Health inspection·September 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the ADON. She stated she keep getting a busy signal. She stated she could not remember who came in next and could not remember if she passed on the need to notify the family. She stated she should have followed up to make sure the family was notified of the Resident's fall. She stated she just got caught up with working on the floor and forgot about it. Attempts to contact LVN B during the investigation on 09/03/2025 at 12:20 pm and 3:30 pm were unsuccessful. In an interview on 09/03/2025 at 2:00 pm the DON stated it was her expectation that all resident change in conditions be reported to the responsible party to ensure the resident gets the care they need. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident#1's RP should have been notified after the fall and staff should have ensured follow up was done if they were not able to reach the family. Review of the facility's undated policy Notifying the physician of change in status reflected .The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. Review of the facility's undated policy Resident Rights reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 4. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care. Event ID: Facility ID: 676385 If continuation sheet Page 2 of 6 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 09/03/2025 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop, and implement a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan updated interventions after Resident #1 experienced multiple falls. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being.Findings include:Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was assessed to have functional limitation in range of motion on both sides for her upper and lower extremities. Resident #1 was further assessed to require supervision or touching assistance with transfers. Resident #1 was assessed to have falls since admission. Review of Resident #1's Event Nurses' notes-fall reflected she had falls on 01/18/2025, 01/25/2025 x 2, 01/26/2025, 01/29/2025, 02/07/2025, 02/12/2025, 04/19/2025, 06/01/2025, and 08/12/2025. Review of Resident #1's fall event note dated 08/12/2025 reflected Resident #1 had a fall in room at 5:44 am which was unwitnessed and resulted in an abrasion to her right forearm. Description of the event Discovered on floor as light was on. Abrasion to right forearm, bruise to wrist lateral and right forearm. Review of Resident #1 comprehensive care plan reflected a focus area dated 01/20/2025 The resident is risk for falls. Goals included The resident will be free of falls through the review date. Interventions included: call don't fall sign hung in room, Date Initiated: 04/22/2025; Anticipate and meet the resident's needs; Date Initiated: 01/20/2025; Be sure the resident's call light is within reach and encourage the resident to use it, Date Initiated: 01/20/2025; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Date Initiated: 01/20/2025; Ensure resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Date Initiated: 01/20/2025;frequent reminders to use call light for assistance, Date Initiated: 01/27/2025, Keep furniture in locked position, Date Initiated: 01/20/2025; Keep needed items, water, etc., in reach, Date Initiated: 01/20/2025; low bed w/ fall mat, Date Initiated: 01/27/2025; mat to floor at bedside, Date Initiated: 01/20/2025; med review, Date Initiated: 02/14/2025; non- skid foot wear, Date Initiated: 01/20/2025; Pt evaluate and treat as ordered or PRN, Date Initiated: 01/20/2025; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Date Initiated: 01/20/2025; Scoop mattress, Date Initiated: 01/27/2025; Staff x 2 to assist with transfers, Date Initiated: 01/20/2025; The resident needs activities that minimize the potential for falls while providing diversion and distraction, Date Initiated: 01/20/2025; therapy screen for cognition/safety awareness Date Initiated: 02/07/2025; Therapy to provide reacher, Date Initiated: 06/04/2025; Toilet and/or ensure clean/dry prior to going to bed, Date Initiated: 01/29/2025. Further review revealed the care plan did not address her actual falls, cause of falls, and was not updated after her unwitnessed fall on 08/12/2025. In an interview on 09/03/2025 at 12:28 pm Resident #1 stated she had a lot of falls, and she was impatient and if they do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 3 of 6 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 09/03/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not come right away, she will just do it herself. Resident #1 stated she could not transfer herself at times. She stated she did not recall her last fall or why she fell. Resident #1 stated she did hurt her wrist. In an interview on 09/03/2025 at 2:00 pm the DON stated the facility only had a regional MDS nurse, and the care plan should have been reviewed and updated after Resident #1's 08/12/2025 fall to prevent further falls. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident #1's care plan should have been reviewed and interventions updated as appropriate. She stated Resident#1's fall on 08/12/25 had not yet been reviewed and the care plan was updated after the review occurred. She stated it should have been updated after each fall to make sure the root cause of the fall was identified to prevent reoccurrence. Review of the facility's policy comprehensive care planning undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . 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. Event ID: Facility ID: 676385 If continuation sheet Page 4 of 6 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 09/03/2025 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 interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to develop and implement individualized interventions for Resident #1 after the resident experienced multiple falls. This failure placed residents with falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or significant changes in condition.Findings included: Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was assessed to have functional limitation in range of motion on both sides for her upper and lower extremities. Resident #1 was further assessed to require supervision or touching assistance with transfers. Resident #1 was assessed to have falls since admission. Review of Resident #1's Event Nurses' notes-fall reflected she had falls on 01/18/2025, 01/25/2025 x 2, 01/26/2025, 01/29/2025, 02/07/2025, 02/12/2025, 04/19/2025, 06/01/2025, and 08/12/2025. Review of Resident #1's fall event note dated 08/12/2025 reflected Resident #1 had a fall in room at 5:44 am which was unwitnessed and resulted in an abrasion to her right forearm. Description of the event Discovered on floor as light was on. Abrasion to right forearm, bruise to wrist lateral and right forearm. 08/12/2025 reflected LVN B documented Resident #1's RP was notified on 08/12/2025 at 5:50 am. Review of Resident #1 comprehensive care plan reflected a focus area dated 01/20/2025 The resident is risk for falls. Goals included The resident will be free of falls through the review date. Interventions included: call don't fall sign hung in room, Date Initiated: 04/22/2025; Anticipate and meet the resident's needs; Date Initiated: 01/20/2025; Be sure the resident's call light is within reach and encourage the resident to use it, Date Initiated: 01/20/2025; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Date Initiated: 01/20/2025; Ensure resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Date Initiated: 01/20/2025;frequent reminders to use call light for assistance, Date Initiated: 01/27/2025, Keep furniture in locked position, Date Initiated: 01/20/2025; Keep needed items, water, etc., in reach, Date Initiated: 01/20/2025; low bed w/ fall mat, Date Initiated: 01/27/2025; mat to floor at bedside, Date Initiated: 01/20/2025; med review, Date Initiated: 02/14/2025; non- skid foot wear, Date Initiated: 01/20/2025; Pt evaluate and treat as ordered or PRN, Date Initiated: 01/20/2025; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Date Initiated: 01/20/2025; Scoop mattress, Date Initiated: 01/27/2025; Staff x 2 to assist with transfers, Date Initiated: 01/20/2025; The resident needs activities that minimize the potential for falls while providing diversion and distraction, Date Initiated: 01/20/2025; therapy screen for cognition/safety awareness Date Initiated: 02/07/2025; Therapy to provide reacher, Date Initiated: 06/04/2025; Toilet and/or ensure clean/dry prior to going to bed, Date Initiated: 01/29/2025. The care plan did not address her actual falls and was not updated after her unwitnessed fall on 08/12/2025. In an interview on 09/03/2025 at 2:00 pm the DON stated it was her expectation that all resident change in conditions be reported to the responsible party to ensure the resident gets the care they need. She stated regarding the care plan that the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 5 of 6 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 09/03/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete only had a [NAME] MDS nurse, and the care plan should have been reviewed and updated after Resident #1's 08/12/2025 fall to prevent further falls. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident #1's care plan should have been reviewed and interventions updated as appropriate. She stated Resident#1's fall on 08/12/25 had not yet been reviewed by the IDT and the care plan is updated after the review occurs. She stated it should have been up after the fall to make sure the root cause of the fall was identified to prevent reoccurrence. Review of the facility's policy fall policy undated reflected Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. Appropriate education will be provided to all staff members as needed on fall prevention. Event ID: Facility ID: 676385 If continuation sheet Page 6 of 6