Health inspection·April 6, 2023

F 0656 Plan was to meet with Resident/Responsible Party to determine current health status, Level of Harm - Minimal harm or potential for actual harm short-term and long-term goals. The MDS/RN stated all Care Team staff developed specific portions of the Plan of Care; stated Plan of Care was implemented so all staff Residents Affected - Some were on same page and actively involved in achievement of set/stated goals. The MDS/RN stated MDS Coordinators were responsible for placing Code Status in Resident Plan ofCare. The MDS/RN stated the DON was responsible for getting orders signed and providing them to the MDS Coordinator(s). The MDS/RN stated no excuse for failure to include Code Status in Plan of Care. Interview on 4/06/23 at 10:37 AM with the LVN/MDS Coordinator stated the resident Plan of Care was designed to provide information about the resident. The LVN/MDS Coordinator stated the Plan of Care provided information to staff of the type of care needed, short-term goals and long-term goals. The MDS/LVN Coordinator stated MDS Coordinators gathered information from various members of the care team as well as resident chart. The LVN/MDS Coordinator stated if portions of care were omitted from plan of care it would affect the resident and stated care plan was accessible to all care staff. The LVN/MDS Coordinator stated the purpose of Code Status was to provide staff with information on how to react to resident death and stated code status information was needed very quickly. The LVN/MDS Coordinator stated facility policy made inclusion of Code Status essential. The LVN/MDS Coordinator stated he just failed to include Code Status in the resident Care Plan. Interview on 4/06/23 at 11:07 AM with facility Social Worker (SW) stated the MDS Coordinators started the Resident Plan of Care and she just added elements to that. The SW stated she performed Advance Directive in the admission process. The SW stated the Care Plan informed staffof how to care for a resident; stated care plan were updated quarterly and with residentchange. The SW stated she frequently reviewed physician orders for changes. The SW statedthe Code Status should be on the Care Plan because that directed staff what to do if a resident quit breathing; stated that was important. The SW stated the MDS Coordinators were responsible for checking Care Plan to insure completeness. Interview on 4/06/23 at 12:02 PM with the DON stated a Care Plan was used by staff to provide needed/preferred care. The DON stated failure to complete a resident Care Plan might prevent resident from receiving specific care. The DON stated all staff were responsible for insuring MDS staff received needed know how to respond to sudden arrest - whether resident received Full Code or did not receive services. The DON stated failure to follow code preferences could affect resident in many ways and facility in legal ways. The DON stated Code Status should be in all care plans. Interview on 4/06/23 at 12:14 PM with Administrator stated information for care plans were provided by the resident, family, lab results, doctor orders and medical records as well as therapy, nursing, dietary, etc. The Administrator stated Code Status should be included in all care plans. The Admistrator stated having code status on the Care Plan alerted staff to how to proceed in an emergency. The Administrator stated it was very important for staff to know code status. Review of facility Advance Directive Policy, undated, reflected the following: Resident Care Plan: The resident's Advance Directive and Do Not resuscitate status will be addressed in the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure each resident's environment remains as free of accident hazards as is possible for 2 of 4 used sharps (used to store sharp medical instruments) containers on treatment carts reviewed for accidents and hazards. The facility failed to ensure the storage of contaminated sharps bins on two treatment carts on Station One were secured and safe. These failures placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens. Findings included: An observation on 04/06/2023 at 8:30AM revealed one treatment cart behind Nursing Station One and one treatment cart in the entranceway to Nursing Station One. Both carts had plastic sharps bin inserts, approximately half full, were set on top of the cart. The metal locking mechanism on the side of the cart behind the nurses' station was taped closed with duct tape. Residents were observed ambulating in the halls and around the nurses' station. An interview on 04/06/2023 at 8:32AM with RN A revealed there were two treatment carts on Nursing Station One. She stated the plastic sharps bins should be secured in the locking holder on the side of the carts, however, they did not fit into the holders. She said the inserts were too large for the locking holders. She stated she told the DON about it a while ago and was told they were working on it. She said the sharps bins should be secured to ensure they did not spill their contents causing a hazard to staff and residents. In an interview on 04/06/2023 at 8:38AM LVN C stated the sharps bins should be secured to ensure they do not spill. She stated the unsecured bins on top of the two treatment carts could tip over and spill needles or contaminated liquids placing residents at risk of harm. An interview on 04/06/2023 at 8:43AM with LVN D revealed she was the nursing supervisor. She stated she was aware the sharps bin inserts did not fit in to the securing bin on the side of the treatment carts. She said it had been that way since December of 2022. She said the DON was made aware and was looking into getting bin inserts that fit into the securing bin on the side of the carts. She said the securing bin on the side of one cart was taped closed to prevent staff from putting used sharps in the bin when there was no plastic insert in the bin. She said the sharps bins need to be secured to ensure they do not spill causing a safety hazard. In an interview on 04/06/2023 at 8:53AM LVN E stated she was a charge nurse and usually worked on Nurse' Station Two. She stated she had seen the sharps bins on top of the treatment carts on Station One and knew they should be attached to the cart to prevent a safety hazard. An interview on 04/06/2023 at 8:57AM with the DON revealed the facility had 4 treatment carts (two on each Nurse' Station One and Two). She said the facility changed supply companies and could not get the sharps insert bins that fit into the two treatment carts on Station One. She said she was aware, and the sharps bins had been like that for a couple months. She stated she had been working on getting the proper inserts. She stated the sharps bins on top of the treatment carts were a safety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 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 hazard for residents and staff since they could spill. Level of Harm - Minimal harm or potential for actual harm An interview on 04/06/2023 at 9:55AM with the ADON/IP revealed the sharps bins need to be secured to the cart to ensure they do not spill causing a safety hazard to residents and staff. She stated the DON had been actively looking for the correct size sharps bin insert but had not been successful to date. She stated she was not sure if the facility had a policy that addressed how sharps gins were stored. She only provided the following policy: Residents Affected - Some Record review of the facility's undated policy titled, Sharps and Needles Disposal, revealed .Sharps will be placed directly into impervious, leak-prof and puncture resistant containers to eliminate the hazard of physical injury FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments, permit only authorized personnel to have access to the keys, and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for two (Nurses' Station Two Medication Cart #1 and #2) of five medication carts reviewed for security. 1. The facility failed to ensure staff maintain medication cart keys in a safe and secure manner. This failure placed the residents at risk for diversion of controlled substances. Findings included: An observation and interview on 04/05/2023 beginning at 6:50AM at Nurses' Station Two, revealed medication cart #1 positioned at the nurses' station facing outwards with the keys on top of the cart. LVN F, LVN G and RN B were observed behind the desk with their backs to the cart. Residents were observed ambulating in the area around the nurses' station. An interview with LVN F revealed she was an agency nurse, and the cart was assigned to her. She stated the medication cart keys need to be secured at all times. She said they should not be left on the cart because anyone could get them. She said securing medication carts was important to prevent the risk of drug diversions. In interview on 04/05/2023 at 11:20AM with the Administrator, she stated agency staff are oriented to the facility's policies and are provided with a list of basic job expectations. She said nursing management were responsible for the orientations. She said her expectation is for nurses transferring possession of the med carts and secure the med cart keys to minimize the risk of drug diversion. An interview on 04/05/2023 at 11:37AM with the DON revealed the medication cart keys need to be on the nurses' person. She said that is what the facility's policy reflects. She said the purpose was to limit or prevent medication errors and/or drug diversions. She stated agency staff are monitored like any other staff member through in services and audits. She said they get a verbal mini orientation of the facility's protocols when they come to work at the facility. She said this was provided by herself of the charge nurses. An interview on 04/05/2023 at 11:55AM with the ADON/IP revealed nurses are expected to ensure medication carts are secured at all times. She stated this meant to ensure keep cart keys on them at all times. She said not doing this could result in a drug diversion. She stated nursing management was responsible for checking that these were being done. Record review of the facility's undated policy titled, Controlled Medication, revealed .the key to the med cart and locked box is to be carried by the licensed nurse or CMA at all times. The keys may not be left on the desk or in a drawer. Failure to secure the keys will result in disciplinary action FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Memory Care, 1East Hall, and 2North Hall) of six clean linen closets and one of one mecanical lifts reviewed for infection control. Residents Affected - Some The facility failed to ensure clean linen closets were kept free of equipment that had not been sanitized before and after use. The facility failed to ensure CNAs K and L sanitized the mechanical lift (equipment used to lift residents) between use on two residents. This failure could place residents at risk of infections. Findings included: Observation and interview on 04/05/2023 beginning at 12:40PM with the Laundry Supervisor revealed three (Memory Care, 1East Hall, and 2North Hall) of six clean linen closets with Hoyer and stand-up lift in them. The Laundry Supervisor stated all mechanical lifts should be sanitized before being placed in the clean linen closets by staff who used them, but she could not be sure that they were. She stated the clean linen closets should only contain clean linen. She said having equipment or anything else in the closets pose a risk of cross-contamination and infection to the residents. In interviews on 04/05/2023 at 2:30PM with CNAs H, I, and J they revealed they stored the mechanical lifts in the clean linen closets because there was nowhere else to store them. They said the Administrator did not want them stored in the halls. They all stated they did not always disinfect the lifts between use on residents or prior to placing them into the clean linen closets. They said they had been trained in infection control policy and knew this was a risk of spreading infection to residents but often get busy and forget. An interview on 04/05/2023 at 3:23PM with the ADON/IP revealed she had been made aware that staff were storing lifts in the clean linen closets. She stated staff had been in-serviced on infection control and sanitizing equipment but there was no guarantee that staff were sanitizing doing it. She said this was a risk of spreading infection between residents. She said as the IP she tracked infections and currently had one resident with a wound infection and two with UTIs. She said although there were no current major infections in the facility, there had been in the past. She said she was working on finding alternate storage arrangements for the lifts. An interview on 04/05/2023 at 3:28PM with the Administrator revealed she told staff they could not store lifts in the halls and as a result they had been storing them in the clean linen closets. She stated although she expected equipment to be sanitized between use on residents, she could not be sure this had been done consistently. She said storing equipment in the clean linen closets posed a risk of the spread of infection to residents. An observation and interview on 04/06/2023 beginning at 7:57AM in the Secured Unit revealed CNAs K and L took a mechanical lift into Resident #25's room. A few minutes later, CNA K exited the room with the lift and entered Resident #76's room. An interview with CNA K revealed she and CNA L had used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm the lift on Resident #25 then to lift Resident #76. CNA K stated she had not sanitized the lift between residents. Both CNAs K and L stated all equipment needed to be sanitized between use on residents to limit the risk of spreading infections. They stated they were not allowed to leave the lifts in the halls and the storage rooms were full, so they stored them in the clean linen closets. They said this was a risk of cross-contamination. Residents Affected - Some An interview on 04/06/2023 at 7:46AM with LVN G revealed her expectation for CNAs was to sanitize equipment between uses. She said she reminded them frequently but believed they do not do it every time. She said clean linen closets should only contain clean linen. She said storing lifts in the closet could spread infection to residents because all residents come into contact with linen from the clean linen closets. A review of the facility's in-service records dated 11/04/2022 and 01/11/2023 and titled COVID-19 signs and symptoms, revealed staff were in serviced on infection control including sanitizing equipment. An in serviced dated 06/02/2022 and titled Stop the Spread: In service on Infection Control, also addressed disinfecting equipment. Record review of the facility's undated policy titled, Linen Room Storage Process, states To prevent the spread of virus and bacteria within the facility .Linen rooms are to be used exclusively for the storage of clean linen Record review of the facility's undated policy titled, Cleaning Equipment, states Nursing staff will clean and sanitize all equipment after each use. This includes Standaides, Mechanical Lifts, blood pressure equipment, pulse oximeters, thermometers, shower chairs, stethoscopes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 If continuation sheet Page 7 of 7