual MDS assessment, dated 04/29/2022, indicated Resident #45 understood others and made herself understood. The assessment indicated Resident #45 was moderately cognitive impaired with a BIMS score of 12. The assessment indicated Resident #45 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #45 had a diagnosis of diabetes mellitus. The MDS assessment indicated Resident #45 received insulin during the last 7 days since admission/entry. Record review of Resident #45's care plan, with a revision, dated of 09/02/2021, indicated Resident #45 had a dx of diabetes mellitus. The care plan interventions included, take diabetic medications as ordered by the physician, monitor/document side effects and effectives, monitor/document/report to MD PRN s/sx of hypo/hyperglycemia. Record review of the MAR, dated 11/02/2022-11/30/2022, indicated RN U did not administer Resident #45's Lantus Solostar or check her blood sugar on 11/2/2022 at 8:00 p.m. Record review of the MAR dated, 12/01/2022-12/31/2022, indicated RN U did not administer Resident #45 Lantus Solostar or check her blood sugar on 12/19/2022 and 12/26/2022 at 8:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 17 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 Record review of the MAR dated, 12/01/2022-12/31/2022, indicated LVN O did not administer Resident #45 Lantus Solostar or check her blood sugar on 12/20/2022 at 8:00 p.m. Record review of the MAR dated, 12/01/2022-12/31/2022, indicated LVN V did not administer Resident #45 Lantus Solostar or check her blood sugar on 12/23/2022 at 8:00 a.m. Residents Affected - Few Record review of the MAR dated, 01/01/2023-01/31/2023, indicated RN U did not administer Resident #45 Lantus Solostar or check her blood sugar on 01/19/2023 at 8:00 p.m. During an observation and interview on 01/23/2022 at 1:45 p.m., Resident #45 was unable to recall if she received her insulin or her blood sugars was checked on 11/2/2022, 12/19/2022, 12/20/2022, 12/23/2022, 12/26/2022, and 01/19/2023. Resident #34 did not have any negative outcomes from the Lantus Solostar not given and blood sugars not checked. During an interview on 01/25/2023 at 9:59 a.m., RN U stated she was Resident #45's 2p-10p charge nurse on 11/02/2022, 12/19/2022, 12/26/2022, and 01/19/2023. RN U stated, per documentation, it appeared her blood sugar was not checked, or insulin administered. RN U stated to her, knowledge the medication was given, and her blood sugar was checked. RN U stated she was in a hurry and forgot to document on the MAR. RN U stated this failure could potentially put Resident #45 at risk for hypo/hyperglycemia. During an interview on 01/25/2023 at 10:21 a.m., LVN O stated she was Resident #45's 2p-10p charge nurse on 12/20/2022. LVN O stated, per documentation, it appeared her blood sugar was not checked, or insulin administered. LVN O stated to her knowledge, the medication was given, and her blood sugar was checked. LVN O was unable to give a reason it was not documented on the MAR. LVN O stated this failure could potentially put Resident #45 at risk for hypo/hyperglycemia. An attempted telephone interview on 01/25/2023 at 11:12 a.m. with LVN V, the LVN charge nurse for 12/23/2022, was unsuccessful. During an interview on 01/25/2022 at 2:01 p.m., the DON stated she expected charge nurses to document when Resident #45's insulin was administered, and blood sugars checked. The DON stated she monitored the dashboard (shows missing documentation) weekly. The DON stated during monitoring, it would prompt her if any charting was not documented. The DON stated the last few months had only showed vital signs were not documented. The DON stated the facility will be revamping the dashboard to ensure all documentation was placed in the residents' electronic medical records. The DON stated this failure could potentially put Resident #45 at risk for hypo/hyperglycemia. During an interview on 01/25/2023 at 2:27 p.m., the Operational Manager stated he expected charge nurses to document when Resident #45's insulin was administered, and blood sugar checked. The Operational Manager stated this was monitored by the DON. The Operational Manager stated this failure could potentially put Resident #45 at risk for hypo/hyperglycemia. Record review of the facility's policy titled, Medication & Treatment Order, revised on 05/2007 revealed, .It is the policy of this facility that medications and treatments are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe . 5. Medications shall be administered as soon as possible . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 18 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. 27 opportunities were observed with a total of 3 errors, resulting in a 11.11 percent medication error rate. Two (Residents #37 and Resident # 25) of five residents reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure Resident #37 received oxycodone-acetaminophen tablet 10/325mg to be administered at 6:00 a.m. CMA H administered the medication at 8:33 a.m. to Resident #37. The facility failed to ensure Resident #25 received Tramadol 50 mg at 6:00 a.m. and Protonix 40 mg at 6:30 a.m. The medications were administered at 8:51 a.m. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1.Record Review of Resident #37's face sheet (01/25/23) indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. The face sheet indicated he had a diagnosis of Hypertension (force of the blood against the artery walls is too high), chronic pain syndrome and Type 2 diabetes (blood sugar disorder). Record review of Resident #37's MDS assessment (11/22/2022) indicated Resident #37 had a BIMS score of 15 for cognitively intact. The MDS assessment indicated Resident #37 had a diagnosis of pain in left shoulder and pain in his left upper arm. The MDS assessment indicated Resident #37 received scheduled pain medications and had not received any PRN medications. Record review of Resident #37's care plan (01/26/22) indicated Resident #37 had a potential for chronic pain related to CVA (cerebrovascular accident causing loss of blood flow to part of the brain), chronic pain syndrome, left shoulder pain, Neuropathy (pain from nerve damage), rheumatoid arthritis (inflammation and pain in joints), Fibromyalgia (muscle pain and fatigue), PVD (peripheral vascular disease is a condition in which narrowed blood vessels reduce blood blow to the limbs) and an old myocardial infarction (blockage of blood flow to the heart muscle). The interventions indicated to respond immediately to any complaint of pain and assessment of pain every shift. Record review of Resident #37's physician orders (11/07/22) indicated Resident #37 had oxycodone-acetaminophen tablet 10-325mg one tablet by mouth every 6 hours for severe pain. Record review of Resident #37's medication administration record (01/01/23-01/31/23) indicated the oxycodone-acetaminophen tablet 10-325 mg was given every 6 hours for severe pain at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The medication administration record indicated the oxycodone was last given at 12:00 a.m. During an observation and interview on 01/23/23 at 8:33 a.m. with CMA H, CMA H administered an oxycodone-acetaminophen tablet 10/325mg at 8:33 a.m. to resident #37. CMA H stated that she was running late with the med pass and that was why Resident #37 received his oxycodone late. CMA H stated not giving the oxycodone on time could have caused the resident increased pain and if the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 19 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0759 hypertension, the increased pain could have made the residents blood pressure high. Level of Harm - Minimal harm or potential for actual harm 2. Record Review of Resident #25's face sheet (01/25/23) indicated Resident #25 was a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #25's face sheet indicated she had a diagnosis of GERD (gastro esophageal reflux disease in which stomach acid or bile irritates the food pipe lining), bipolar (episodes of mood swings ranging from depressive lows to manic highs) and Type 2 diabetes (too much sugar in the blood). Residents Affected - Few Record review of Resident #25's MDS (12/24/22) indicated she did not have a BIMS score. Resident #25's MDS assessment indicated she was able to make herself understood and understood others. Resident #25's MDS indicated she had a diagnosis of gastro esophageal reflux disease and received scheduled pain medication. Record Review of Resident #25's care plan dated (02/10/21) indicated Resident #25 had gastroesophageal reflux disease and the intervention included to give medication as ordered. Resident #25's care plan indicated she was on pain medication related to osteoarthritis. The interventions included to administer medication as ordered. Record Review of Resident #25's physician orders (02/20/22) indicated she was taking a Protonix tablet delayed release 40mg once daily for GERD. Resident #25's physician orders indicated she was taking Tramadol 50mg every 8 hours for chronic pain. Record review of Resident #25's medication administration record (01/01/23-01/31/23) indicated she was taking Protonix 40mg by mouth once daily for GERD and Tramadol 50mg by mouth every 8 hours for chronic pain scheduled at 6:00 a.m., 2:00 p.m. and 10 p.m. During an observation and interview on 01/23/23 at 8:51 a.m. with CMA H, she administered a Protonix 40mg tablet and a Tramadol 50mg tablet to Resident #25 at 8:51 a.m. CMA H stated that she was running late with the med pass and that was why Resident #25 received her medications late. CMA H stated not giving the Tramadol on time could have caused the resident increased pain and if the resident had hypertension, increased pain could have made the residents blood pressure high. During an interview on 01/25/23 at 11:16 a.m. with the DON, the DON stated medication times and physician orders should have been followed when administering medications and the facility was allowed 1 hour before and after the scheduled medication times to have given medications. The DON stated it was not adequate for CMA H to give the scheduled medications late. The DON stated pain medications should have been given at the correct times to have controlled the residents pain. The DON stated not getting pain medications at the correct time could have caused the resident to be in more pain. During an interview with the Administrator on 1-25-23 at 11:36 a.m., the Administrator stated he expected the nurses to follow the physician orders and to have given the meds per order. The Administrator stated if a resident did not receive pain meds when ordered it could have impacted pain management. Record review of the policy on Medication Administration revised on 05/2007 indicated to verify medication cards with medication orders, read the medication card, and read the label on the bottle as it was removed from the shelf. Check labels with medication orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 20 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meals (the lunch meal), as evidenced by: Residents Affected - Some The facility failed to ensure [NAME] C followed the recipe for pureeing the country fried steak and California blend vegetables. The facility failed to ensure [NAME] C used a #6 scoop to serve the country fried steak. The facility failed to ensure [NAME] C used a #12 scoop to serve the California blend vegetables. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an observation and interview on 01/23/23 starting at 10:07 AM, [NAME] C pureed the California blend vegetables. [NAME] C poured from a pot the California blend vegetables and water from the vegetables into a canister to puree them and added salt, no measurements used. After this, [NAME] C pureed the country fried steak. [NAME] C put 2 country fried steaks in the puree canister and added beef broth without measuring. [NAME] C said she did not have a recipe book to follow. She said she used to have one, but she did not know what the Dietary Manager had done with it. [NAME] C said she had been doing this (cooking) for 11 years, so she knew how to puree the food with no recipe or measurements. [NAME] C said she did not know she was supposed to follow the recipe when she pureed food. [NAME] C said not following the recipe could diminish the strength of the food and cause weight loss. The Dietary Manager said [NAME] C not following the recipe to make the pureed country fried steak and California blend vegetables was the Dietary Manager's fault for not providing [NAME] C with the recipe. The Dietary Manager said [NAME] C not following the recipe could cause the residents to have weight loss. Record review of the facility's undated recipe for the pureed country fried steak, titled P Country Fried Steak, Category: Beef/Veal, Recipe#: 4115, no author, indicated cooked country steak 5 servings, thickener 3 tablespoons, and liquid hot water or low sodium broth 1 cup. Record review of the facility's undated recipe for the pureed California blend vegetables, titled, P California Blend Vegetables (S), Category: Vegetable, Recipe #: 2524, no author, indicated California blend vegetables 2 ½ cups and thickener 2 tablespoons and 1 ½ teaspoons. During an observation and interview starting at 11:55 AM on 01/23/23, [NAME] C said she always liked to use a #8 scoop to serve all the food items because it was bigger than the other scoops and she liked to give the residents good portions. [NAME] C used a #8 scoop to serve the pureed country fried steak (#6 scoop was required) and the pureed California blend vegetables (#12 was required). [NAME] C said she did know she was supposed to be using the menu to tell her what size scoop she should be using. [NAME] C said not using the correct scoop size could result in the residents losing weight. Record review of the menu dated Week 2 Sunday indicated country fried steak pureed #6 scoop and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 21 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0803 California blend vegetables pureed #12 scoop. Level of Harm - Minimal harm or potential for actual harm Record review of the Resident Council document titled Department Reviews, dated 10/2022 indicated portion sizes were small and there was not enough food for seconds. Residents Affected - Some During an interview on 01/25/23 at 10:27 AM, The Dietary Manager said [NAME] C was not supposed to be using the same scoop for every food item. The Dietary Manager said she did most of the cooks' trainings one-on-one, and she did in-services with the kitchen staff at least every other month on different topics of the kitchen. The Dietary Manager said [NAME] C had been trained on how to know what scoop size to use. The Dietary Manager said she monitored the cooks at different meals to ensure they were serving correctly. The Dietary Manager said she noticed [NAME] C occasionally using the wrong scoop size and she told [NAME] C she needed to follow the menu, but [NAME] C continued to use the scoop she wants. The Dietary Manager said if the scoop size used was too small, it could cause weight loss and malnutrition. The Dietary Manager said if the scoop was too big the residents would not eat it because a lot of food on a plate was unappetizing, and this could also cause weight loss. The Dietary Manager said [NAME] C was supposed to be following the recipe when pureeing food because adding too much water or too much thickener could affect the consistency of the pureed food. The Dietary Manager said, in the past, she had to have [NAME] C remake pureed food because [NAME] C added too much water and too much thickener when pureeing food items. The Dietary Manager said she trains all the cooks on how to puree food and tries to observe them making pureed food. The Dietary Manager said if the cooks add too much beef base or water when pureeing, it altered the flavor of the food and it also altered the nutritional value. The Dietary Manager said it was important to follow the menu when pureeing food because if the food did not taste good the residents would not eat it and altering the nutritional value of the food could result in the residents losing weight. During an interview on 01/25/23 at 11:38 PM, the Registered Dietician said the same scoop size should not be used to serve all the food. The Registered Dietician said the spreadsheet menu indicated what scoop size or serving size to use. The Registered Dietician said the Dietary Manager was responsible for training the cooks. The Registered Dietician said it was the responsibility of the cook to ensure they were serving with the correct scoop size. The Registered Dietician said it was important to serve with the correct scoop size to ensure the residents received the correct amount of nutrients, and not serving with the correct scoop size could result in weight loss or weight gain. The Registered Dietician said, when pureeing food, the recipe should be followed. The Registered Dietician said the Dietary Manager was responsible for making sure the cooks followed the recipes, and not following the recipes when making pureed food could result in decreased nutritive value, not having the correct texture and weight loss. During an interview on 01/25/23 at 2:14 PM, the Operational Manager said the Dietary manager was responsible for ensuring the cooks followed the recipes and served the correct portion sizes. The Operational Manager said he expected the cooks to follow the recipe and use the correct scoop size when serving. The Operational Manager said not following the recipe when pureeing food could make it too thin and could take nutrients away. The Operational Manager said not using the correct scoop size could cause weight loss. During an interview with the Dietary Manager on 01/25/23 at 10:30 AM, the facility's policy regarding following the menus was requested and not provided before exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 22 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 5 of 22 residents (Resident #36, Resident #41, Resident #46, Resident #50, and Resident #59) reviewed for dietary services. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was not hot and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During a resident interview on 01/22/2023 at 10:36 AM, Resident #50 stated the food was disgusting. Resident #50 stated the food was not hot and the gravy was too watery. During a resident interview on 01/22/2023 at 10:41 AM, Resident #59 stated the food was bland. During an interview on 01/22/23 at 10:44 AM Resident #36 stated the food was bland. During a resident interview on 01/22/2023 at 11:14 AM, Resident #46 stated the food was bland. During an interview on 01/22/23 at 11:28 AM, Resident #41 stated she did not like the food. She stated it tasted bad and did not have any spices. Resident #41 said she told the staff but could not remember who it was. During an observation and interview on 01/23/23 starting at 1:09 PM, a lunch tray was sampled by the Dietary Manager and five surveyors. The sample tray consisted of chicken fried steak with gravy, California vegetable blend, mashed potatoes, cornbread, and caramel pound cake. The chicken fried steak with gravy was mushy, soggy, and bland, seemed like it was not fried long enough. The Dietary Manager stated it could use more flavor and needed to be fried longer. The California vegetable blend and mashed potatoes were bland. The Dietary Manager said the California vegetables and the mashed potatoes needed more seasoning. The caramel pound cake was too warm. The Dietary Manager said the caramel pound cake needed to be a little colder. During an interview on 01/25/23 at 10:37 AM, the Dietary Manager said she had not heard any food complaints in an overwhelming way, but there had been one or two residents that said the food did not have any taste. The Dietary Manager said she had no resident complaints of the temperature of the food. The Dietary Manager said management did room rounds every morning and as far as she knew, nobody had complained about the food being too hot or too cold. The Dietary Manager said if she had any food complaints she would go to the resident and address it with the resident. The Dietary Manager said if during the Resident Council meetings there were food complaints, she would be notified and she tried to address the concerns. The Dietary Manager said the cook should be tasting the foods, and occasionally she would get a test tray, and if she found anything wrong, she would have the cook fix it. The Dietary Manager said if she was not going to eat a meal, she would not serve it. The Dietary Manager said if the residents did not like the food or it was not the right temperature the residents would not eat the food, and this could result in them being hungry and weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 23 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/25/23 at 11:21 AM, [NAME] C said she did taste the food before serving it. [NAME] C said she did not put any salt and pepper in the mashed potatoes or California blend vegetables because she thought she could not add any. [NAME] C said she did not fry the chicken fried steak more because she was afraid the residents would not be able to eat it. [NAME] C said she had not had any residents complain about the food. [NAME] C said if the food did not taste good and was not the right temperature, the residents would not eat it, and this could cause weight loss. During an interview on 01/23/23 at 11:49 AM, the Registered Dietician said the cook should be testing all the food before it was served. The Registered Dietician said the cook was responsible for ensuring the food served was the right temperature and was palatable. The Registered Dietician said she did not always do a test tray on her monthly visits, but if she did do a test tray, it was usually dinner and she had had no issues. The Registered Dietician said the Operational Manager should be doing a test tray, but she was not sure how often. The Registered Dietician said the food not being the correct temperature and not being palatable, resulted in the resident's decreased acceptance of the food, the residents not eating the food, and weight loss. During an interview on 1/25/23 at 1:53 PM, the DON said she had not received any complaints about the food. The DON said in the past, resident council had complained about the food, but she could not remember the exact complaints. The DON said if she had any food complaints she would address the concerns with the Dietary Manager, and they came up with a plan to address the concerns. The DON said if the food was not palatable and not the correct temperature, the residents could have weight loss. During an interview on 01/25/23 at 1:59 PM, CNA B said residents complained to her about not liking the food. CNA B said when she had food complaints, she told the Dietary Manager. CNA B said if the residents did not like the food, it would cause them to be hungry and cause malnutrition. During an interview on 01/25/23 at 2:20 PM, the Operational Manager said there had been complaints about the food in resident council, but he did not remember what the complaints were. The Operational Manager said if there were any complaints about the food, the complaints were taken to the Dietary Manager, and she would meet with the residents to alleviate the issue. The Operational Manager said he had a test tray last month and it was good. The Operational Manager said if the food was not the right temperature and not palatable this could result in weight loss. During an interview with the Dietary Manager on 01/25/23 at 10:30 AM, the facility's policy regarding serving palatable food and at correct temperatures was requested and not provided before exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 24 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o expired food items were discarded. o the vent hood was clean. o the juice dispenser nozzle was clean. o the juice drain on the floor was clean. o the toaster was free of food debris. o the ice machine was clean. o a food cart was clean. o a fan on the floor in the kitchen was clean. o the floor was clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 25 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 These failures could place residents at risk for foodborne illness. Level of Harm - Minimal harm or potential for actual harm Findings included: During an observation on 01/22/23 starting at 09:02 AM, Residents Affected - Some Reach in refrigerator: 1 gallon of dill pickle relish with no open date 1 16 oz package of beef bologna with no open date Kitchen shelf: 1 11 oz container of parsley flakes use by date 12/17/22 1 18 oz container of Hungarian style paprika use by date 3/26/22 1 28 oz container of lemon pepper seasoning no open date 1 24 oz container of blackened seasoning use by date 11/19/22 1 package of opened bag of Lays classic chips with no open date Freezer: 2 pumpkin pies 10'' no receive date 1 open bag of catfish fillets no open date 1 open bag of hushpuppies no open date 1 open bag of brussel sprouts no open date 1 open bag of frozen vegetables no open date Walk in refrigerator: 1 open box of diced colorful veggie blend no open date 1 bag of boiled eggs with no label, no date, no expiration 1 open bag of [NAME] with 29 [NAME] expired 1/18/23 3 12 oz packages of turkey bacon with no receive date 1 cantaloupe cup with no date 1 16oz package of strawberries with white, brown/black fuzzy on them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 26 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 1-pint blueberries with no open date Level of Harm - Minimal harm or potential for actual harm Dry storage: 1 14 oz container of whipped chocolate frosting no receive date Residents Affected - Some 6 30 oz containers of Real Mayo no receive date 6 loaves of bread no receive date 2 2lb bags of powdered sugar no receive date 1 bag of spaghetti opened not sealed (open to air) dated 11/17/22 1 bag of fettucine egg noodles box opened not sealed (open to air) no date 1 bag of curly egg noodles no open date and not sealed (open to air) 1 bag of Folgers coffee no receive date Storage bins: Bin of Cheerios with use by date of 11/17/22 Bin with [NAME] Krispy's with no dates, no label White thickener in a bin had black particles in it During an observation on 01/22/23 starting at 10:10 AM, the vent hood had grease and dark brown stains on one side. The juice dispenser had pink dry residue on the inside and the outside. The juice dispenser drain on the floor had dried pink residue and a pink dried ball like particle on it. The toaster had brown residue and food particles in it. A food cart had white particles and stains on it. A fan on the floor blowing in the kitchen where the food was being prepared had dust and grey fuzzy build up in between the vents. The floor was grimy and slippery with dark brown stains throughout. The ice machine in the kitchen had brown-black stains on the outside and black residue on the inside. During an interview on 01/25/23 10:48 AM, the Dietary Manager said all the kitchen staff should have cleaned the kitchen and equipment. The Dietary Manager said she was responsible for checking the kitchen for cleanliness. The Dietary Manager said she did not hold the kitchen staff accountable as often as she should for not doing what they should be doing. The Dietary Manager said she occasionally monitored for cleanliness and the staff had a cleaning list they should be signing off. The Dietary Manager said the Registered Dietician does an audit once a month. The Dietary Manager said not keeping the kitchen clean could result in contamination of the food, bacteria could grow on the food, and cause sickness to the resident. The Dietary Manager said all the food should have a receive date, open date, and a use by date once opened. The Dietary Manager said leftovers should be labeled with the date it was made and a use by date, which is 3 days from the open date. The Dietary Manager said the unsealed pasta should have been discarded. The Dietary Manager said the spices should have an open date and a use by date. The Dietary Manager said the storage bin should have a label indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 27 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 what is in it, when it was opened, and how long it can be in the storage bin. The Dietary Manager said once a week the cooks and the dietary aides were responsible for making sure food items were labeled, dated, and discarded. The Dietary Manager said she should have been paying better attention at what was and was not opened and what needed to be discarded, but the kitchen staff also should have been doing it. The Dietary Manager said labeling, dating, and discarding expired food items was important to ensure they did not give the residents something that was out of date because it would not taste good, could lose its texture, for the quality of the food, bacteria could start growing on the food and make the residents sick. During an interview on 01/25/23 at 11:53 AM, the Registered Dietician said she had provided the Dietary Manager options of cleaning schedules and she also included instructions on what should be done in her audit. The Registered Dietician said the Dietary Manager was responsible for making sure the kitchen staff followed the cleaning schedules. The Registered Dietician said on her last audit there were a couple things that needed to be cleaned and she notified the Dietary Manager. The Registered Dietician said cleanliness in the kitchen was important for sanitation purposes, to prevent cross contamination, and prevent the serving of unsafe food. The Registered Dietician said physical contaminants would get in the food and cause food-borne illness and serving unappetizing things could decrease the resident's intake and lead to weight loss. The Registered Dietician said she noticed on the audit, food items that needed to be labeled and dated. The Registered Dietician said all food items should have a received date, open date, and dispose by date. The Registered Dietician said everything should have been dated and all the kitchen staff knew they should be doing this. The Registered Dietician said the Dietary Manager was responsible for monitoring the kitchen staff to ensure they were labeling and dating correctly. The Registered Dietician said proper storage did not include leaving food items open to air. The Registered Dietician said labeling and dating food items was important to know what the product was and to know how long it should be there. The Registered Dietician said not correctly storing, dating, and labeling food items could result in contamination and illness. During an interview on 01/25/23 at 11:29 AM, [NAME] C the toaster should have been cleaned after every use and she had cleaned it the last time it was cleaned, and other people did not do what they were supposed to do. [NAME] C said the juice nozzle should be cleaned after every shift and she did not know why it was not cleaned. [NAME] C said she did not know why the fan was not cleaned and the kitchen had not been mopped. [NAME] C said if the kitchen was dirty, it could make the residents sick. [NAME] C said all food items should have an open date and a use by date. [NAME] C said if she saw something needed to be thrown out, she would throw it out. [NAME] C said if something did not have a date, she would throw it away. [NAME] C said serving expired food items could make the residents sick. On 01/25/22 at 12:14, a phone call for an interview was attempted to [NAME] D with no answer. On 01/25/22 at 12:15, a phone call for an interview was attempted to Dietary Aide E with no answer. During an interview on 01/25/23 at 12:17 PM, Dietary Aide G said she was only responsible for cleaning her area (the dishwashing area) and the cooks kept the kitchen clean, and she was responsible for cleaning the meal carts after each meal. Dietary Aide G said she might have missed cleaning the carts and it was important to keep them clean to prevent cross contamination. During an interview on 01/25/23 at 12:22 PM, Dietary Aide F said he was not responsible for cleaning the vent hood or the ice machine and he did not know why they had not been cleaned. Dietary Aide F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 28 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 said he did not know who was responsible for cleaning the vent hood or the ice machine. Dietary Aide F said it was important to keep them clean to make sure germs were not present. Record review of the facility's policy last revised 10/2007 titled, Section: Dietary Services Subject: Dietary, Sanitation, revealed, It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas . 4. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner . Record review of the facility's policy last revised 05/2007, titled, Section: Departmental, Subject: Dietary Services, revealed, It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. 1. Director of food service responsibilities A. Provide safe food services for residents and employees . F. Provide for the proper receipt and storage of all food supplies . 8. Dietary Housekeeping A. All food carts should be sanitized after each meal. B. Ranges and grills should be cleaned daily. C. Dirty equipment should never touch food. D. All work surfaces, utensils and equipment should be cleaned and sanitized after each use . F. All floor surfaces must be wet mopped daily and as needed using a bucket with wringer and germicide . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 29 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 3 of 22 residents reviewed for personal food safety. (Resident #16, Resident #63, and Resident #59) Residents Affected - Some The facility did not implement the personal food policy related to personal refrigerators for Resident #16, Resident #63, and Resident #59. This failure could place the residents at risk for food borne illnesses. The findings included: 1. Record review of Resident #16's order summary report, dated 01/25/2023, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), osteoarthritis (degeneration of joint cartilage and the underlying bone), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the MDS assessment, dated 10/19/2023, revealed Resident #16 had clear speech and was able to be understood by staff. The MDS revealed Resident #16 was able to understand others. The MDS revealed no behavior problems or refusal of care during the look-back period. The MDS revealed Resident #16 required supervision and set-up help only assistance with eating. Record review of the comprehensive care plan, last revised 11/30/2021, revealed Resident #16 had an ADL self-care performance deficit. During on observation on 01/22/2023 at 10:31 AM, an undated, unlabeled container of black-eyed peas were in a personal refrigerator in Resident #16's room. During an observation and resident interview on 01/22/2023 at 3:44 PM, an undated, unlabeled container of black-eyed peas were in a personal refrigerator in Resident #16's room. Resident #16 was laying in the bed with head of bed slightly elevated. Resident #16 stated the facility staff checked her fridge daily. Resident #16 stated housekeeping staff checked her fridge earlier that morning. Resident #16 was unable to identify how long the container had been in her fridge. During an observation on 01/23/2023 at 8:22 AM, an undated, unlabeled container of black-eyed peas were in a personal refrigerator in Resident #16's room. 2. Record review of Resident #63's order summary report, dated 01/25/2023, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypothyroidism (thyroid gland does not produce enough thyroid hormone), history of cerebral infarction (stroke), and primary open-angle glaucoma, right eye, severe stage (group of eye conditions that damage the optic nerve). Record review of the MDS assessment, dated 11/18/2022, revealed Resident #63 had clear speech and was able to be understood by staff. The MDS revealed Resident #63 was able to understand others. The MDS revealed Resident #63 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #63 had no behaviors or refusal of care during the look-back period. The MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 30 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0813 revealed Resident #63 required extensive, one-person assistance with eating. Level of Harm - Minimal harm or potential for actual harm Record review of the comprehensive assessment, last revised 12/09/2022, revealed Resident #63 had a self-care performance deficit. Residents Affected - Some During an observation on 01/22/2023 at 10:57 AM, an undated, unlabeled bag with 5 squares of cheese was noted in personal refrigerator in Resident #63's room. During an observation and resident interview on 01/22/2023 at 4:00 PM, an undated, unlabeled bag with 5 squares of cheese was noted in personal refrigerator in Resident #63's room. Resident #63 was laying in the bed with head of bed slightly elevated. Resident #63 stated the facility staff checked her personal refrigerator daily. Resident #63 was unable to remember if they had checked her personal fridge that day. Resident #63 was unable to remember how long the bag of cheese had been in her personal fridge. During an observation on 01/23/2023 at 9:10 AM, an undated, unlabeled bag with 5 squares of cheese was noted in personal refrigerator in Resident #63's room. 3. Record review of Resident #59's order summary report, dated 01/25/2023, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), polyosteoarthritis (type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone), and unspecified dementia with behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the MDS assessment, dated 12/22/2022, revealed Resident #59 had clear speech and was understood by staff. The MDS revealed Resident #59 was able to understand others. The MDS revealed Resident #59 had a BIMS score of 8 which indicated his cognition was mildly impaired. The MDS revealed Resident #59 had inattention and disorganized thinking continuously present. The MDS revealed no behavior problems or refusal of care during the look-back period. The MDS revealed Resident #59 required supervision with one-person assistance with eating. Record review of the comprehensive care plan, last revised 10/05/2022, revealed Resident #59 had an ADL self-care performance deficit. The interventions included: set-up help with supervision with 1 staff assistance to eat. During an observation on 01/22/2023 at 10:41 AM, an undated, unlabeled container of one brownie was noted in the freezer part of a personal refrigerator in Resident #59's room. During an observation and attempted resident interview on 01/22/2023 at 3:45 PM, an undated, unlabeled container of brownie was noted in the freezer part of a personal refrigerator in Resident #59's room. Resident #59 was sitting up in his recliner in his room. An interview was attempted with Resident #59 but was unable to interview him related to confused conversation. During an observation on 01/23/2023 at 9:22 AM, an undated, unlabeled container of one brownie was noted in the freezer part of a personal refrigerator in Resident #59's room. During an interview on 01/25/2023 at 2:42 PM, Housekeeper W stated housekeeping staff was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 31 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsible for checking the residents' personal refrigerators in their rooms. Housekeeper W stated housekeeping staff were to check personal refrigerators daily to log temperatures and check for undated, unlabeled food items. Housekeeper W stated food items in containers or bags should have been labeled and dated. Housekeeper W stated she was unsure why Resident #16, Resident #63, or Resident #59 had undated, unlabeled containers or bags in their personal refrigerators. Housekeeper W stated the failure for leaving undated, unlabeled items inside a resident's personal refrigerator was the potential for residents to become sick. During an interview on 01/25/2023 at 3:15 PM, the Operational Manager stated all staff was responsible for checking residents' personal refrigerators. The Operational manager stated he expected this to be completed daily. The Operational Manager stated the failure for leaving undated, unlabeled food in the residents' personal refrigerators would be the potential to ingest something expired that could make the residents' sick and cause multiple health issues. Record review of the Refrigerator in Nursing Facility policy, last revised March 2009, revealed 6. If foods are retained in the refrigerator, they shall be covered and clearly identified as to contents and date initially covered. 7. Food will be disposed of after 72 hours from date of initially covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 32 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 4 meetings (November 2022, December 2022, and January 2023) reviewed for QAPI. Residents Affected - Few 1. The facility did not ensure the Administrator attended their QAPI meetings in November 2022, December 2022, and January 2023. 2. The facility did not ensure the Infection Preventionist attended their QAPI meeting in December 2022 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets indicated the Administrator did not sign in for their meetings from November 2022 to January 2023. Record review of the facility's QAPI Committee sign-in sheets indicated the Infection Preventionist did not sign in for their meetings from December 2022 to January 2023. During an interview on 01/25/2023 at 9:38 a.m., the ADON stated she was the facility's Infection Preventionist. The ADON stated she did attend the meetings in December and January but forgot to sign the sign-in sheets. The ADON stated it was important to attend the meetings to ensure that everyone was up to date on the resident care and provide input. The ADON stated this failure could potentially put residents at risk for infections. During an interview on 01/25/2023 at 10:00 a.m., the Clinical Market Lead stated the Administrator and Infection Preventionist should have attended the monthly QAPI meetings. During an interview on 01/25/2023 at 12:09 p.m., Administrator Q stated he did not attend the QAPI meetings in November 2022 and December 2022. Administrator Q stated the Operational Manager was knowledgeable of the everyday operations of the facility. Administrator Q stated the Operational Manager would notify him if there was any issues or concerns in the facility. Administrator Q stated, my license is just on the building. During an interview on 01/25/2023 at 12:16 p.m., Administrator R stated he did attend the meeting in January but forgot to sign the sign in sheet due to him running late. Administrator R stated it was important for him to sign the sheet so he can acknowledge what was discussed. When asked what the failure was of not attending a QAPI meeting, he stated nothing because I am not caring for the resident. During an interview on 01/25/2023 at 2:27 p.m., the Operational Manager stated he had not obtained his administrator license at that time. The Operational Manager stated the Administrator who was overseeing him, at that time, should have attended the QAPI meetings. The Operational Manager stated neither one of the Administrators attended the QAPI meetings in November 2022, December 2022, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 33 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0868 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete January 2023. The Operational Manager stated the active Administrator should have been included in the meetings, so they know what was going on in the facility. The Operational Manager stated he did not feel there was a failure with them not attending the QAPI meetings due to him communicating with them. Record review of the facility's policy titled, Quality Assurance and Performance Improvement, revised on 1/2022 revealed, . 1. Quality Assessment and Assurance Committee a. members of the committee will include . Administrator and Infection Preventionist . Event ID: Facility ID: 676190 If continuation sheet Page 34 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (Residents #18, Resident #4, Resident #25 and Resident #69) reviewed for infection control. Residents Affected - Some 1.The facility did not ensure Resident #4 utilized appropriate PPE use throughout the facility. 2.The facility failed to ensure CMA H disinfected the wrist blood pressure monitor between Resident #25 and Resident # 69. 3.The facility failed to ensure NA K changed her gloves and performed hand hygiene during incontinent care provided to Resident #18. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: 1.Record review of Resident #4's face sheet (01/25/23) indicated she was a [AGE] year-old female that was admitted to the facility on [DATE]. The face sheet indicated Resident #4 had a diagnosis of schizophrenia (affects the ability to think, fell and behave clearly), Type 2 diabetes (too much sugar in the blood) and HTN (force of blood against the artery walls is too high). Record Review of Resident #4's physician orders dated 01/18/23 indicated she was on isolation precautions: droplet. Record Review of Resident #4's MDS assessment dated [DATE] indicated she had a BIMS score of 11 for moderately impaired. Resident #4 was marked a (1) under rejection of care indicating she rejects care 1 to 3 days a week. Record Review of Resident #4's care plan did not indicate Resident #4 refused to wear a N95 mask outside of her room. During an observation made on 01/22/23 at 10:30 a.m., Resident #4 was sitting up in her wheelchair at the end of C hall waiting to go outside and smoke. Resident #4 was not wearing a mask or any PPE. During an observation on 01/22/23 at 11:13 a.m., Resident #4 had a sign for warm resident hanging on the wall outside of her room and PPE available. Resident #4 was rolling herself independently down C hall with no mask on. During an observation and interview on 01/23/23 at 10:45 a.m., Resident #4 was being propelled by a staff member wearing a N95 mask from the smoking area in her wheelchair. Resident #4 was not wearing a mask and stated staff did not tell her she had to wear a mask when she was outside of her room. During an interview on 01/25/23 at 10:23 a.m., CNA S stated residents in the warm zone must wear a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 35 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0880 N95 mask if they were not in their room. Level of Harm - Minimal harm or potential for actual harm During an interview with the ADON (Infection Preventionist) on 01/25/23 at 10:38 a.m., the ADON stated residents that were in the warm zone should have worn a N95 mask when they were outside of their room. Residents Affected - Some During an interview with the DON on 01/25/23 at 11:16 a.m., the DON stated residents should have worn a N95 mask outside of their room if they were in a warm zone room, but staff could not force residents to wear one because it was the residents right. The DON stated if warm residents were not wearing a mask, it could make other residents sick. The DON stated it was the responsibility of all staff to make sure residents in warm zones were wearing a N95 mask. 2.During an observation and interview with CMA H during a medication administration on 01/23/23 starting at 8:23 AM, CMA H used the wrist blood pressure monitor to check Resident #25's blood pressure. After using the wrist blood pressure monitor, CMA H placed the blood pressure monitor back on top of the medication cart without disinfecting it. CMA H administered Resident #25's medications. CMA H then took the wrist blood pressure monitor without disinfecting it and checked Resident #69's blood pressure. After checking Resident #69's blood pressure, CMA H did not disinfect the wrist blood pressure monitor and placed it back on top of the medication cart. CMA H stated she forgot to disinfect the blood pressure monitor and if not done, it could have spread germs to other residents. During an interview on 01/25/23 at 11:16 a.m., the DON stated staff should have cleaned the blood pressure cuff between each resident. The DON stated if the blood pressure cuff is not cleaned it could have caused an infection or skin irritation. During an interview with the Administrator on 01/25/23 at 11:36 a.m., the Administrator stated he expected the blood pressure cuff to have been cleaned between residents to prevent infection. The Administrator stated he expected COVID precautions to be followed. 3. Record review of Resident #18's order summary report, dated 01/24/2023, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of wedge compression fracture of the T11-T12 vertebra (fracture in the thoracic spine), gram-negative sepsis (infection in the blood stream caused by a gram-negative bacteria), and mild cognitive impairment (condition characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 11/09/2022, revealed Resident #18 had clear speech and was understood by staff. The MDS revealed Resident #18 was able to understand others. The MDS revealed Resident #18 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #18 had no behaviors or refusal of care. The MDS revealed Resident #18 required extensive assistant with one person staff assistance with toilet use. The MDS revealed Resident #18 was always incontinent of bowel and bladder. Record review of the comprehensive care plan, last revised on 10/19/2022, revealed Resident #18 had an ADL self-care performance deficit. The care plan revealed Resident #18 had potential for bowel and bladder incontinence. During an observation on 01/22/2023 at 03:35 PM, NA K performed incontinent care, placed new brief on Resident #18, pulled up Resident #18's pants, pulled up Resident 18's covers, raised Resident #18's head of bed up, moved Resident #18's bedside table closer to the bed, and pulled the privacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 36 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0880 curtain in room separating residents using the same gloves. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2023 at 11:47 AM, NA K stated gloves should have been changed and hand hygiene performed during incontinent care when going from clean to dirty. NA K stated during incontinent care on Resident #18, she should have changed her gloves and performed hand hygiene. NA K stated she had performed a skills check-off for incontinent care. NA K stated she forgot to change gloves and perform hand hygiene during incontinent care. NA K stated forgetting to change gloves and perform hand hygiene during incontinent care was putting Resident #18 at an increased risk of infection. Residents Affected - Some During an interview on 01/25/2023 at 12:13 PM, LVN M stated NAs were responsible for ensuring incontinent care was completed. LVN M stated she helped provide incontinent care at times. LVN M stated NAs were to change gloves and perform hand hygiene during incontinent care when going from dirty to clean, and after care was completed. LVN M stated skills checkoffs were completed regularly for incontinent care. LVN M stated the failure to Resident #18 for forgetting to change gloves and perform hand hygiene during incontinent care was an increased risk of infection. During an interview on 01/25/2023 at 2:42 PM, NA P stated staff should have changed their gloves and performed hand hygiene while providing incontinent care when going from dirty to clean. NA P stated she has performed a skills check-off on incontinent care. NA P stated failure to change gloves and perform hand hygiene during incontinent care would put residents at an increased risk of infection. During an interview on 01/25/2023 at 2:57 PM, the DON stated CNAs or NAs were responsible for performing incontinent care. The DON stated incontinent care was monitored by performing random checks. The DON stated she expected staff to change gloves and perform hand hygiene when going from clean to dirty and after incontinent care was completed. The DON stated performing inaccurate incontinent care would put residents at increased risk of infection. During an interview on 01/25/2023 at 3:15 PM, the Operational Manager stated he expected nursing staff to monitor direct care staff for improper incontinent care. The Operational Manger stated the failure to residents for providing inaccurate incontinent care was an increased risk of infection. Record review of the facilities policy on Standard and Transmission-Based Precautions revised on 02/2021 indicated patient care equipment (blood pressure cuffs) should have been cleaned and disinfected before use on another resident. Droplet Precautions are used for patients known or suspected to have been infected with pathogens. Source control should have been implemented by placing a mask on the patient, use of personal protective equipment appropriately and donned a mask upon entry into the patient's room or patient space. If the resident was on droplet precautions a mask should have been placed on the affected individual and encouraged them to follow respiratory hygiene and cough etiquette to minimize dispersal of droplets. Record review of the Nursing Clinical Policy and Procedure with Subject: Incontinent Care, last revised May 2007, did not address glove changes or hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 37 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 2 of 5 residents reviewed for immunizations. (Resident #3 and Resident #10). Residents Affected - Few 1 The facility failed to ensure Resident #3's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. 2. The facility failed to ensure Resident #3's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. The facility failed to ensure Resident #10's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. The facility failed to ensure Resident #10's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings included: 1.Record Review of Resident #3's order summary report, dated 01/25/2023, indicated Resident #3 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis of dementia (memory loss and confusion), hypertension (the force of the blood against the artery walls is too high) and COPD (Chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #3's annual MDS, dated [DATE], indicated Resident #3's mental status was rarely or never understood and unable to determine the BIMS score. Resident #3's MDS assessment indicated he received the influenza vaccine on 11/10/2022 in the facility. Record review of Resident #3's electronic health record indicated he received his influenza vaccine on 11/10/22. Record review of Resident #3's electronic health record indicated he had received his pneumovax dose 1 on 11/15/22. Record review of Resident #3's progress notes did not indicate education was provided on the pneumococcal vaccine given on 11/15/22. Record review of Resident #3's progress notes did not indicate education was provided on influenza vaccine given on 11/10/22. 2. Record Review of Resident #10's order summary report, dated 01/25/23, indicated she was an [AGE] year-old female that was admitted to the facility on [DATE]. Resident #10's face sheet indicated she had a diagnosis of Acute Respiratory Distress Syndrome (accumulation of fluid and other changes in the lungs that result in severely impaired oxygenation of the blood), Chronic Kidney Disease (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 38 of 39 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 676190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillhouse Rehabilitation and Healthcare Center 2900 Stillhouse Road Paris, TX 75462 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 0883 (build-up of waste in the blood due to kidney failure) and COPD (breathing disorder). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #10's MDS, dated [DATE], indicated Resident #10 had a BIMS score of 06. Resident #10's MDS assessment indicated she was offered and declined the influenza and pneumococcal vaccines. Residents Affected - Few Record Review of Resident #10's electronic health record indicated she received the influenza vaccine on 11/10/22. Record Review of Resident #10's electronic health record indicated she received the pneumococcal vaccine on 11/15/22. Record review of Resident #10's progress notes did not indicate education was provided on the pneumococcal vaccine that was given on 11/15/22. Record review of Resident #10's progress notes did not indicate education was provided on the influenza vaccine given on 11/10/22. During an interview on 1/25/23 at 10:38 a.m., the ADON (infection preventionist) stated she was responsible for giving the residents their vaccines and charting the education on the influenza and pneumococcal vaccines that were given in the electronic health record. The ADON stated she verbally gave education on the vaccines to residents and family members, but did not chart anywhere that the education was given to them in the electronic health record because she did not know she was required to until. The ADON stated, I just noticed in the electronic health chart that there was a box to check showing that education was provided to the residents, and I will start checking it from now on. The ADON stated that charting education on the vaccines during the time they were given was important due to possible outcomes of the vaccine or possible adverse reactions. During an interview on 01/15/23 at 11:16 a.m., the DON stated it was important to chart that education was given to residents during the time their vaccines were given so that residents knew what vaccines they are getting and so they would be informed. The DON stated if residents were not informed of the vaccines they are getting, they could have been allergic to something. During an interview with the Administrator on 01/25/23 at 11:36 a.m., the Administrator stated he expected education to be given and documented on vaccines given to the residents. The Administrator stated documenting education on vaccines was important to show what the nurses were doing. Record Review of the policy on Immunizations-Influenza and Pneumococcal revised on 06/2021 indicated it was the policy of the facility to offer and administer influenza and pneumococcal immunizations to eligible residents, after providing education on the risks and potential side effects for the vaccines and obtaining consent. Before offering the influenza and pneumococcal immunizations, each resident and resident representative will receive the Vaccine Information Statement and document that the education regarding the benefits and potential side effects of influenza and pneumococcal immunizations were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676190 If continuation sheet Page 39 of 39