Health inspection·March 12, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired thought processes. Intervention: Keep the resident's, routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Observation on 03/12/2024 at 9:04 AM, CNA B entered Resident #1's room. She proceeded to pick up the fall mat on the right side of the bed. She rolled the fall mat and propped it against the nightstand and exited the room. There was a fall mat on the left side between the bed and window. Observation on 03/12/2024 at 9:45 AM Resident #1's fall mat continued to be propped against the nightstand in Resident #1's room. Observation on 03/12/2024 at 10:04 AM Resident #1's fall mat continued to be propped against the nightstand in Resident #1's room. Observation on 03/12/2024 at 2:00 PM Resident #1 was in a wheelchair sitting near nurse station. He was out of bed after lunch and sat near the nurse's station. Interview on 03/12/2024 at 10:16 AM, ADON C stated no one was to remove Resident #1's fall mat while he was in bed. She stated all the information about Resident #1's care was on his care plan and the [NAME] for the CNAS to follow in the electronic medical record. She stated in Resident 1's care plan and on the [NAME] it reflected Resident #1 was to have fall mats beside his bed whenever he was in bed. ADON C also stated all staff was expected to follow the interventions on the care plan and the [NAME]. Interview on 03/12/2024 at 11:45 AM, CNA D stated the CNAs reviews the [NAME] in the electronic medical records to confirm what type of care a resident needed. She also stated on Resident #1's [NAME] it did state to have fall mats beside Resident #1's bed when he was in bed. She also stated no one was to remove a fall mat from the floor beside a resident's bed when the resident was in bed. She stated the [NAME] in the electronic medical record was from the resident care plans. Interview on 03/12/2024 at 1:05 PM, LVN F stated all the information about a resident was on the [NAME] in the electronic medical records for the CNAs to follow. She stated on the care plan and on the [NAME] for Resident #1 it was documented for Resident #1 to have fall mats beside his bed when he was in the bed. She stated the staff was expected to follow the [NAME] and the Care plan. LVN F also stated the CNAs were expected to review the [NAME] prior to giving any type of care to the resident. She also stated anyone was not to remove a fall mat when a resident was in bed especially if this was an intervention on his care plan and [NAME]. Record review of the facility's Policy on Comprehensive Care Planning, not dated, reflected the comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 2 of 7 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 03/12/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's new intervention of a fall mat was placed on the right side of bed when Resident #1 was lying in bed. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings include: 1. Record review of Resident #1's face sheet, dated 03/12/2024, reflected a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses which included abnormalities of gait and mobility (unable to walk in a typical way), unsteadiness on feet ( can increase your risk for falls and injurywhen you are not stable when walking), difficulty with walking (loss of balance, where one faces difficulty in taking steps), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety( a memory loss without a specific diagnosis-the person does not have any symptoms of behavioral disturbances), aneurysm of unspecified site ( may press on nerves and cause double vision, dizziness, or headaches), altered mental status ( it can lead to changes in awareness, movement and behaviors), and major depressive disorder ( a mental health condition that can cause feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, or suicidal thoughts). Record review of Resident #1's Significant Change MDS, dated [DATE], reflected Resident #1 had a BIMS score of one reflecting his cognition was severely impaired. Resident #1 required the staff to do more than half of the following ADLs: oral and toileting hygiene, bathing, lower body dressing, and personal hygiene. He required supervision with sit to lying and roll left and right. He also required partial assistance from staff with sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Resident #1 also required partial assistance (helper does less than half) of wheeling self in wheelchair 50 feet and make two turns. He did require partial assistance (helper does less than half) when wheeling his wheelchair 150 feet without making any turns. Resident #1 had a fall prior to this assessment. Record review of Resident #1's Comprehensive Care Plan, revised on 2/22/2024 reflected Resident #1 was at risk for falls. Interventions: Fall mats to bedside for safety when Resident #1 was in bed. One person staff assist with transfers. Resident #1 needed a safe environment free spills and/or clutter, adequate, glare-free light and reachable call light, the bed in low position at night, handrails on walls, personal items within reach. Resident #1 needed activities that minimize the potential for falls while providing diversion and distraction. Resident #1 had impaired cognitive function/dementia or impaired thought processes. Intervention: Keep the resident's, routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Record review of Resident #1's Physician orders revealed: may have fall mat beside bed date initiated on 2/22/2024. (unknown by the physician order saved who received the physician order from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 3 of 7 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 03/12/2024 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 0689 physician). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Nurses Note dated 02/19/2024 reflected fall mats beside bed and bed in low position. Signed by LVN A. Residents Affected - Few Record review of Resident #1's CNAs [NAME] information from the electronic medical record reflected fall mats while in bed. Record review of in-service record on preventive strategies to reduce falls was held on 02/20/2024 and CNA B did attend the in-service. Observation on 03/12/2024 at 9:04 AM, CNA B entered Resident #1's room. She proceeded to pick up the fall mat on the right side of the bed. She rolled the fall mat and propped it against the nightstand and exited the room. There was a fall mat on the left side between the bed and window. Interview on 03/12/2024 at 9:08 AM Resident #1 stated he did not know why he was there. He stated he would fall at home, and he thought this may be reason he was there. He did not answer any other questions about history of falls. Observation on 03/12/2024 at 9:45 AM Resident #1's fall mat continued to be propped against the nightstand in Resident #1's room. Observation on 03/12/2024 at 10:04 AM Resident #1's fall mat continued to be propped against the nightstand in Resident #1's room. Observation on 03/12/2024 at 2:00 PM Resident #1 was in a wheelchair sitting near nurse station. He was out of bed after lunch and sat near the nurse's station. Interview on 03/12/2024 at 10:16 AM, ADON C stated she was making her rounds and entered Resident #1's room and his fall mat was rolled up and was against Resident #1's nightstand in his room. She stated the fall mat was expected to be on the floor by the right side of the bed. She stated this was new intervention began on February 22 of this year (2024). She stated the fall mat was expected to be always on the floor when resident was in bed. ADON C stated Resident #1 had a history of sliding out of his chair. A pommel cushion was used to prevent him from sliding; however, he would sometimes find a way to get over the middle section of the pommel cushion to prevent a resident from sliding. She also stated Resident #1 had not attempted to slide out of his bed or attempt to transfer self from his bed. ADON C stated there was a potential for Resident #1 to fall out of bed. She also stated if there was not a fall mat beside his bed and he fell out of bed, it was possible he may hit his head, break a bone, or have skin tears. ADON C stated no one reported to her of removing the fall mat and placing it against the nightstand. She also stated no one was to remove Resident #1's fall mat while he was in bed. She stated all the information about Resident #1's care and not to remove fall mats while resident in the bed was documented on the CNAs [NAME] (a form in the electronic medical records the CNAs reviews to know what type of care a resident needed) in the electronic medical record. Interview on 03/12/2024 at 11:35 AM, can B stated she entered Resident #1's room and did pick up the fall mat on the right side of Resident #1's bed. She stated she rolled the fall mat and leaned the fall mat on the nightstand in Resident #1's room. CNA B stated no one informed her to pick up the fall mat. She stated she moved the fall mat to be more convenient for visitors to get closer to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 4 of 7 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 03/12/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 when speaking with him. CNA B stated no one asked her to move the fall mat, she made the decision on her own and realized now it was the wrong decision. She stated she was in serviced in February 2024 on Resident #1 specifically to always keep both fall mats on the floor by his bed when Resident #1 was in bed. She stated it was her mistake and she will never move a fall mat no matter who was visiting him. She stated three times during the conversation no visitors to the facility and the staff did not inform her to pick up Resident #1's fall mat. CNA B stated she did not report to anyone she removed the fall mat and propped it against Resident #1 nightstand. She stated she was not assigned to Resident #1 today (on 03/12/2024). CNA B stated she did not report to the CNA giving Resident #1 care about removing the fall mat or Resident #1's nurse who was the ADON C she removed the fall mat. She stated Resident #1 was at risk for falls especially when he was in his wheelchair. He would slide out of his wheelchair even when he was using a special cushion. She stated to her knowledge Resident #1 had not attempted to get out of bed or slide of out bed. CNA B also stated Resident #1 had a potential to fall out of bed. She stated if he fell out of bed and there was not a fall mat beside his bed, he could break a bone, hit his head on something and cause a bump on his head, or have any type of injury and needed to be transferred to hospital for further care. Interview on 03/12/2024 at 11:45 AM, CNA D stated she was assigned to Resident #1 on this date (03/12/2024). She stated she checked on Resident #1 approximately 8:30 AM and there were floor mats on each side of his bed at that time. She stated Resident #1 only had one floor mat prior to 02/22/2024 and new order for him to have 2 fall mats on each side of his bed as a precaution. CNA D also stated Resident #1 had a history of sliding out of his wheelchair and having 2 fall mats beside his bed and his bed in low position would help prevent injury if Resident #1 slid out of his bed. She stated she had not witnessed and there were no reports of Resident #1 attempting to transfer self out of bed or slide out of bed. CNA D stated no one informed her of anyone removing Resident #1's fall mat from the floor and propped it against the nightstand in Resident #1's room. She stated she was expected to make rounds every two hours and the ADON found the floor mat propped against the nightstand. CNA D also stated it was not time for her to make rounds when the ADON found the floor mat against the nightstand. She stated she would have found it when she made rounds approximately at 10:30 AM. She stated if Resident #1 had fallen off the bed and there were not any floor mats beside his bed, there was a possibility he may have a head injury from hitting his head on the floor or break a bone and need to be admitted to the hospital. She also stated she had been in-serviced on Resident #1 interventions during a fall in-service toward the end of February 2024. She stated during the fall in-service Resident #1 name was mentioned of new intervention to keep both fall mats beside his bed while Resident #1 was in bed. She stated the CNAs reviews the [NAME] in the electronic medical records to confirm what type of care a resident needed. She also stated on Resident #1's [NAME] it did state to have fall mats beside Resident #1's bed when he was in bed. She also stated no one was to remove a fall mat from the floor beside a resident's bed when the resident was in bed. Interview on 03/12/2024 at 11:59 AM, CNA E stated she had given care to Resident #1 in the past. She stated she was not aware of Resident #1 attempting to transfer self out of the bed. She stated he would slide out of his wheelchair and the nurses placed a special cushion in his wheelchair to prevent his from sliding. She stated during an in-service toward the end of February the DON explained fall protocol, documenting about falls and preventions of falls. CNA E stated the DON specifically discussed Resident #1 and stated fall mats were to be on both sides of his bed when Resident #1 was in bed. She stated the CNAs referred to the [NAME] in the electronic medical record to determine what type of interventions residents needed for all their physical and mental needs. She also stated if a fall mat wasn't beside a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 5 of 7 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 03/12/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm resident bed who was at risk for falls there was a possibility the resident may attempt to transfer self out of bed and fall. She stated a resident had a potential to sustain an injury such as: broken bones, head injury or skin tears. CNA E stated it was a possibility a resident may need to be transferred to hospital for further care depending on the type of injury. She also stated if a resident was required to have a fall mat beside the bed, no one was to remove that fall mat while resident was in bed. Residents Affected - Few Interview on 03/12/2024 at 1:05 PM, LVN F stated she was in serviced on fall protocol, fall assessments and preventions of falls last 2 weeks of February 2024. She stated during the in-service it was discussed Resident #1 was to have a fall mat on each side of his bed when Resident #1 was in bed. She stated if a fall mat was not beside a resident bed and the resident was at risk for falls, there was a possibility a resident may fall out of the bed and hit their head on the floor and/ or break a bone. She stated it was determined by the physician to keep a resident with an injury after a fall at the facility or transfer the resident to the hospital for further treatment. LVN F stated there was a possibility a resident may need further treatment and care at the hospital. She stated all the information about a resident was on the [NAME] in the electronic medical records. LVN F also stated the CNAs were expected to review the [NAME] prior to giving any type of care to the resident. She also stated anyone was not to remove a fall mat when a resident was in bed especially if this was an intervention on his care plan and [NAME]. Interview via phone on 03/12/2024 at 1:27 PM, the Corporate Nurse stated she expected the fall mats to be on the floor while Resident #1 was in bed. She stated if Resident #1 had a physician order, and it was an intervention on the care plan for fall mats be beside Resident #1 bed while he was in bed no one was expected to move the fall mats unless Resident #1 was out of bed. She stated if Resident #1 had fallen out of bed when the floor mat was propped against the nightstand, there was a possibility Resident #1 may sustain any type of injury such as head injury or a broken bone. She stated the DON did an in-service in February 2024 related to fall preventions/ interventions/ fall protocol. The Corporate Nurse stated all residents care the CNA required to follow was documented on the [NAME] in the electronic medical record. Interview on 03/12/2024 at 3:00 PM, the DON stated the fall mat on the right side of Resident #1's bed was initiated on 2/20/2024. Resident #1 had a fall mat to the left of bed by the window prior to 2/22/2024. She stated he had a history of sliding out of chairs when he was at home, and he was a risk for falls when he was admitted in 01/2024. She also stated Resident #1 had not slid or attempted to transfer self out of his bed, however, as a precaution the administration team decided to place a fall mat to the right side of his bed 2/20/2024. She stated during in-service on preventive strategies to reduce falls, she did discuss to ensure Resident #1 had a fall mat on the right and left side of his bed, however, she stated she did not document specifically about Resident #1 on the in-service form. She also stated it was discussed not to remove the fall mats while resident was in bed. The DON stated it was updated on his care plan and it was on the CNAs [NAME] to have fall mats beside bed when Resident #1 was in bed. She stated the CNAs had been educated to follow the [NAME] when giving care and if they had any questions to ask their charge nurse. The DON stated CNA B was not to move the fall mat this morning (03/12/2024 AM). She stated if Resident #1 had fell out of bed when the floor mat was off the floor there was a possibility, he could have sustained a serious injury to his head or a broken hip, arm, or leg. She stated CNA B did not follow the proper protocol for the care of Resident #1 by removing the fall mat while he was in bed. She stated they began an investigation of why CNA B removed the fall mat this AM (03/12/2024 AM) and it was determined no one informed CNA B to remove the fall mat on 03/12/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 6 of 7 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 03/12/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/12/2024 at 3:20 PM, the Administrator stated Resident #1's fall mats on both side of his bed was expected to be on the floor when Resident #1 was in bed and not to be removed for any reason. She stated the CNAs were required to follow the care instructions on the [NAME] in the electronic medical record. She stated if Resident #1 had fell while the fall mat was against the nightstand there was a potential, he may have injured his arm, leg or hit his head on the floor and caused an injury to his head. She also stated there was all types of injuries Resident #1 may have received such as: bruises, broken bone and/or skin tears. The Administrator stated it was the charge nurse responsibility to monitor the CNAs. She also stated there was an in-service given to the nursing staff on 02/20/2024 on fall preventions and fall protocols. She stated during this in-service the DON specifically reviewed Resident #1 new interventions of one fall mat on each side of Resident #1 bed and not to remove the fall mats while Resident #1 was in bed. Interview on 03/12/2024 at 3:00 PM, the DON stated the fall mat on the right side of Resident #1's bed was initiated on 2/20/2024. Resident #1 had a fall mat to the left of bed by the window prior to 2/22/2024. She stated he had a history of sliding out of chairs when he was at home, and he was a risk for falls when he was admitted in 01/2024. She also stated Resident #1 had not slid or attempted to transfer self out of his bed, however, as a precaution the administration team decided to place a fall mat to the right side of his bed 2/20/2024. She stated during in-service on preventive strategies to reduce falls, she did discuss to ensure Resident #1 had a fall mat on the right and left side of his bed, however, she stated she did not document specifically about Resident #1 on the in-service form. She also stated it was discussed not to remove the fall mats while resident was in bed. The DON stated it was updated on his care plan and it was on the CNAs [NAME] to have fall mats beside bed when Resident #1 was in bed. She stated the CNAs had been educated to follow the [NAME] when giving care and if they had any questions to ask their charge nurse. The DON stated CNA B was not to move the fall mat this morning (03/12/2024 AM). She stated if Resident #1 had fell out of bed when the floor mat was off the floor there was a possibility, he could have sustained a serious injury to his head or a broken hip, arm, or leg. She stated CNA B did not follow the proper protocol for the care of Resident #1 by removing the fall mat while he was in bed. She stated they began an investigation of why CNA B removed the fall mat this AM (03/12/2024 AM) and it was determined no one informed CNA B to remove the fall mat on 03/12/2024. She also stated the staff was expected to follow the interventions on the care plan and [NAME]. She agreed on the care plan and the CNAs [NAME] it was documented fall mats beside Resident #1's bed while he was in bed Record review of the facility's Policy on Preventive Strategies to Reduce Fall Risk, dated 10/05/2016, reflected the goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. Record review of the facility's Policy on Comprehensive Care Planning, not dated, reflected the comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 7 of 7