Health inspection·August 30, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a Pre-restraining Evaluation dated 08/10/23 indicated Resident #56 was not alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:44 a.m., revealed Resident #56 was resting in bed. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad . During an observation and interview on 08/28/23 at 11:15 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. The resident was confused and did not answer questions appropriately. During an observation on 08/28/23 at 12:06 p.m., revealed Resident #56 was in the dining room in a merry walker. Lunch was being served to Resident #56 on a bedside table placed just above the merry walker. During an observation on 08/29/23 at 9:28 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. When the resident was asked if she could remove the strap and open the bar to the merry walker, she only laughed. Resident #56 never attempted to follow commands. The residents in the common area were being observed by Medication Aide G. During an interview on 08/29/23 at 9:32 a.m., Medication Aide G said Resident #56 was able to stand and walk around in the merry walker. She said Resident #56 was not capable of opening up the bar on the merry walker. She said the resident had falls before the merry chair was used. She said staff had been using the merry chair approximately 6 months for Resident #56. During an observation on 08/30/23 at 9:48 a.m., revealed Resident #56 was sitting in a merry walker in the common area. During an observation and interview 08/30/23 at 9:55 a.m., revealed Resident 56's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad. Medication Aide G said staff always used a bed alarm on Resident #56's bed. 2. Record review of a face sheet dated 08/30/23 revealed Resident #12 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (a decrease in cognitive abilities or mental decline), generalized muscle weakness, and kidney disease. Record review of the most recent MDS dated [DATE] indicated Resident #12 was usually understood and usually understood others. The MDS indicated a BIMS of 2 indicating Resident #12 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm. The MDS did not indicate a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 2 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm . The care plan did not indicate a bed alarm. Record review of the physician's orders for Resident #12 indicated an order with a start date of 05/04/23 for Chair alarm to chair while OOB. There was no stop date for the order. There was not an order for a bed alarm. Record review of a Pre-restraining Evaluation dated 07/18/23 indicated Resident #12 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation and interview on 08/30/23 at 10:00 a.m., Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. During an observation and interview on 08/30/23 at 10:21 a.m., revealed Resident #12 was sitting in a wheelchair participating in an activity. There was a tab alarm hanging on the chair with a clip attached to the resident's shirt. The resident did not answer questions. The resident was confused and said, I don't know who brought me in here. 3. Record review of a face sheet dated 08/30/23 revealed Resident #23 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including dementia (a general decline in cognitive abilities), anxiety disorder, and stroke. Record review of the most recent MDS dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated a BIMS of 2 indicating Resident #23 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm and a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm and a bed alarm. Record review of the physician's orders for Resident #23 indicated an order with a start date of 05/05/23 for a bed alarm on at all times. There was no stop date for this order. There was an order with a start date of 05/05/2023 for May have chair alarm on at all times. There was no stop date for this order. Record review of a Pre-restraining Evaluation dated 07/12/23 indicated Resident #23 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:24 a.m., revealed Resident #23 was sitting in a wheelchair in the common area. There was a tab alarm attached to the back of the wheelchair and clipped to the back of her shirt. During an observation and interview on 08/30/23 at 9:50 a.m., revealed Medication Aide G was observing the residents in the locked unit common area. She said there were two residents that used the chair alarms on the locked unit. She said the residents that used the chair alarms were Residents #12 and Resident #23. She said Residents #56, Resident #12, and Resident #23 had bed alarms. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 3 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0604 the merry walker, the bed alarms, and the chair alarms were all used as a fall prevention for each resident. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 08/30/23 at 9:58 a.m., revealed Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. Residents Affected - Some 4. During a record review the resident face sheet dated 08/30/2023 indicated Resident #27 was a 91- yearold male, admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a group of conditions associated with the elevation or lowering of a person's mood), and anxiety (a feeling of fear, dread, and uneasiness). During the record review, the MDS assessment dated [DATE] indicated Resident #27 had a BIMS of 03, which indicated severe cognitive impairment. The MDS indicated the required extensive assistance with 2 staff members for bed mobility, and transfer. The MDS indicated Resident #27 was totally dependent for sitting in a chair to standing. The MDS indicated Resident #27 had no falls since admit or entry. The MDS indicated daily use of a restraint in chair on out of bed, daily use of bed alarms, and chair alarms. During the record review the care plan for Resident #27 revealed it did not indicate the use of restraints, bed alarms or chair alarms During the record review of the consolidated physician orders for Resident #27 dated August 2023 did not indicate the use of restraints, bed alarms or chair alarms During the record review the quarterly physical restraint evaluation dated 07/04/223 indicated Resident #27 used a Geri chair (a chair used for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) for poor trunk control, a bed alarm, and a chair alarm to prevent falls. During an observation on 08/28/23 at 9:20 a.m., revealed Resident #27 was noted to be reclined in Geri chair sitting in the dining room while activity was being conducted. Resident #27 was noted to have a clip alarm pinned to the back of his sweatshirt while in the Geri chair. During an observation on 08/28/23 at 2:50 p.m., revealed Resident #27 was noted to be in bed with a bed alarm on under the incontinent pad on the mattress, bed lowered to the floor and a mattress on the floor beside the bed as a fall mat. During an observation on 08/29/23 at 10:00 a.m., revealed Resident #27 was noted to be up in Geri chair in a reclined position with a clip alarm pinned to the back of his shirt. During an interview on 08/30/23 at 12:48 p.m., LVN E said he was the nurse for hall 1 and the left side of hall 3. LVN E said he was not aware of any residents with restraints. LVN E said he knew of 5 residents that had alarms. LVN E said Resident #27 had a chair alarm and a bed alarm. He said the Resident #27 was bad about getting up and trying to get out of bed himself. LVN E said Resident #27 had not moved nearly as much for the last 6 months since getting the alarms. LVN E said he provided care to Resident #56 on the locked unit. He said he made observations on the locked unit every 1 - 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 4 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0604 Level of Harm - Minimal harm or potential for actual harm hours. He said those observations were not charted. He said restraint evaluations were completed quarterly. He said he did not consider the merry walker a restraint. He said he considered wrist constraints a restraint. He said he thought Resident #56's family pushed for her to use the merry walker because she was having falls. He said Resident #56 could crawl out of the merry walker but could not open the merry walker. He said she was able to crawl out by getting a leg over the strap and slipping under the walker. Residents Affected - Some During an interview on 08/30/23 at 1:02 p.m., LVN A said there were residents with bed alarms. She said she had 5 or 6 total with alarms. She said some were on beds and some on chairs. She said all the residents with alarms were a fall risk and that was why the alarms were used. She said some had falls and they were trying to prevent falls. She said some residents were getting out of the bed. She said Resident #56, she used to walk in the merry walker. She said it kept her from falling. She said the merry walker was a restraint. She said a restraint could keep the resident from ambulating and doing certain things. She said Resident #56 could not open the bar of the merry walker by herself. She said nursing staff did document on poor trunk control for Geri chairs. She said nursing staff did not chart specific observations on restraints. During an interview on 08/30/23 at 1:14 p.m., the MDS Coordinator said a restraint was anything that limited a resident's movement such as getting out of bed or walking. She said the Geri chair and alarms were restraints for Resident #27 . She said both were used daily. She said Resident #56's merry walker and bed alarm were coded as restraints. She said Resident #56 had falls in the past and she thought that was why she was in the merry walker. She said the nurses completed the restraint assessments. She said she would consider an alarm a restraint . She said Resident #23's alarms were being used for fall prevention. She said Resident #12 had an alarm. She said the alarm was used for fall prevention. During an interview on 08/30/23 on 1:28 p.m., the DON said a restraint was anything that would prevent a resident from moving around and physically be mobile. She said there were no residents in the facility with physical restraints. She said they only put residents in Geri chairs with poor trunk control. She said Resident #56 was very mobile in her merry walker. She said she had the merry walker awhile and she had been able to get out of it. She said the merry walker was because she was having a lot of falls. She said she thought she had the merry walker over a year or two. She said personal alarms were not considered restraints. She said they did not keep anyone from getting up. She said it just alerted the staff and they were only placed after the resident had had several falls. She said she was not familiar with the regulation concerning restraints. During an interview on 08/30/23 at 1:44 p.m., the Administrator said she did not feel there were any restraints in the building. She said a restraint was something that prevented a resident from doing something they would normally do independently. She did not consider the merry walker a restraint. She said when Resident #56 was first admitted she had back-to-back falls. With the merry chair she was able to walk. She felt it was more helpful for her to prevent major injuries from falls. She said she did not know if she could walk without the merry chair. She said she did not know if she could lift herself out of the merry chair. She said she did not feel chair alarms and bed alarms were restraints. She said they were not the first go to intervention and was the last intervention as a fall prevention. Review of a Use of Restraints facility policy dated April 2017 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 5 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .Examples of devices that are/or may be considered physical restraints include .Geri-chairs .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment . Record review of an Abuse, Grievances, and Restraints facility in-service dated 03/07/23 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 6 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain bathing were provided for 1 of 16 residents reviewed for ADLs (Residents # 60). Residents Affected - Few The facility did not provide scheduled showers, grooming and nail care for Resident #60. The failure could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: Record review of a face sheet dated 08/28/2023 indicated Resident #60 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), diabetes mellitus type II ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), and hyperlipidemia (an excess of lipids or fats in your blood). Record review of the MDS dated [DATE] indicated Resident # 60 understood others and made herself understood. The MDS indicated Resident #60 was moderately cognitively impaired with a BIMS score of 12. The MDS indicated Resident #60 did not reject evaluation or care. The MDS indicated the resident required extensive assistance with transferring, dressing, and personal hygiene. Record review of the comprehensive care plan dated 08/24/2023 for Resident #60 indicated no refusal or rejection of care. The care plan did not address her bathing needs. Record review of the Completed ADL Report for August 2023 indicated Resident #60 received a bath on 08/03/2023, 08/22/2023, and 08/26/2023. Record review of an undated Shower Schedule indicated Resident #60 was listed as a Tuesday, Thursday, and Saturday bath. During an observation on 08/28/2023 at 10:00 a.m., revealed Resident # 60 was observed to have 20-30 thick ½ inch gray whiskers to her chin. Resident #60 was noted to have a thick brown substance under her fingernails. During an interview on 08/28/2023 at 10:00 a.m., Resident #60 said she had not had a bath since the previous Tuesday (08/22/2023), 6 days ago. Resident #60 said it was embarrassing to her to have chin hair. Resident #27 said the aides were supposed to shave her when she got a bath, but it had been nearly a week. Resident #60 said her whiskers grew back fast. Resident #60 said she also had to get the nurse to trim her pubic hair because she did not get a bath enough to keep the odor in her pubic area and the hair collected dried feces and odor. Resident #60 stated she was too picky about the way she wanted to be bathed and when she asked the CNAs to bathe her they would say they would come back and never did. During an interview on 08/29/2023 at 2:35 p.m., CNA H said Resident #60 was picky about how she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 7 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few liked her bath and Resident #60 would tell the aides exactly where to put the towels and wash clothes and how to wash her peri area. CNA H said she was unsure why Resident #60 had missed baths in August. CNA H said Resident #60 would ask to wait for a CNA working another hall to have free time to come and assist her (Resident #60) with her bath. During an interview on 08/30/2023 at 2:10 p.m., LVN A said Resident #60 was scheduled to get a bath on Tuesday, Thursday, and Saturday. LVN A stated it was the responsibility of the CNA bathing her to make sure her whiskers and nails were taken care of. LVN A said Resident #60 only liked one CNA to give her a bath and that was why she only got 3 in August. LVN A said that the CNA often worked another hall. LVN A said the CNA could have given Resident #60 a bath even when working another hall. LVN A said Resident #60 would not refuse baths but Resident #60 would say she preferred to wait for the other CNA to assist her, when she had free time. LVN A said the CNA often did not have free time to come assist Resident #60. During an interview on 08/30/2023 at 2:30 p.m., the DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to provide bathes to the residents three days per week at minimum. The DON said she was aware Resident #60 was particular about who gave her a bath, but the facility could make accommodations to make sure Resident #60 got her bath. The DON said each resident was to get 12-15 baths per month depending on the schedule and it was unacceptable that Resident #60 only got 3. The DON said not getting a bath could lead to feeling bad about oneself and depression. During an interview on 08/30/2023 at 2:40 p.m., the Administrator stated it was the job of the nursing department to ensure all residents were bathed and personal hygiene was maintained. The Administrator stated she was unaware Resident #27 had missed 2-3 baths per week for the month of August. The Administrator said not having a regular bath could lead to skin issues and psychological issues. The ADL policy was requested on 08/30/2023 at 10:15 a.m. and was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 8 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #22) reviewed for dialysis services. Residents Affected - Some The facility failed to develop a process to communicate with the dialysis facility, where Resident #22 received hemodialysis services. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #22's face sheet, dated 08/30/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included severe intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level and function in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and chronic kidney disease, stage 5 (a disease that has progressed to a stage where the kidneys have lost nearly all their ability to do their job effectively). Record review of Resident #22's annual MDS assessment, dated 07/25/23, indicated he had a BIMS score of 99 which indicated the resident was unable to complete the brief interview for mental status. He did not exhibit behaviors of wandering or rejection of care. He required supervision assist for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, eating, and toileting. He required limited assistance for dressing, and personal hygiene. The assessment indicated he received dialysis as a resident at the facility. Record review of Resident #22's physician's orders, active as of 08/30/23, indicated he had these orders: *Dialysis every Tuesday, Thursday, Saturday at [dialysis facility] at 10:40 AM. The start date was 5/22/23. *Remove pressure dressing at bedtime on dialysis days. The start date was 5/9/23. *check for bruit (a sound heard through a stethoscope) and thrill (a vibration caused by blood flowing through a dialysis access site) every shift. The start date was 5/18/23. Record review of Resident #22's care plan, dated 08/30/23, indicated a care plan for renal disease: requires dialysis. The goal was to resolve without complications. Interventions included provide and coordinate transportation to the dialysis center, monitor shunt for patency (bruit and thrill), and remove pressure dressing at bedtime on dialysis days, dialysis on Tuesday's, Thursday's, Saturday's. During an interview on 08/30/23 at 07:50 AM, LVN E said he was the nurse assigned to Resident #22 on 08/30/23. He said he does not send any sort of communication sheet to dialysis when Resident #22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 9 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some goes to dialysis. He said he did not call dialysis or receive any communication about how the dialysis session went. He said they do not receive a sheet after dialysis with any information. He said the dialysis center does not reach out to the facility after dialysis to communicate any information. During an interview on 08/30/23 at 8:00 AM, LVN A said she was not assigned to Resident #22 on 08/30/23. She said she did not take care of him often, but she thought there was a dialysis communication sheet when they used paper charts, and she thought they communicated with the dialysis center electronically through the electronic medical record. During an interview on 08/30/23 at 08:10 AM, the DON said they did not typically communicate with the dialysis company. She said they received calls from the dialysis company if there was a complication, but otherwise there was not typically any communication. She said they did not receive or request communication about vital signs, weights, or how the dialysis session went. During an interview on 08/30/23 at 08:17 AM, the DON said they did not use anything to communicate with the dialysis company each visit. She said they did an in-service with both nurses on shift on 08/30/23 and they will now print out a dialysis communication sheet to send with Resident #22 when he goes to dialysis. During an interview on 08/30/23 at 09:54 AM, the dialysis center clinic manager said she was the clinic manager for the dialysis center that Resident #22 attended for dialysis sessions. She said the facility never sent a communication form for them to fill out. She said if he had complications during a session they call the facility, but otherwise they had no communication with the facility. During an interview on 08/30/23 at 12:49 PM, the ADON said she expected the nurses to call and discuss with the kidney center about Resident #22's dialysis sessions. She expected the nurses to obtain information that included any complications, vital signs, whether there were issues with his shunt access, and any change in condition. She said the risk to the resident was that the facility would not know if the kidney center had trouble accessing his shunt, or if his vital signs were out of normal limits. She said if they did not know those things it would put the resident at risk of harm. During an interview on 08/30/23 at 12:51 PM, the DON said she expected the nurses to communicate with the dialysis center via telephone. She expected the nurses to communicate any pain, abnormal vital signs, and any complications. She said the resident could suffer sickness or possible harm since they did not facilitate communication with the dialysis center During an interview on 08/30/23 at 12:53 PM, the Administrator said she expected the nurses to follow the policy and communicate with the dialysis center. She said the resident could suffer harm, or critical labs. She said now they would change and communicate with a sheet of paper to be filled out by the dialysis center. She said if they did not get the sheet of paper back from the kidney center then the nurse would call the kidney center to get the information. Record review of the facility's policy, care of a resident with end-stage renal disease, revised September 2010, stated: .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 10 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0698 .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: . Level of Harm - Minimal harm or potential for actual harm .b. how information will be exchanged between facilities; Residents Affected - Some Record review of the facility's dialysis contract, effective 12/20/19, stated: .This Agreement is made by and between [facility owner] (hereinafter referred to as the Owner) and [dialysis center owner] (hereinafter referred to as the Company). Effective upon the date of last signature . .3. Interchange of information. The Long-Term Care Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents. Including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 11 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0791 Provide or obtain dental services for each resident. 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 obtain routine dental services to meet the need of each resident for 1 of 23 residents reviewed for dental services. (Resident #48) Residents Affected - Few The facility failed to provide routine and follow up dental services for Resident #48, who had missing and decayed teeth, and recent tooth infection/abscess. This failure could place the residents at risk for not receiving care and services to prevent further decline, dental pain, and infections. Findings included: Record review of face sheet dated 8/29/2023 indicated Resident #48, admitted to the facility on [DATE] and was an [AGE] year old with diagnoses including disturbances in tooth eruption, cellulitis (serious skin infection) and abscess of mouth, diabetes, and Parkinson's disease. Record review of physicians' orders dated 9/27/2021 indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #48 was alert, oriented and had a BIMs of 15 indicating cognitively intact. The assessment indicated the resident had a cavity or broken natural teeth. She required supervision assistance in perform most activities of daily living. Record review of the care plans dated 08/02/2023 indicated Resident #48 had a tooth infection with interventions of monitoring vital signs, assess level of consciousness, and administer antibiotic of Penicillin as ordered. There were no dental service care plan interventions listed prior to this 8/2/2023 start date. During observation and interview on 08/28/2023 at 2:30 p.m., revealed Resident #48 had missing teeth to the top and bottom jaw and multiple decayed teeth with black areas to both jaws. The resident said she was seen by the facility dentist since she was admitted to the facility. She said when the dentist visited 2/9/2023 & 4/4/2023, they told her she needed dentures, but it still had not happened. She said she had to go to a local dentist for emergency dental care 8/1/2023 because her mouth and teeth were hurting, and her teeth got infected/abscessed. She said the local dentist told her to come back for a follow up visit after completing the 7-day antibiotics treatment, and they would evaluate her for dentures, but that appointment was not scheduled. She said the facility said they would forward the emergency dental visit information to the facility dentist and when he came to facility, he could assess the resident and follow up. Resident #48 said I still have not seen the facility dentist for the follow up, and they all know I need dental care. The resident denied dental pain. During an interview and record review on 08/29/2023 at 10:02 a.m., the SW said Resident #48 was placed on the schedule to see the facility dentist for July & August 2023, but the contracted dental company cancelled the visit, and the company was no longer in business. She said the facility has now contracted with a new dental company and they were to begin visiting the facility mid-September 2023. The SW said Resident #48 was seen by the facility dentist on 2/9/2023 and 4/4/2023. The SW provided a document from a contract dental company dated 2/9/2023 with Resident #48 listed as a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 12 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seen and services rendered: 11-14, 22-27, f/f and a document from the contract dental company dated 4/4/2023 with Resident #48 listed as a resident seen and services rendered: Cop, x-ray, F/C. The SW unable to transcribe the meaning of services rendered on documents and reports the contract dental service was no longer in business and was unable to verify services rendered. The SW said the facility's contracted dentist did not document in a resident's medical records, but the dentist provided a list of residents seen and services rendered which was kept in the SW's office. The document from the contract dental company has a disclosure stating to enhance communications they presented the list of residents seen today in the facility. The dental provider had already made the appropriate documentation in the patient's chart. The SW said Resident #48 had an emergency dental visit on 8/1/2023 with a local dentist. The SW said Resident #48 was on the list to be seen by the new contract dental company at the next scheduled visit mid-September 2023. During an observation and interview on 08/30/2023 at 10:24 a.m., LVN A, acknowledged that Resident #48 had missing teeth and decayed teeth. LVN A said residents who needed dental service/care were reported to the SW and they were scheduled to see the contracted dentist who came to the facility. She said if it were an emergent/urgent dental concern, they would send a resident to the local dentist office for care. She said Resident #48 has not complained to her about tooth pain or needing dental services. She said the possible negative outcome of not seeing the dentist could be fragments of teeth falling out, pain, further decay, and weight loss. During an interview on 8/30/2023 at 12:55 p.m., the local dental office staff said their office provided emergency care to Resident #48 on 8/1/2023 for tooth and mouth pain. The office staff reported when a patient comes in for tooth pain/infection, standardly the patient was prescribed an antibiotic, pain medications, a proposed treatment plan, and a scheduled time to return to the office for a follow up visit. The local dental office staff said the facility staff did not schedule the follow up appointment for Resident #48 at the time of the initiate emergent/urgent visit on 8/1/2023. During an interview on 08/30/2023 at 3:14 p.m., the DON and the Administrator said their expectations were for the residents to receive dental services as needed. The DON said the nurses should be assessing the residents routinely to ensure their needs were taken care of. They both acknowledge that Resident #48 should be seen by dentist to follow up after recent tooth infection/ abscess. The Administrator said residents should be seen by dental services at least quarterly; however, after reviewing the facility's dental policy, she said the policy indicated residents would be seen monthly. The Administrator and the DON both acknowledged the possible negative outcome of not receiving dental services/care could be tooth/mouth infection, pain and/or poor nutrition/weight loss. Record review of facility policy titled Dental Services and last revised December 2016 indicated in part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation, 1. Routine and 24-hour emergency dental services are provided to our residents through: a. A contract agreement with a licensed dentist that comes to the facility monthly; b. Referral to resident's personal dentist; c. referral to community dentists; or d. referral to other care organization that provided dental services. 11. All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 13 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #60). Residents Affected - Few The facility failed to ensure the refrigerator for Resident #60 did not contain expired orange juice. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated 08/28/2023 indicated Resident #60 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoseis including dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), diabetes mellitus type II ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), and hyperlipidemia (an excess of lipids or fats in your blood). Record review of the MDS dated [DATE] indicated Resident #60 understood others and made herself understood. The MDS indicated Resident #60 was moderately cognitively impaired with a BIMS score of 07. The MDS indicated Resident #60 did not reject evaluation or care. The MDS indicated Resident #60 required set up and supervision for eating. Record review of a care plan for Resident #60 dated 08/24//2023 revealed Resident #60 required supervision setup by staff participation to eat. During an observation and interview on 08/28/2023 at 09:50 a.m., Resident #60 said she got food and drinks from her personal refrigerator herself when she wanted. Her personal refrigerator had an unopened 240 ml bottle container of orange juice with the expiration date of 10/15/2022. When asked if staff checked her refrigerator, she said the staff cleaned and took care of the refrigerator for her. Resident #60 said the people she raised (non-biological children) brought her food and drinks when they visited. Resident #60 said she was unsure how long the orange juice had been in the refrigerator. During an interview and observation on 08/29/2023 at 2:10 p.m. CNA H said housekeeping was responsible for cleaning out the resident refrigerators and making sure there is no expired food. CNA H said she does not think there is a facility policy for personal refrigerators. CNA H removed the expired orange juice from Resident #60's personal refrigerator. During an interview on 08/29/2023 at 2:20 p.m., the Housekeeping Supervisor said housekeeping had always been responsible for cleaning the personal refrigerators. She said she was not sure how Resident #60's refrigerator was missed. She said personal refrigerators are to be cleaned daily when the resident's room is cleaned. She said there was no formal paperwork to show that the task of checking the fridge was completed. During an interview on 08/30/2023 at 2:40 p.m., the Administrator said it was the policy of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 14 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 facility for the housekeepers to keep the refrigerators cleaned out daily. She said they checked the temperature every day when they cleaned the rooms and checked for expired foods. Record Review 08/30/2023 at 08:50 a.m., of policy titled Foods Brought by Family/Visitors indicated, the nursing staff will discard perishable foods on or before the use by date. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 15 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. Residents Affected - Many The facility did not ensure the arbitration agreement contained the required elements: *Failed to provide the right to rescind in 30 calendar days of signing This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the resident or the resident's representative had the right to rescind the agreement within 30 calendar days of signing the agreement. During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they had a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said she had gotten the agreement from another facility and did not know it did not reflect the right to rescind within 30 days. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 16 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator and a convenient venue for 1 of 1 facility reviewed for Arbitration Agreements . Residents Affected - Many The facility failed to ensure the provision of a neutral arbitrator. The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the provision of a neutral arbitrator and a section indicating the provision of a convenient venue . During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they have a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 17 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0926 Have policies on smoking. 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 follow their established smoking policy for 3 or 24 (Residents #37, #58, and #14) residents reviewed for smoking. Residents Affected - Some The facility failed to ensure Residents #37, #58 and #14 did not have smoking supplies at their bedside and in their possession . This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #37's face sheet dated 2/19/23 revealed he was an [AGE] year-old male, who was admitted to the facility on [DATE] with the diagnoses of Conduct Disorder (a group of behavioral and emotional problems characterized by a disregard for others), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), and Cerebral Infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.) Record review of Resident #37's quarterly MDS dated [DATE] indicated he had a BIMS of 15, which indicated he was cognitively intact. Resident #37 normally used a wheelchair as a mobility device. Resident #37 required a one person assist with transfer, bed mobility, and personal hygiene. Record review of Resident #37's care plan dated 7/1/23 revealed the resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession, be informed of facility smoking policies, be assessed as a safe smoker. Record review of Resident #37's safe smoking evaluation, dated 6/26/23, indicated he was safe to smoke unsupervised. The evaluation further indicated he was able to independently follow smoking policies, and that he return the smoking material to the appropriate storage. During an observation and interview on 8/28/23 at 10:45 a.m., Resident # 37 stated that he had cigarettes and a lighter in his shirt pocket. He stated that he smoked by himself and with other residents outside in the smoking section. He said that he keeps his cigarettes and lighter and didn't give it to the nurse's station when he was finished smoking. He stated that he smoked when he wanted to and kept his cigarettes in his dresser drawer. The Surveyor observed cigarettes in Resident #37's shirt pocket. During an observation and interview on 8/29/23 at 2:56 p.m., revealed Resident #37 was in room lying in bed. He stated that his cigarettes were in his dresser drawer. The Surveyor asked if he could look in Resident #37's drawer which he stated, Yes. The Surveyor observed cigarettes and a lighter in Resident #37's dresser drawer. During an interview on 8/30/23 at 9:42 a.m., CNA F stated that Resident #37 does smoke. She stated that she believes that Resident #37 he goes out every hour to smokes once an hour each dayeach day. She stated that residents are supposed to leave smoking supplies at the nurse's station. She stated that residents are not allowed to keep cigarettes or lighters on their person. She stated that usually residents are supposed to ask the staff at the nurse's station to get their smoking supplies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 18 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #58's face sheet, dated 08/29/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), cerebral infarction (the pathologic process that results in an area of necrotic [dead] tissue in the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), and aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension). Record review of Resident #58's annual MDS, dated [DATE], indicated she had a BIMS score of 8, which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. She required supervision assist for bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. Record review of Resident #58's care plan, dated 08/29/23, indicated a care plan for safe smoker. The start date was 06/12/23. The goal was resident will have no injury from smoking through next review date. Interventions included: *resident will be informed of the facility smoking policy *resident will sign smoking agreement with facility *resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession *assess resident to ensure they are following facility's safe smoke guidelines *resident will smoke in supervised approved smoking area only Record review of Resident #58's safe smoking evaluation, dated 08/28/23, indicated she was safe to smoke unsupervised. The evaluation further indicated she was able to independently able to follow smoking policies, and that she returns the smoking material to appropriate storage. During an observation and interview on 08/28/23 at 10:37AM, Resident #58 was lying in bed in her room. She was unable to speak but nodded yes when theis surveyor asked if she was a smoker. She showed theis surveyor her pack of cigarettes and it had cigarettes and a lighter inside. During an observation on 08/29/23 at 09:54 AM, Resident #58 was lying in her bed in her room. There was a pack of cigarettes and a lighter at her bedside. During an observation on 08/29/23 at 02:53 PM, Resident #58 was lying underneath a blanket in her bed in her room. She had her cigarettes and a lighter on her bedside table. During an observation on 08/30/23 at 09:37 AM, Resident #58 had cigarettes and a lighter on her bedside table. She was lying in bed under her blanket. 3. Record review of Resident #14's face sheet, dated 08/29/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 19 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0926 Level of Harm - Minimal harm or potential for actual harm anxiety disorder (persistent and excessive worry that interferes with daily activities), type 1 diabetes mellitus (a lifelong disease in which there is a high level of sugar in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Residents Affected - Some Record review of Resident #14's quarterly MDS, dated [DATE], indicated he had a BIMS score of 9, which indicated moderate cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. He required supervision assist with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. He normally used a wheelchair as a mobility device. Record review of Resident #14's care plan, dated 08/29/23, indicated a care plan for safe smoker. The start date was 06/12/23. The goal was resident will have no injury from smoking through next review date. Interventions included: *resident will be informed of the facility smoking policy *resident will sign smoking agreement with facility *resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession *assess resident to ensure they are following facility's safe smoke guidelines *resident will smoke in supervised approved smoking area only Record review of Resident #14's safe smoking evaluation, dated 07/10/23, indicated he was safe to smoke unsupervised. The evaluation further indicated he was able to independently able to follow smoking policies, and that he returns the smoking material to appropriate storage. During an observation on 08/29/23 at 09:53 AM, Resident #14 was self-ambulating with his wheelchair near the nurse's station. He had an unlit cigarette in his mouth. During an observation on 08/29/23 at 09:56 AM, Resident #14 had a pack of cigarettes on his bedside table in his room . During an interview on 08/30/23 at 09:38 AM, CNA D said she was taking care of Residents #58 and #14 on 08/30/23. She said residents should not have smoking materials at the bedside. She said the smoking materials were supposed to be locked up at the nurse's station. She said sometimes Resident #58's family member would sneaks cigarettes in and give them to her without notifying the staff. During an interview on 08/30/23 at 09:40 AM, LVN E said he was taking care of Residents #58 and #14 on 08/30/23. He said residents should not have cigarettes or a lighter at the bedside. He said the supplies should have been locked up at the nurse's station. He said Resident #58's family member probably brought them to her without telling staff. He said the risk to the residents could be they could start a fire. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 20 of 21 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 676269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rayburn Health Care & Rehabilitation 144 Bulldog Avenue Jasper, TX 75951 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/30/23 at 12:57 p.m., the DON stated that residents are supposed to take cigarettes from the nurse's station and leave their lighters at the nurse's station when they are finished e done smoking. She stated that if residents arewere allowed to keep their cigarettes and lighters, they might smoke in their rooms or harm themselves. She stated that the residents could also be placed at risk for causing a fire. She stated that the facility was not following company policy by allowing residents to have lighters and cigarettes in their bedroom. During an interview on 8/30/23 at 12:57 PM the Administrator stated that facility policy is that residents are not allowed to keep cigarettes and lighters in their rooms. She stated that residents are supposed to leave their cigarettes and lighters at the nurse's station when they are done smoking. She stated that residents could be placed at risk by keeping a lighter in their rooms by starting a fire. Record review of an undated facility policy entitled Smoking Policy revealed that, The resident is not allowed to keep matches, cigarettes, lighters, or other smoking paraphernalia in the room. These are kept at the nurse's station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676269 If continuation sheet Page 21 of 21