Health inspection·November 21, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/21/23 at 1:45 p.m. revealed Resident #1 was lying in her bed and sleeping. She shared her room with another resident. RN A and CNA B entered the room for providing peri care and wound care. At first CNA B completed peri care while RN A waited and observed the peri care. After CNA B completed her task RN A finished wound care as per the physician's order. Neither RN A nor CNA B closed the door and drew the privacy curtain fully, of Resident #1's room while they performed their tasks. Resident #1's buttocks, naked front side and uncovered body were exposed to the hallway. The State Surveyor attempted to interview Resident #1 however it was unsuccessful due to her cognitive deficit. During an interview on 11/21/23 at 2:30 p.m., RN A stated by not closing the door the privacy and dignity of Resident #1 were compromised as anyone who passed by the room or hallway could see resident's exposed body. She said, in a hurry she had forgotten to ensure the privacy of the resident by closing the door. RN A stated she received in-services on resident's rights long ago however could not remember when it was exactly. During an interview on 11/21/23 at 2:35 p.m., CNA B stated the door should have been closed completely to prevent Resident #1 from being exposed to the open hallway. She stated, exposing someone's body even if it was unintentional, affected their dignity. CNA B stated she was new at the facility and did not receive any in services since she started working at the facility about a month ago. During an interview with the DON on 11/21/23 at 3:00 p.m., she stated privacy must be provided during nursing care and the door to Resident #1's room should have been closed completely by RN A and CNA B before starting their nursing tasks. She said what both the staff did was a violation of the resident's right and dignity. The DON stated the facility ensured all the newly hired employees completed skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge which included competency in privacy/confidentiality. During an interview on 11/21/23 at 3:30 p.m., the ADM stated residents' privacy should be maintained during nursing care by closing the room door, closing window blinds, and pulling the curtains. During record review of the facility's policy Resident Rights , revised on 05/14/2019, reflected: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has a right to be treated with respect and dignity . The resident has a right to personal privacy and confidentiality of his or her personal and medical records The resident has a right to a safe, clean, comfortable, and home like environment, including but not limited to receiving treatment and supports for daily living safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 2 of 5 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 establish and 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 1 of 2 residents (Residents #1) reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure RN A sanitized the scissors before and after using it to cut open the bandage over the wound on Resident #1's leg. 2. The facility failed to ensure CNA B changed her soiled gloves before handling clean peri care items during peri care for Resident #1. These failures could place residents at risk of transmission of disease and infection. The findings include: Record review of Resident #1's face sheet, dated 11/21/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Obstructive Pulmonary Disease (Difficulty to breath due to lung diseases), Asthma, Type 2 Diabetes Mellitus, Hypertension (High blood pressure), Urinary Incontinence, Alzheimer's Disease, Psychotic Disturbance, Mood Disturbance, Anxiety, Unsteadiness on feet, Pain in right knee, Pain in left knee, Need for assistance with personal care, Muscle weakness, Need for continuous supervision, Reduced mobility, History of falling, Muscle wasting ,Malnutrition, Weakness, and Encounter for palliative care. Record review of Resident #1's care plan, dated 09/29/23, reflected: I have a Skin Tear/potential for skin tear to the left calf. and the related interventions were Complete treatment to left calf per MD orders. Monitor skin tear to left calf for signs and symptoms of infection. Notify MD of any changes as needed. Record review of Resident #1's quarterly MDS assessment, dated 10/23/23, reflected a BIMS of 6, which indicated severely impaired cognition. Section H of the MDS reflected Resident #1 was always incontinent with bowel and bladder. Section M of MDS reflected the resident was at risk of developing pressure ulcers/injuries with the presence of unhealed pressure ulcers. Record review of Resident #1's physician's order, dated 10/28/23, reflected: Right Anterior Medial Shin: Cleanse with wound cleanser, pat dry, apply Anacept [wound cleanser] to wound bed, cover with nonadherent dressing, wrap with Kerlix wrap [ bandage]. Daily. During an observation on 11/21/23 at 1:45 PM revealed CNA B performed peri care for Resident #1. RN A observed and waited for CNA B to complete her task so she could do the wound care. CNA B washed her hands and then donned (putting on disposable gloves) gloves. She then removed Resident #1's brief and cleaned the area with wet wipes. After that she changed her dirty gloves and donned a new pair of gloves. She applied barrier cream at the buttock, perineal area, and the rest of the back of Resident #1 as instructed by RN A. CNA B then without changing the soiled gloves, picked up the barrier cream tube and the wet wipe packet and stored them with the stock of peri care items in a drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 3 of 5 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/21/23 at 2:00 PM revealed RN A provided wound care for Resident #1. RN A sanitized her hands and donned (putting on disposable gloves) gloves. She then collected the necessary wound care materials from the wound care cart as per the physician's order. RN A doffed (took off) her gloves and donned a new pair of gloves and went into Resident#1's room. She then picked up a pair of scissors from her scrub's pocket and without sanitizing it, used it to cut open the Kerlix wrap around the wound on Resident#1's right anterior medial shin (middle of the outer side of calf). She then without sanitizing put back the scissors into her scrub's pocket for future use. During an interview on 11/21/23 at 2:30 PM revealed RN A stated she was supposed to sanitize the scissors before and after the use and should not carry it in the scrub's pocket. RN A stated she never thought of the infection control compromise by carrying it in her pocket. RN A stated the facility provided training all the time on various subjects and quite frequently on infection control. RN A stated her actions could affect the residents because there was a danger of spreading diseases by not sanitizing the scissors before and after its use on wounds and then carry the contaminated scissors in scrubs pocket for using on the next resident. During the interview on 11/21/23 at 2:35 PM, CNA B stated she was new to the facility and had not thought of the infection control compromise. She stated she understood the situation and her action was not scientific due to the contamination. She stated she contaminated several peri care items by handling them with dirty gloves. CNA B stated her actions could affect the residents because there was a danger of spreading diseases. During an interview on 11/21/23 at 4:00 PM, the DON stated RN A and CNA B should have followed the infection control protocols while providing nursing care. The DON stated the risk of transmission of communicable diseases could be minimized through proper procedures while doing wound care and peri care. When the State Surveyor asked about the training program on wound care at the facility, the DON stated that RN A was a very experienced person with more than 50 years of nursing experience. The DON stated CNA B was new to the facility, however she should know the peri care policies and procedure as she had completed Nurse Aids Skills Exam. There were no in-services specifically on wound care, however, the facility conducted lots of in-services and trainings on hand washing and other infection control topics. The DON stated she identified deficient practices in wound care by making regular rounds on the floor and random participation in nursing care activities. During an interview on 11/21/23 at 3:30 PM, the ADM stated RN A and CNA B were expected to follow the standard precaution for infection control and procedures of wound care and peri care. Record review of the in-services and training folders reflected there was an in- service on Hand Hygiene conducted on 09/29/23. Sign in sheet indicated RN A and CNA B did not participate in the in-service. No other related trainings were conducted since 07/01/2023. Record review of the facility's, undated, policy titled Perineal Care/ Incontinent care reflected: Wash bands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely . a. Clean and store reusable items and discard disposables per facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 4 of 5 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 676196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cornerstone Gardens LLP 763 Marlandwood Rd Temple, TX 76505 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 b. Level of Harm - Minimal harm or potential for actual harm If gloved, remove and discard gloves following facility policy at the appropriate time to avoid environmental contamination. Wash bands. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676196 If continuation sheet Page 5 of 5