Health inspection·July 26, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm the corner of the room. An attempt was made to interview the resident. The resident was non-verbal and did not answer questions. During an observation on 07/24/23 at 3:19 p.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. Residents Affected - Some During an observation on 07/25/23 at 7:43 a.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an observation on 07/25/23 at 8:53 a.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an observation on 07/25/23 at 11:00 a.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an observation on 07/25/23 at 2:10 p.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an observation on 07/25/23 at 4:04 p.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an interview on 07/26/23 at 9:10 a.m., a family member for Resident #33 said they did expect Resident #33 to be out of bed every day. The family member said he should be sitting up. The family member said they did not want Resident #33 to stay in bed all day. The family member said they had made this request to staff and wanted this in Resident #33's care plan; they thought it was in his care plan. During an observation at 07/26/23 at 9:16 a.m., Resident #33 was in bed. The resident remained non-verbal. There was a Geri chair in the corner of the room. During an interview on 07/26/23 at 9:32 a.m., CNA A said she had provided care to Resident #33. She said the aides were responsible for getting him out of bed. She said he was normally left in the bed, but she had seen him out of bed . She said he was not gotten out of bed every day. During an interview on 07/26/23 at 9:49 a.m., RN B said the aides were responsible for getting Resident #33 out of bed. She said he was normally out of bed on shower days. She said his shower days were Monday, Wednesday, and Friday. She said normally the family would call saying they wanted him out of bed. She said when he was gotten up, he did stay in his chair for a good while. She said the resident sitting up would benefit him with preventing skin breakdown and help with his respiratory function. She said it would help him to have more social interaction. During an interview on 07/26/23 at 10:30 a.m., the DON said the nursing staff were responsible for getting Resident #33 out of bed. She said she felt staff were obligated to follow physician's orders. She said being out of bed daily would benefit him by providing socialization. During an interview on 07/26/23 at 11:04 a.m., the Administrator said Resident #33 had the right not to get out of bed if he did not want to be out of bed. She said if he had refused at any time she would have expected the refusal to have been charted in the progress notes. She said not being out of bed could cause increased risk of pressure sores and he would not have any communal interaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 2 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a Resident Right's facility policy dated 11/28/16 indicated, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility .A facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life .the facility must treat the decisions of a resident representative as the decision of the resident .the resident has the right to interact with members of the community and participate in community activities both inside and outside the facility . Event ID: Facility ID: 676385 If continuation sheet Page 3 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident #26) Residents Affected - Few The facility failed to document visual impairment and anti-anxiety use on the MDS for Resident #26. These failures could place residents at risk for not receiving needed care and services. Findings included: Record review of a face sheet dated 07/24/2023 revealed Resident # 26 was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of Multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system), legal blindness (your vision is 20/200 or less in your better eye or your field of vision is less than 20 degrees), and anxiety ( a feeling of fear, dread, and uneasiness). Record review of a quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 14 which indicated minimal cognitive impairment. The MDS revealed Resident #26 required extensive to dependent assistance with ADLs. The MDS revealed no anti-anxiety medications were received by Resident #26. The MDS revealed no visual impairment was noted for Resident #26. Record review of the Medication Administration Record for May 2023 revealed clonazepam (anti-anxiety) 1mg was administered daily from 05/01/2023 to 05/19/2023 for Resident #26. Record review of the physician consolidated orders dated May 2023 revealed a diagnosis of legal blindness for Resident #26 since 02/25/2020. During an interview on 07/25/2023 at 3:30 p.m., the MDS Coordinator stated Resident #26 was legally blind because of nystagmus ( uncontrolled eye movements) related to his Multiple Sclerosis diagnosis and he received clonazepam daily during the look back period for the 05/16/2023 MDS. The MDS Coordinator stated missing that information on Resident #26's MDS was an oversite. During an interview on 07/26/2023 at 10:00 a.m., the DON stated the MDS nurse was responsible for accurate MDS production for all residents in this facility. The DON stated MDS inaccuracy could lead to reimbursement issues and not providing adequate care to each resident. During an interview on 07/26/2023 at 11:00 a.m., the Administrator stated it was he expectation that all MDSs be an accurate reflection of individual residents. The Administrator stated accurate MDSs were important for accurate care plans to be made and individualized care to be carried out. Review of the facility policy titled MDS accuracy dated 07/2021 indicated, the facility will ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident .According to CMS's RAI Version 3.0 manual; the MDS is a core set of screening, clinical, and functional status elements .which forms the foundation of a comprehensive assessment for all residents of nursing homes .the items of the MDS standardize communication about resident problems and conditions with nursing homes, between nursing homes, and outside agencies .Federal regulations .require that .the assessment accurately reflects the resident's status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 4 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for 2 of 17 residents reviewed for baseline care plans. (Resident #49 and Resident #54) The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #49. The facility failed to develop a complete baseline care plan for Resident #54. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 7/25/23 revealed Resident #49 was a [AGE] year-old female, who admitted to the facility on [DATE], with the diagnoses of dementia (progressive or persistent loss of intellectual functioning; impairment of memory, thinking, and often personality changes), weakness, hypertension (high blood pressure), congestive heart failure (the heart does not pump blood as well as it should), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease (decreased function in the kidneys' ability to filter waste and excess fluid from the blood), anxiety (feeling of fear, dread, and uneasiness), and bipolar (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of the Order Summary report dated 7/25/23 revealed Resident #49 revealed the following medications were started on 3/10/23: alendronate 70 mg once a day on Mondays (increases bone density, reducing risk of bone fractures), aspirin 81 mg daily (blood thinner), donepezil 10 mg at bedtime (treats dementia), Eliquix2.5 mg two times daily (blood thinner), escitalopram 20 mg daily (treats bipolar/depression), furosemide 40 mg twice daily (diuretic to remove fluid build-up due to heart failure or kidney disease), gabapentin 100 mg twice daily for pain, levothyroxine 100 mcg daily for thyroid, and mirtazapine 7.5 mg daily for bipolar/depression. The orders revealed Resident #49 was a flight risk, was on a regular diet, and she had a full code status. Record review of Resident #49's electronic chart for the Baseline Care Plan revealed a baseline care plan had not been developed within 48 hours to include the care areas of dementia, bipolar with the use of antipsychotic and anticonvulsant medications, anticoagulant therapy, fall risk, hypertension, full code status, congestive heart failure, history of making suicidal comments for manipulative purposes, history of making false allegations, and risk for malnutrition. Record review of Resident #49's progress note dated 3/10/23 revealed she arrived at the facility, and she was placed on one-on-one with a sitter due to her being an elopement risk. During an interview on 7/26/23 at 9:56 AM, the Nurse F said Resident #49's baseline care plan was initiated on 3/13/23. Nurse F said the baseline care plans should be completed within 48 hours of admission. Nurse F said Resident #49's baseline care plan was not completed within the 48-hour timeframe. Nurse F said the importance of the baseline care plan was so the staff could provide the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 5 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0655 appropriate care to the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/26/23 at 10:13 AM, RN G revealed she had worked at the facility for approximately 2 months as a Charge Nurse. RN G said the MDS nurse was responsible for completing the baseline care plans. RN G said she was not part of the baseline care plan process and did not know the timeframe for the baseline care plan to be completed. Residents Affected - Few During an interview on 7/26/23 at 10:52 AM, the Administrator said the baseline care plan should be completed within 48 hours of the resident's admission. The Administrator said the Charge Nurse was responsible for completing the baseline care plan during the admission process. The Administrator said she would expect the baseline care plan to be completed within the required 48-hour timeframe. The Administrator said all staff used the base line care plan to reference to meet the needs of the resident. 2. Record review of a face sheet dated 07/25/23 revealed Resident #54 was [AGE] years old and was admitted on [DATE] with a diagnosis of congestive heart failure. The face sheet did not indicate any further diagnosis. The face sheet indicated a discharge date of 05/06/23. Record review of the consolidated physician orders dated 05/06/23 indicated Resident #54 was admitted to hospice service. There was an order dated 05/04/2023 for DNR (do not resuscitate). There was an order for Morphine Sulfate (opiate pain medication) Oral Solution 20 milligrams/5 milliliters. There was an order for Lorazepam (a controlled medication used for anxiety) oral tablet 1 milligram dated 05/03/23. There was an order dated 05/04/23 for BiPap (a machine that helps with breathing. It is a form of non-invasive ventilation that a provider might use if someone could breathe on their own but are not getting enough oxygen) with oxygen via the BiPap. The orders included the Bipap settings. Record review of a care plan dated 05/04/23 indicated Resident #54 was at risk for an unplanned weight loss or gain. The care plan did not address any other focus areas. The care plan did not indicate the resident had been admitted to hospice services, the resident had orders for Morphine and Lorazepam, or that the resident required ventilation with a Bipap machine. During an interview on 07/26/23 at 9:49 a.m., RN B said the baseline care plan was to be initiated on admission by the admitting nurse. She said there was a second part to the baseline care plan that the DON was responsible for. She said the purpose of a baseline care plan was to monitor a resident's needs. She said it was to monitor a resident's over all care and to set goals for their care. During an interview on 07/26/23 at 10:30 a.m., the DON said the charge nurse was responsible for creating the baseline care plan on admission. She said a baseline care plan should include the needed care for the residents. She said the base line care plan should be completed within 48 hours of admission. She said it would be more difficult to provide care for the resident without a complete baseline care plan. During an interview on 07/26/23 at 11:04 a.m., the Administrator said the charge nurse that takes the admission was responsible for completing the baseline care plan. She said a baseline care plan should be completed in 48 hours. She said she would have expected for Resident #54 to have been complete and thorough. She said the care plans needed to be complete because the staff look to the care plan to provide care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 6 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of an undated Baseline Care Plans facility policy indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing staff, increase resident safety, and safe guard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial delivery of care and services by receiving a written summary of the baseline care plan .The baseline care plan will be developed within 48 hours of a resident's admission .Include the minimum healthcare information necessary to properly care for a resident .The baseline care plan will reflect the residents' goals and objectives, and include interventions that address his or her current needs. It will be based on admission orders . Event ID: Facility ID: 676385 If continuation sheet Page 7 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 20 residents reviewed for care plans. (Resident #51, Resident #28, and Resident #33) The facility failed to develop a comprehensive person-centered care plan including an active problem of bowel and bladder incontinence, oxygen usage, and risk for malnutrition for Resident #51. The facility failed to develop a comprehensive person-centered care plan including an active problem of pain, use of foley catheter, use of diuretics, use of opioid medications, and need for assistance with ADLs for Resident #28. The facility failed to develop a comprehensive person-centered care plan for Resident #33 that included a physician's order to have the resident up and in Geri chair (a chair used for those with mobility issues and can be used for bedridden residents who have difficulty sitting upright) during the day. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include: 1. Record review of the face sheet dated 4/7/2023 revealed Resident #51 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (results from acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia), muscle weakness (Muscle weakness happens when full effort doesn't produce a normal muscle contraction or movement), need for assistance with personal care, malignant neoplasm of right main bronchus (a group of extremely rare neoplasms situated in large airways between the [NAME] and hilum of the lung), cognitive communication deficit (difficulty with thinking and how someone uses language.) Record review of Resident # 51's MDS assessment dated [DATE] revealed Resident #51 had a BIMS of 8, which indicated she had mildly impaired cognition. Shows that Resident #51 triggered for oxygen therapy, bladder incontinence, bowel incontinence, and nutrition risk. Record review of Resident # 51's care plan revealed that oxygen therapy, bladder incontinence, bowel incontinence, and risk for malnutrition had not been care planned until 7/25/2023. Care planning for these MDS triggers was created after surveyor spoke to facility staff regarding the failure to properly develop care plans. 2. Record review of the face sheet dated 07/24/2023 revealed Resident # 28 was a [AGE] year-old male, and admitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), 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), and congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 8 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 your body a normal supply). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #28's quarterly MDS assessment revealed the use of a foley catheter, the use of routine opioid medications for pain, the use of diuretics, and varying degrees of assistance needed for ADLs for Resident #28. Residents Affected - Some Record review of Resident #28's care plan dated 06/12/2023 revealed no care plan for a foley catheter, no care plan for pain, no care plan for daily opioid use, no care plan for daily diuretic use, and no care plan out lining the assistance needed for ADLs. Record review of Resident #28's MD orders dated 07/26/2023 revealed an order for a foley catheter dated 03/29/2023, and order for Tramadol 50mg twice daily dated 04/04/2023, and an order for Lasix 20 mg daily dated 03/29/2023. 3. Record review of a face sheet dated 07/24/23 revealed Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including stroke, high blood pressure, and lack of coordination. Record review of current physician's orders for Resident #33 indicated an open-ended order with a start date of 10/07/22 to Please have resident up in geri chair during day as tolerated per family request. Record review of the most recent MDS dated [DATE] indicated Resident #33 was rarely to never understood and rarely to never understood others. The MDS indicated a BIMS of 00 indicating Resident #33 was severely cognitively impaired. The MDS indicated Resident #33 required extensive assistance with bed mobility and transfers. The resident was totally dependent on staff for locomotion on and off the unit. Record review of a care plan last revised on 07/17/2023 indicated Resident #33 did not indicate a physician's order to have the resident up in geri chair during the day. During an interview on 07/25/23 at 9:10 a.m., a family member for Resident #33 said they expected Resident #33 to be out of bed sitting up every day. The family member said they had made this request to staff. They said they wanted this in Resident #33's care plan and they thought it was in his care plan. During an interview on 07/25/2023 at 2:30 p.m., the MDS Coordinator stated she was the individual responsible for creating, updating, and maintaining all care plans in the facility except for baseline care plans. The MDS Coordinator stated she care planned all Care Area Assessments, medications, and special needs or instructions for each resident. The MDS Coordinator stated the care plan was used to direct the floor staff to care for each resident as an individual. The MDS Coordinator stated the missed items for Residents #51, #28, and #33 were oversites and should have been care planned to instruct staff on the resident's needs. During an interview on 07/26/2023 at 10:00 a.m., the DON stated it was the sole responsibility of the MDS nurse to ensure all pertinent information was care planned for each resident. The DON stated the care plan was used as a set of instructions to provide optimal care of each resident and no having everything care planned could lead to missing important parts of the resident's care. During an interview on 07/26/2023 at 11:00 a.m., the Administrator stated it was the role of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 9 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 FORM CMS-2567 (02/99) Previous Versions Obsolete MDS Coordinator to care plan all residents care needs. The Administrator stated not having items care planned could result in the resident's not receiving important aspects of care. Review of a facility policy titled Comprehensive Care Plans dated 12/2022 revealed .(c) Comprehensive care plans. (1) The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Event ID: Facility ID: 676385 If continuation sheet Page 10 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 provide the necessary services to maintain personal hygiene for 1 of 16 residents reviewed for ADLs (Residents #25.) Residents Affected - Few The facility did not clean or trim Resident #25's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings were: Review of Resident #25's electronic face sheet dated 01/9/2022 revealed he was a [AGE] year old 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), urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), muscle weakness ( Muscle weakness happens when full effort doesn't produce a normal muscle contraction or movement), cognitive communication deficit (difficulty with thinking and how someone uses language.) Record review of Resident #25's annual MDS dated [DATE] revealed a BIMS with a score of 12, which indicated resident #25 has moderately impaired cognition. The MDS also revealed, Resident #25, required limited assistance with personal hygiene. Resident #25 required one-person physical assistance with personal hygiene, including nail hygiene. Record review of Resident #25's care plan dated 01/13/2022 revealed that, BATHING: Check nail length and trim and clean on bath day and as necessary. During an interview and observation on 07/24/2023 at 1:57 p.m., Resident # 25 was observed with long and dirty fingernails. His nails were approximately ¼ to ½ an inch long with a black substance underneath the nails. He stated he does not cut his own nails and the nurses come around and volunteer to do it sometimes. He said that he would like his nails cut today. He stated that that he doesn't ask the nurses to cut his nails because he doesn't want to boss them around and he doesn't feel its ok to ask for his nails to be cut. During an interview on 07/24/2023 at 2:31 p.m., Resident # 25 stated that he has his baths on Tuesdays. He said that he did not get his nails cut last week. He said that he does not remember the last time he had his nails cut. During an observation on 07/25/2023 9:13 a.m., Resident # 25 nails had yet to be cut or cleaned. His nails appeared long about ¼ to ½ an inch in length with a black substance underneath the nails. During an observation on 07/25/2023 at 3:14 p.m., Resident # 25 nails had yet to be cut or cleaned. His nails appeared long about ¼ to ½ an inch in length with a black substance underneath the nails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 11 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 During an interview on 07/26/2023 at 8:23 a.m., Resident # 25 nails had yet to be cut or cleaned. His nails appeared long about ¼ to ½ an inch in length with a black substance underneath the nails. During an interview on 07/26/2023 at 8:34 a.m., CNA A 07/26/23 08:35 a.m., Resident #25 takes bathes on Tuesdays. She stated that the treatment nurse, LVN I, will clean and trim his fingernails but its also the CNAs job to cut and clean them when they see they are long or dirty. She stated that Resident #25 scratches his butt and the dark matter underneath his nails is probably feces. During an interview on 07/26/2023 at 8:36 a.m., LVN I stated that she cuts Resident #25's fingernails. She stated that sometimes he gets his nails cut with his bath. She stated that if aides notice that Resident #25's nails need to be cut they should also cut or clean his nails. She stated that she does her skin assessments on Mondays, and she will cut nails herself. She stated that she is sure she cut Resident #25's fingernails last week. During an interview on 07/26/2023 at 10:20 a.m., The DON stated that she expected residents who are dependent or require assistance for ADL care should have their nails clipped when they are scheduled or whenever it was needed. She stated that if a resident was observed with long fingernails that have feces or an unknown substance underneath their nails then the resident's nails should have been cleaned and clipped. She stated that residents could be placed at risk for infection having long and dirty fingernails. During an interview on 07/26/2023 at 10:31 a.m., the Administrator stated that she expects her staff to keep resident's nails clean as it can place residents at risk for an infection. She stated that residents who are dependent or required assistance for ADLs should have their needs met by her staff. Review of the facility policy and procedure on care of Nail Care dated 2003 revealed that the purpose of the procedure is, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath . Nail care will be performed regularly and safely. The resident will free from abnormal nail conditions The resident will be free from infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 12 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0685 Assist a resident in gaining access to vision and hearing 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 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #33) Residents Affected - Few The facility did not address Resident #33's need for a vision exam. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem. Findings included: Record review of a face sheet dated 07/24/23 revealed Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including changes in retinal vascular appearance (retinal vascular conditions generally involve a blockage of blood low, leakage of fluid, or rupture of a retinal vessel in eye), left eye primary optic atrophy (damage to the optic nerve), and stroke. Record review of the most recent MDS dated [DATE] indicated Resident #33 was rarely to never understood and rarely to never understood others. The MDS indicated a BIMS of 00 indicating Resident #33 was severely cognitively impaired. The MDS did not indicate any visual impairment. Record review of a care plan last revised on 07/17/2023 indicated Resident #33 had impaired visual function. There was an intervention to identify and record factors affecting visual function. Record review of a progress note dated 10/06/22 indicated, (Family Member of Resident #33) .called requesting resident be on the list to be seen by eye doctor in house email has been sent to social worker for request . Record review of an electronic medical record accessed on 07/24/23, 07/25/23, and 07/26/23 did not indicate any documentation of Resident #33 being evaluated or treated by an eye doctor. During an interview on 07/24/23 at 2:39 p.m., a family member of Resident #33 said they had requested for Resident #33 to be seen an eye doctor. The family member said they were told an eye doctor would come to the facility to see him, but she did not think that they had. During an interview on 07/25/23 at 4:33 p.m., Social Worker C said she had been the Social Worker at the facility for 5 weeks. She said the eye doctor came to the facility quarterly. She said they were at the facility at the end of June 2023. She said if it was not an emergency they just add the resident to the list to be seen when the eye doctor came. She said the charting for eye doctor visits should under the documents section of the electronic medical record. She said she did not know off the top of her head if Resident #33 had been seen by the eye doctor. She said she had not sent Resident #33 out of the facility to see an eye doctor. During an interview on 07/26/23 at 9:10 a.m., a family member of Resident #33 said Resident #33 had glaucoma and they wanted him to see an eye doctor. The family member said they had asked staff many times for him to see an eye doctor. The family member said they were told the in-house eye doctor only came quarterly to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 13 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/26/23 at 9:30 a.m., Social Worker D said she worked at the facility as the social service director from July 2022 to May 2023. Social Worker D said her job included social service assessments, scheduling vision, and scheduling care plan meetings with the family quarterly. Social Worker D stated she attempted twice a month to contact the in-house vision service company. The vision service did not come to the facility the entire time she worked at the facility to see any residents for visual checkups. Social Worker D stated there were a few residents that went to visual checkups in the community, but Resident #33 was not one of them. Social Worker D did recall a request from the family to have Resident #33 be seen by the eye doctor but was unable to get the contractor eye doctor to come to the facility. During an interview on 07/26/23 at 10:30 a.m., the DON said she did not know if Resident #33 had been seen by an eye doctor since it was requested in October 2022. She said currently they had not found any documentation of Resident #33 being seen by an eye doctor. She said Resident #33 not having been an eye doctor, he might have diagnoses they do not know about. During an interview on 07/26/23 at 10:50 a.m., Regional Nurse E said the facility did not have a specific policy concerning eye care. During an interview on 07/26/23 at 11:04 a.m., the Administrator said there should have been a follow up to see if Resident #33 had been seen by the eye doctor. She said the social worker was responsible for making the appointment and following up to make sure he had been seen by the eye doctor. Review of an Appointments facility policy dated 2003 indicated, .The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 14 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #15 and Resident #51). Residents Affected - Few 1. The facility failed to ensure Resident #15's oxygen concentrator had a filter in place to change weekly per physician orders. 2. The facility failed to ensure Resident #51's nasal cannula was sanitarily stored when not in use. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of Resident #15's face sheet dated 7/24/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #15 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, impairment in memory, thinking, personality change caused by disease of the brain), hypertension (high blood pressure), anxiety (feeling of fear, dread, and uneasiness), and depression (persistent feeling of sadness). Record review of Resident #15's quarterly MDS dated [DATE] revealed she was understood and understood others. Resident #15 had a BIMS of 9, which indicated she had moderate cognitive impairment. Resident #15 required extensive assistance of 1-2 persons for most ADLs, but she was totally dependent on staff for bathing. Record review of Resident #15's undated care plan revealed she had oxygen therapy as needed. Record review of Resident #15's Order Summary Report dated 7/24/23 revealed an order to change respiratory concentrator water, clean filter every seven days on Sunday night shift. There was an order stating resident may have oxygen at 2 LPM by nasal cannula continuously for shortness of breath/wheezing related to anxiety. Record review of Resident #15's TAR dated 7/01/23-7/31/23 revealed to change respiratory concentrator water and clean filter every 7 days on Sunday night shift was not documented as completed on 7/23/23. During an observation and interview on 7/24/23 at 10:43 AM, Resident #15 was sitting up in bed with her oxygen nasal cannula tied around the grab bar of the bed. The oxygen concentrator did not have a filter. The oxygen concentrator's air inlet, where the filter should have been, was covered with fuzzy dust-like particles and hair-like particles. Resident #15 said she wears her oxygen often daily for shortness of breath, but she did not need it at that time. She said she did not have a bag to store her oxygen nasal cannula in when she was not using it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 15 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 7/24/23 at 2:11 PM revealed Resident #15 was wearing her oxygen nasal cannula at 2 LPM. The oxygen concentrator continued to have no filter and the air inlet had fuzzy dust-like particles and hair-like particles. During an observation on 7/25/23 at 8:11 AM revealed Resident #15 was wearing her oxygen nasal cannula at 2 LPM. The oxygen concentrator continued to have no filter and the air inlet had fuzzy dust-like particles and hair-like particles. During an observation and interview on 7/25/23 at 3:18 PM, LVN H said she had worked at the facility for 3 ½ years. LVN H said the nurses were responsible for changing/cleaning oxygen filters and tubing once weekly and she thought it was done on the day shift. LVN H said that it would show in the orders when it was to be changed or cleaned and would be documented on the TAR. LVN H said the resident's oxygen could become clogged and the resident would not get the proper oxygen if the filter was dirty or there was not a filter. LVN H and surveyor entered Resident #15's room. LVN H checked the oxygen concentrator filter and said the filter was not on the concentrator and there was dust and stuff in it. LVN H said she would replace Resident #15's filter. During an interview on 7/25/23 at 3:45 PM, LVN H said she replaced the entire oxygen concentrator for Resident #15. During an interview on 7/26/23 at 7:25 AM, RN B said she had worked at the facility for three years. RN B said the nurses were responsible for changing oxygen tubing and cleaning the oxygen concentrator filters. RN B said there was a place on the TAR to document when the oxygen tubing and cleaning the oxygen concentrator filters was completed. RN B said residents could have a decreased oxygen level and/or the machine would not work properly if the filter was missing or dirty. During an interview on 7/26/23 at 10:13 AM, RN G said the nurses were responsible for changing the oxygen tubing, but she was not sure who was responsible for cleaning the oxygen filters. RN G said the oxygen tubing change would be documented on the TAR. RN G said the nurses should be checking the oxygen filters to ensure they were clean. RN G said the resident could get an infection without an oxygen filter or a dirty filter. RN G said if the oxygen concentrator did not have a filter, it would not filter any dust and stuff. During an interview on 7/26/23 at 10:44 AM, the DON said the night nurses were responsible for changing oxygen equipment and cleaning oxygen filters on the night shift on Sundays. The DON said the nurses would document on the TAR when it was completed. The DON said the resident was at an increased risk of infection if the oxygen filter was dirty and/or missing. During an interview on 7/26/23 at 10:52 AM, the Administrator said she would expect the oxygen filters should be cleaned and the oxygen concentrator should have a filter. The Administrator said the resident could breathe germs, dust, or anything into their lungs if the filter was missing or dirty. The Administrator said a dirty or missing oxygen filter could cause an infection. 2. Record review of the face sheet dated 4/7/2023 revealed Resident #51 was a [AGE] year-old, female, and admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (results from acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia), muscle weakness (Muscle weakness happens when full effort doesn't produce a normal muscle contraction or movement), need for assistance with personal care, malignant neoplasm of right main bronchus (a group of extremely rare neoplasms situated in large airways between the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 16 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 [NAME] and hilum of the lung), cognitive communication deficit (difficulty with thinking and how someone uses language.) Record review of Resident #51's MDS dated [DATE] revealed Resident #51 had a BIMS of 8, which indicated she had mildly impaired cognition. Shows that Resident #51 triggered for oxygen therapy. Residents Affected - Few Record review of the Resident #51's order summary report dated 5/16/2023 revealed an order for oxygen @ 2L per minute as needed to keep oxygen saturation greater than 90%. During an observation and interview on 7/24/2023 at 10:27 AM, Resident #51 stated that she used her oxygen concentrator daily. She stated that when she was done using her oxygen cannula, she would lay it on the floor. She stated that she does not use a bag to store her cannula and her cannula had never been stored in a bag. Resident's nasal cannula was observed laying on the floor. Floor had an unknown dusty substance that the cannula was laying in underneath the bed. During an observation on 07/26/2023 at 8:28 AM, Resident #51's nasal cannula was laying on the floor with the oxygen concentrator on blowing air. During an interview on 07/26/2023 at 10:20 AM, the DON stated that it was not okay to lay nasal cannula on the floor when not in use. She stated that staff could place respiratory equipment in a Ziplock bag for storage when it was not in use. She stated that residents could be placed at a higher risk for infections by not storing their respiratory equipment and tubing in a sanitary manner, During an interview on 7/26/2023 at 10:31 AM, the Administrator stated that she expects that residents keep their oxygen stored in a sanitary manner. She stated that residents could be placed at risk for infection if their equipment is not stored properly. Review of the facility's respiratory policy titled Respiratory Equipment/Supply Disinfecting/Cleaning with a revision date of June 1, 2006, indicated the . all respiratory equipment which cannot be immersed in water is cleaned with a disinfecting solution and allowed to dry. Disinfection is performed on all equipment on a scheduled basis and upon discontinuation from service. Cleaning and disinfection performed by a respiratory therapist, licensed nurse or equipment technician . purpose was to remove microorganisms from the surfaces of equipment . oxygen concentrators rinse and dry the external filter weekly and as needed when visibly dusty . schedule for supply changes . oxygen delivery devices as needed for soiling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 17 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 5 of 24 residents (Resident #50, Resident #21, Resident #10, Resident #29, and Resident #18). The facility failed to follow the menu. The facility failed to update residents' meal tickets to match what they were served. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: Record review of the facility's menu for 7/24/23 revealed the lunch meal consisted of BBQ pork on bun, chuckwagon beans, hot southwest potato salad, BBQ relish, cherry fried pie, and iced tea. Record review of the facility's menu for 7/25/23 revealed the lunch meal consisted of fried chicken with southern chicken gravy, mashed potatoes, collard greens, cornbread, margarine, strawberry shortcake, and iced tea. 1.Record review of a face sheet dated 7/25/23 revealed Resident #50 was a [AGE] year-old female, who admitted to the facility on [DATE], with the diagnoses of rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet), depression (persistent feeling of sadness), anxiety (feeling of fear, dread, and uneasiness), cachexia (multifactorial disease characterized by weight loss with skeletal muscle and adipose (fat) tissue loss, an imbalance in metabolic regulation, and reduced food intake). Record review of Resident #50's quarterly MDS dated [DATE] revealed she understood and understood others. Resident #50 had a BIMS of 13, which indicated she cognitively intact. The MDS revealed Resident #50 required a mechanically altered diet and a therapeutic diet. Record review of an undated care plan revealed Resident #50 was at risk of malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the that one does eat), and she had a diet order other than regular and was at risk for unplanned weight loss or gain. Record review of Resident #50's Order Summary Report, dated 7/25/23, revealed an order for Fortified/Enhanced diet mechanical soft texture, regular consistency, extra gravy with all meals and large meat portions with a start date of 5/31/23. During an observation and interview on 7/24/23 at 11:11 AM, Resident #50 said the food was not good and she often did not get everything that was on her meal ticket. Resident #50 said often for example, the ticket will say she was supposed to have gravy or a cinnamon roll, but there would be no gravy or cinnamon roll on her meal tray. Resident #50 showed surveyor meal tickets she had kept and wrote what she did not receive on the ticket. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 18 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 During an observation and interview on 7/25/23 at 8:21 AM, Resident #50 gave surveyor copies of her meal tickets that she said she wrote on the tickets when she did not receive an item that was listed. *6/10/23 supper meal ticket listed GR Super Soup and 1 slice of garlic bread. Resident #50 said she did not receive the soup and only received ½ slice of garlic bread. Residents Affected - Some *6/09/23 supper meal ticket listed GR Super Soup and a GR cheeseburger on a bun with bacon. Resident #50 said she did not receive the soup and there was not cheese or bacon on her cheeseburger with bacon. *5/25/23 breakfast meal ticket listed GR breakfast sausage with gravy, Southern Style Biscuit, 2 fluid ounces of cream gravy. Resident #50 said she did not receive the biscuit or cream gravy. *5/23/23 supper meal ticket listed GR Super Soup and a slice of Texas Toast. Resident #50 said she did not receive the soup and only a ½ of the Texas Toast. *5/20/23 lunch meal ticket listed GR Super Soup, 1 slice of Garlic bread, 1 slice of Oreo Cheesecake. Resident #50 said she did not receive the soup, garlic bread, or Oreo cheesecake. *5/20/23 supper meal ticket listed GR Super Soup and Pico de Gallo. Resident #50 said she did not receive the soup or the Pico de Gallo. *5/10/23 supper meal ticket listed GR Super Soup, Southern Style Biscuit, and margarine. Resident #50 said she did not receive the soup, margarine, or a biscuit. Resident #50 said she received a ½ piece of bread. *4/26/23 super meal ticket listed GR Super Soup, Tea, and a breadstick. Resident #50 said she did not receive the soup, tea, and only received ½ piece of bread. *4/26/23 breakfast meal ticket listed a cinnamon roll and breakfast sausage with gravy. Resident #50 said she did not receive a cinnamon roll or gravy. 2.Record review of a face sheet dated 7/25/23 revealed Resident #21 was an [AGE] year-old female, who admitted to the facility on [DATE], with the diagnoses of dementia (progressive or persistent loss of intellectual functioning; impairment of memory, thinking, and often personality changes), cognitive communication deficit, malnutrition, and depression (persistent feeling of sadness). Record review of Resident #21's quarterly MDS dated [DATE] revealed she usually understood others and sometimes was understood. Resident #21 had a BIMS of 3, which indicated she had severe cognitive impairment. Resident #21 required a mechanically altered diet. Record review of Resident #21's undated care plan revealed she was at risk for malnutrition and unplanned weight loss or gain. The care plan revealed Resident #21 had a diet order other than regular with mechanical soft diet restrictions. Record review of Resident #21's Order Summary Report dated 7/25/23 revealed an order for regular diet, mechanical soft texture, and regular consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 19 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 Residents Affected - Some During observations on 7/24/23 beginning at 11:50 AM, dietary staff placed lunch meal trays from the kitchen on a cart located outside the kitchen door in the dining room. The was 2 nurses at the cart, who checked the trays, and then handed the meal trays to other staff to deliver to residents. During an observation and interview on 7/24/23 at 12:09 PM, Resident #21 was observed to have potato salad on her meal ticket, but there was no served potato salad served on her meal tray. When surveyor asked Resident #21 if she wanted potato salad, she said that sounded good. With surveyor intervention, Resident #21 was served potato salad and she immediately opened the container and consumed all the potato salad. 3.Record review of a face sheet dated 7/24/23 revealed Resident #10 was an [AGE] year-old female, who admitted to the facility initially on 7/26/21, with the diagnoses of dementia (progressive or persistent loss of intellectual functioning; impairment of memory, thinking, and often personality changes), muscle wasting, anemia (lack of healthy red blood cells), anxiety (feeling of fear, dread, and uneasiness), and depression (persistent feeling of sadness). Record review of Resident #10's annual MDS dated [DATE] revealed she understood others and was understood. Resident #10 had a BIMS of 12, which indicated she had moderate cognitive impairment. Resident #10 received a therapeutic mechanically alter diet. Record review of Resident #10's undated care plan revealed she had potential for risk of malnutrition and at risk for unplanned weight loss or gain. Resident #10 had a diet order other than regular with NSOT (no salt on tray), mechanical soft, and double vegetables. Record review of Resident #10's Order Summary Report dated 7/24/23 revealed an order for NSOT diet, mechanical soft texture, regular consistency, large/double portions of vegetables. During an observation and interview on 7/24/23 at 12:29 PM, Resident #10's meal ticket said she was to get double portion of vegetables and listed potato salad on the ticket. There was no potato salad served on Resident #10's lunch meal tray. She had sweet peas on her tray, but it was not listed on her meal ticket. Resident #10 said it often happens that things are not served that are on the meal ticket. Resident #10 said she would have liked the potato salad; it would have been good with the meal that was served. Resident #10 only ate part of her cowboy beans and part of her sweet peas. 4.Record review of a face sheet dated 7/25/23 revealed Resident #29 was an [AGE] year-old female, who admitted to the facility initially on 10/04/19, with the diagnoses of malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the that one does eat) and major depression disorder (persistent feeling of sadness). Record review of Resident #29's quarterly MDS dated [DATE] revealed she understood others and was understood. Resident #29 had a BIMS of 13, which indicated she was cognitively intact. Resident #29 required a therapeutic diet. Record review of Resident #29's undated care plan revealed she had a potential risk for malnutrition, at risk for unplanned weigh loss or gain, and potential nutritional problem. Resident #29 had a diet order of regular enhanced and thin liquids. Record review of Resident #29's Order Summary Report dated 7/25/23 revealed an order for a fortified/enhanced diet with regular texture and consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 20 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 Residents Affected - Some During an observation and interview on 7/25/23 at 12:00 PM, Resident #29's meal ticket said she was having collard greens, but there were no collard greens served on her lunch meal tray. Broccoli was served on her meal tray instead and her meal ticket did not reflect a change. Resident #29 said it did not matter to her, she just did not like that the vegetables were overcooked. 5.Record review of a face sheet dated 7/25/23 revealed Resident #18 was an [AGE] year-old female, who admitted to the facility on [DATE], with the diagnoses of senile degeneration of brain, dementia (progressive or persistent loss of intellectual functioning; impairment of memory, thinking, and often personality changes), malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the that one does eat), anxiety (feeling of fear, dread, and uneasiness), and depression (persistent feeling of sadness). Record review of Resident #18's quarterly MDS dated [DATE] revealed she rarely understood others and was rarely understood. Resident #18 had a BIMS of 00, which indicated she had severe cognitive impairment. Resident #18 required a therapeutic mechanically alter diet. Record review of Resident #18's undated care plan revealed she had a potential risk of malnutrition and unavoidable weight loss. Resident #18 had a diet order other than regular with an enhanced mechanical soft diet. Record review of Resident #18's Order Summary Report dated 7/25/23 revealed an order for a fortified/enhanced diet with mechanical soft texture and regular consistency. During an observation on 7/25/23 at 12:02 PM, Resident #18's meal ticket said she was being served collard greens, but there were no collard greens served on her meal tray. Resident #18 was served broccoli on her meal tray instead and her meal ticket did not reflect a change. During an observation and interview on 7/25/23 at 12:42 PM, a lunch tray was sampled by the Dietary Manager and 4 surveyors. The sample lunch tray was served with broccoli and not collard greens as per the menu. The DM said there was 2 residents and the sample tray that was served broccoli, instead of collard greens, because they ran out of collard greens, and she substituted the vegetable. During an interview on 7/25/23 at 3:29 PM, the DM said she had worked at the facility for 5 years. The DM said they had a double check system to ensure residents were served what they were supposed to get. The DM said the 1st step was the dietary staff would plate everything to ensure everything on the meal ticket was on the meal tray. The DM said the 2nd step was the nursing staff double checks everything on the meal tray to ensure everything was on the trays and the diet was correct before the meal trays were served to any of the residents. The DM said they did miss a few potato salads yesterday on some of the residents' trays, but they corrected it as soon as it was brought to their attention. The DM said it was an error on them yesterday on the potato salad and they just missed it. The DM said everything on the meal ticket should be on the meal tray unless there was something wrong with a product. The DM said the meal ticket would be corrected if something changed. The DM said they would mark out an item on the meal ticket and write in the correction to match what was served. The DM said the residents may not be happy if they do not get what was on the meal ticket, but she may have to make a substitution due to a bad product. During an interview on 7/26/23 at 7:25 AM, RN B said the nurses check the diet orders and items on the meal tickets to ensure all the items listed on the meal ticket were on the meal tray during dining. RN B said the dietary staff set up the meal trays and placed them on a cart and then the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 21 of 22 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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 Residents Affected - Some double check that everything was on the meal tray. RN B said if a resident did not get something that was listed on the meal ticket, then the item might not be available. RN B said some items may be substituted and usually they mark it out on the meal ticket and write in the new item. RN B said mostly everyone got what was on their meal tickets. During an interview on 7/26/23 at 10:06 AM, CNA A said she had worked at the facility for five years. CNA A said the nurses checked the meal carts to ensure everything on the meal tickets were on the meal trays and then the nurse would hand the meal tray to the CNA to take to the resident. CNA A said she had residents on the halls tell her they were missing items on the meal tray. CNA A said she also looked at the meal tickets and it there was a missing item, then she would go to the kitchen for it, because the resident would ask for it. CNA A the kitchen did not usually mark on the meal ticket that there was a change, they would just substitute something on the meal tray. CNA A said if the resident did not want what the kitchen substituted, then she would go to the kitchen and have them get the resident something different. CNA A said sometimes the residents were upset when they thought they were having one thing and got something different. During an interview on 7/26/23 at 10:44 AM, the DON said the meal ticket should match the tray. The DON said if the resident requests something different, then the meal ticket was marked substituted. During an interview on 7/26/23 at 10:50 AM, the Regional Compliance Nurse said when dietary made a substitution for an item on the menu, they place it on the Substitution Book in the kitchen. The Regional Compliance Nurse said they do not correct the meal tickets when substitutions were made. During an interview on 7/26/23 at 10:52 AM, the Administrator said the meal tickets should match what the resident was being served on their tray. The Administrator said items should be marked out on the meal ticket and corrected before being delivered to the residents. The Administrator said they have a two-way check when meals come from the kitchen to ensure the meal tickets and trays match. The Administrator said the dietary staff do the 1st check and the nurses do the 2nd check. The Administrator said the nurses checked the meal tickets and tray before approving the tray to be delivered to the resident by other staff. The Administrator said the dietary staff and the nurses should be checking to ensure the residents were getting everything on their meal ticket and the meal ticket should be marked out and corrected if substitution had to be made. The Administrator said residents may feel there wants and needs do not matter if they do not get what was listed on their meal tickets. Record review of the Resident Menu policy, dated 2012, . we will strive to assure the resident's nutritional needs are provided based on the RDA . the standard menu would ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production . if any meal served varied from the planned menu, the change and reason for the change shall be noted in the substitution log . The policy did not address following meal tickets or how substitutions would be handled on the residents' meal ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 22 of 22