Health inspection·February 1, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nails, or them if the resident needed it, but stated she was not sure who was responsible. CNA F stated nail care does show up on the task list for their assignment. An observation of Resident #29's nails was made with CNAs E and F on 01/31/24 at 11:40 a.m. and both stated the residents' nails were long and needed to be trimmed. CNA E stated having long nails and dirty nails put residents at risk of skin tears and infections, and stated with the resident's contracture to her hand she would be at risk of skin problems. Interview with the DON on 01/31/24 at 04:30 p.m. she stated it was the CNAs responsibility to make sure residents nails were trimmed and clean. She stated it assigned on the CNAs task list. She stated she would make sure the staff were aware of their responsibility. She stated failing to keep resident's nails trimmed and clean could cause skin scratches, risk of infections, and someone with contractures could cause skin breakdown. Record review of the facility's policy titled, Care of Fingernails/Toenails, dated December 2023, reflected, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention skin problems around the nail bed .Unless otherwise permitted, do not trim the nails of diabetic resident or residents with circulatory impairments .Trimmed and smooth nails prevent the resident from accidentally scratching or injuring his or her skin .Stop and report to the nurse supervisor if there is evidence of ingrown nails, infection, pain, or if nails are too hard or too thick to cut with ease . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 2 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for two (Residents #29 and Resident #59) of two residents reviewed for feeding tubes. 1. The facility failed to ensure Resident #29's G-tube was flushed with 15-30 ml's water after medication administration and failed to flush between each medication with 15 ml's of water per facility policy. 2. The facility failed to have orders for Resident #29 and Resident #59 for the required amount of water flushes before and after medication administration and between each medication given via the G-tube. These failures could place residents at risk of medication incompatibility and tube obstruction. Findings include: 1. Record review of Resident #29's quarterly MDS assessment, dated 11/17/23, reflected an [AGE] year-old female with an admission date of 12/18/21. Resident #29 was unable to respond to the interview for mental status. Staff assessment listed her as moderately cognitively impaired. Resident #29 had active diagnoses which included heart failure, cerebral vascular accident (stroke) hemiplegia (partial paralysis on one side of the body) and aphasia (language disorder), and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #29's Physician orders report dated 01/31/24 reflected, .Medications to be given via PEG tube with a start date of 07/30/23. There were no orders for water flushes prior to, between each medication and after administration of medication. Record review of Resident #29's care plan dated 07/10/23 reflected, .[Resident #29] require tube feeding related to dysphagia (difficulty swallowing) and inadequate oral intake .Interventions .[Resident #29] is dependent with tube feeding and water flushes. See MD orders for current feeding orders . Record review of Resident #29's Medication administration record for January 2024 did not indicate how much water to flush the g-tube with prior to, between each medication and after medication administration. An observation on 01/31/24 at 07:25 AM of G-Tube medication administration for Resident #29 revealed RN B prepared medication for Resident #29. RN B poured 2.5cc of Keppra 100mg/per ml (anti-seizure), 7 cc of ferrous sulfate Elixir 220 mg/5 ml (iron supplement), 1 tablet Reglan 10 mg (treats heart burn), MiraLAX 17 gm (laxative) 1 capful placed in cup with 8 oz. of water, 2 tablets Simethicone 80 mg (treats gas), 1 tablet Aspirin 81 mg (analgesic), 1 tablet Gabapentin 600 mg (anti-seizure), 1 tablet Lisinopril 20mg (treats high blood pressure), 1 tablet Metoprolol 25 mg (treats high blood pressure), 1 capsule Amoxicillin 500 mg (antibiotic), 1 tablet Xarelto 15mg (blood thinner), and 1 packet Potassium chloride 20 meq (mineral supplement) mixed in 8 oz of water . RN B opened the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 3 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Amoxicillin capsule and placed it in a plastic cup and then crushed each tablet and placed each of them in separate cups and entered the resident's room. RN B then filled a plastic cup with water from the bathroom sink and poured approximately 20 ccs of water into each medication cup. She then retrieved a 60-cc piston syringe and placed the feeding pump on hold. She disconnected the feeding tube from the G-tube and placed the piston syringe into the G-tube connector and checked for residual and flushed the G-tube with 30 cc's of water. RN B then administered each medication by gravity. RN B did not flush with clear water between each medication or after the final medication administration. RN B then reconnected the feeding tube and turned the pump back on. RN B removed gloves and performed hand hygiene. In an interview with RN B on 01/31/24 at 08:20 AM stated she had reviewed with the DON prior to doing the medication pass and was told to dilute the medications with 20 cc of water and flush with 30 cc before and after and none in between. RN B pulled up the physician orders and reviewed and stated it did not indicate how much to dilute medications with or how much to flush with in between. She stated it was important to flush before and after to prevent the tube from clogging. She stated she assumed the 20 ccs to dilute the medications was sufficient. 2. Record review of Resident #59's quarterly MDS assessment, dated 01/04/24, reflected a [AGE] year-old female with an admission date of 04/21/21. Resident #59 was unable to respond to the interview for mental status and staff had not completed the mental assessment. Resident #59 had active diagnoses which included cerebral vascular accident (stroke) hemiplegia (partial paralysis on one side of the body) and aphasia (language disorder), and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #59's Physician orders report dated 01/31/24 reflected, .Medications to be given via PEG tube with a start date of 10/10/23. There were no orders for water flushes prior to, between each medication and after administration of medication. Record review of Resident #59's care plan dated 11/28/23 reflected, .[Resident #59] currently have a PEG tube and receive all nutrition through tube .Interventions .[Resident #59] is dependent with tube feeding and water flushes. See MD orders for current feeding orders . Record review of Resident #59's Medication administration record for January 2024 did not indicate how much water to flush the g-tube with prior to, between each medication and after medication administration. In an interview the DON on 01/31/24 at 09:20 a.m. she stated she had instructed the staff to dilute G-tube medications with 20 cc of water and flush with 30 cc before and after. She stated she was the one who had told them not to flush with water in between, since they were using 20 cc to dilute the medication with. She stated they had batch orders the nurses clicked on when putting in G-Tube medication orders. She stated who ever put in the order was responsible for ensuring the orders for flushing before and after were on the orders as well as how much to dilute the medication with. She stated the batch orders would be the facility's routine orders unless the pharmacist or the physician requested something different. The DON then pulled up the batch orders and stated the batch orders were to dilute medications with 15 ml, flush with 15 ml between each medication and flush with 30 cc before and after medications. She stated she had instructed the staff incorrectly and stated she would re-educate everyone and get the orders up to date. She stated failing to flush between medications could potentially cause the g-tube to occlude. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 4 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the facility's Pharmacist consultant on 01/31/24 at 10:46 a.m. he stated it was important to flush with water between each medication mainly to clear the line and prevent medications from clogging the line. He reviewed the medications administered to Resident #29 and stated none would have a significant interaction with each other. He stated when he does medication pass observation with the staff, he always tells them to flush with at least 10 to 20 cc of water between each medication, before and after just to make sure the tube is clear of all medications to prevent the tube from obstructing. Record review of the facility's Policy titled, Administering Medications through an Enteral Tube, dated December- 2023, reflected, .Check gastric residual volume .When acceptable gastric residual volume have been verified, flush tubing with 15-30 ml warm or room temperature water (or prescribed amount) .Dilute the crushed or split medication with 15-30 ml warm or room temperature water ( or prescribed amount) .Administer medication by gravity flow .If administering more than one medication, flush with 15 ml (or prescribed amount) of warm or room temperature water between medications .When the last of the medication begins to drain from the tubing, flush the tubing 15 ml of warm or room temperature water (or prescribed amount) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 5 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 4 Residents (#58 and #73) reviewed for respiratory care, in that: Residents Affected - Few 1) Resident #58 did not have physician orders for changing and dating all oxygen tubing and equipment and the humidity bottle was not labeled or dated. 2) Resident #73's oxygen concentrator's humidifier bottle and oxygen tubing were not labeled or dated. Potential outcome statement goes here The findings were : 1. Review of Resident #58's face sheet dated 5/17/2023 reflected that Resident #58 was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses include Chronic Obstructive pulmonary disease, Shortness of breath, cerebral infarction (A lack of adequate blood supply to brain cells), unspecified systolic (congestive) heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). Review of Resident #58's Quarterly MDS assessment dated [DATE] reflected that Resident #58 was on oxygen therapy. Review of Resident #58's comprehensive care plan reflected that Resident #58 was on oxygen therapy for Chronic Obstructive Pulmonary disease/Asthma and to give oxygen treatments and nebulizer therapy as per orders. Review of Resident #58's Physician order dated 11/9/2023 revealed may use oxygen concentrator to assist with keeping oxygen saturation greater than 92%. Review of Resident #58's Physician order dated 8/31/2023 revealed oxygen saturation every shift. Observation on 1/30/24 at 10:40 AM revealed that Resident #58 was on Oxygen therapy. Observed there was no date or label on the humidity bottle and the bottle was empty . Observed that oxygen tubing was labeled and dated. Interview with Resident #58 revealed that she used bedside oxygen during nighttime , but she does not remember if staff had changed the oxygen tubing and humidity bottle. 2) Review of Resident #73's Quarterly MDS assessment dated [DATE] revealed that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses include polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), anemia (a condition that develops when your blood produces a lower amount of healthy red blood cells), hypertension (blood pressure higher than normal), Diabetes mellitus ( disease involving inappropriately elevated blood glucose levels), hyperlipidemia (elevated levels of lipids in the blood), and active diagnosis of Covid-19. The Quarterly MDS also revealed that Resident #73 was on oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 6 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 Review of Resident #73's comprehensive care plan dated 1/23/24 revealed that Resident #73 has oxygen therapy related to ineffective gas exchange with interventions of Oxygen settings: Oxygen via nasal cannula at 2 Liters per minute continuously. Review of Resident #73's Physician order dated 10/8/2023 revealed that change and date all oxygen tubing and equipment each Sunday on night shift. Review of Resident #73's Physician order dated 11/20/2023 revealed that Oxygen at 2 Liters per minute via nasal cannula during hours of sleep to maintain oxygen stats greater than 92 percent. Observation on 1/30/24 at 12:35 PM revealed that Resident #73 was on oxygen therapy and the humidity bottle as well as oxygen tubing was not dated or labeled. Interview with Resident #73 on 1/20/24 at 12:38 PM revealed that she uses continuous oxygen, and she thought the bottle and tubing was changed on Sunday 1/28/24 but was not sure about it since she has been in COVID isolation for the past few days. Interview with CNA K on 1/30/2024 at 12:50 PM revealed that both tubing and bottle should be dated and was done by Nursing. CNAs usually were not responsible for changing the tubing. In an interview with LVN D on 1/30/24 at 1:00 PM revealed that she had started working in the facility a couple of days back. She stated that tubing was changed every Sunday by night shift Nursing staff and bottle needs to be changed as needed but at least every 7 days. She also stated that there should be physician orders to change and date tubing and humidifier bottle. She revealed that she could not find orders for changing and dating oxygen equipment on Resident #58's electronic medical record . She stated that if the tubing was not changed or dated , risk for infection increased and the date of change for the humidifier bottle and oxygen tubing remained unknown. In an interview with LVN I on 1/31/24 at 9:13 AM revealed that both the oxygen tubing and oxygen humidifier bottle should be changed every 7 days and dated each time. She also stated that night shift nursing staff were responsible for changing Oxygen supplies and dating them. She revealed if they were not dated risk for infection could increase. In an interview with RN L on 1/31/24 at 1:05 PM revealed that both the oxygen tubing and the humidifier bottle needs to be dated whenever new tubing or bottle was used. The risk of not dating the tubing or bottle was leaving the tubing longer and increased risk of infection. She also revealed that per facility policy nursing staff should change and date oxygen supplies on a weekly basis. In an interview with ADON on 1/31/24 at 2:53 PM revealed that Nursing staff should be changing the tubing and humidifier bottle on a weekly basis , and evening Shift was responsible for dating it. She also revealed they have been utilizing Agency Nursing staff for the evening shift. She also stated that if there was no label or date on either the humidity bottle or oxygen tubing, the nursing staff will replace the tubing immediately and date it. She also revealed that the risk of not dating the oxygen equipment will cause lapses in infection control. In an interview with DON on 1/31/24 at 3:30 PM revealed that it was a standard practice to date and change Nasal cannula and humidity bottles every Sunday and on an as needed basis. The change was usually done by the evening Nursing Staff. The risk for not changing or dating oxygen supplies can lead to infection lapses. She revealed that physician orders were important to treat Residents and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 7 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 FORM CMS-2567 (02/99) Previous Versions Obsolete failure to obtain orders can lead to risk of resident not getting the appropriate care. Her expectation was all physician orders be followed by all Nursing staff. Review of facility's policy dated December 2023 for oxygen administration stated that Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Event ID: Facility ID: 676488 If continuation sheet Page 8 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for one (Resident #70) of one resident reviewed for dialysis. Residents Affected - Few The facility failed to ensure Resident #70's dialysis communication sheets were completed to coordinate care with the dialysis center. This failure placed residents at risk of not receiving proper care and adequate coordination of care. Findings included: Review of Resident #70's admission MDS assessment dated [DATE] reflected Resident #70 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (abnormal heartbeat), hypertension, end stage renal disease, diabetes and respiratory failure. Resident #70 was independent with cognitive skills for daily decision making. Review of Resident #70's face sheet dated 02/01/24 reflected Resident #70 was dependent on renal dialysis. Review of Resident #70's comprehensive care plan initiated on 09/06/23 reflected Resident #70 needed hemo dialysis due to renal failure on MWF . Review of Resident #70's clinical record reflected the last dialysis communication sheet was on 12/29/23 for Resident #70. Interview on 01/30/24 at 12:38 PM with Resident # 70 revealed she went to dialysis on Mondays, Wednesdays and Fridays. She stated she had personal transportation to dialysis and facility did not provide documentation for her to take to dialysis. She stated when she was at facility before her hospitalization the facility nurse would ensure she had dialysis communication sheet to take with her to dialysis and she would return with the dialysis communication sheet completed by dialysis nurse so she could give it the facility nurse when she returned from dialysis. She stated dialysis center did not provide her any documentation to give nursing facility. Interview on 01/31/24 at 2:58 PM with LVN I revealed Resident #70 was at dialysis today. She stated Resident #70's family member coordinated dialysis. She stated the facility did not do pre-weights for Resident #70 on dialysis days. She stated when she did complete dialysis communication sheets she would put fasting blood sugar from before breakfast and the blood pressure and pulse from that morning based on Resident #70's physician order when giving her blood pressure medications. She stated she did assess Resident #70's dialysis shunt prior to dialysis. She stated Resident #70 usually left for dialysis about noon and would ensure Resident #70 got her lunch tray early before she left. She stated sometimes she did not complete the dialysis communication sheet for Resident #70. Telephone Interview on 01/31/24 at 3:23 PM with Clinical Coordinator from Dialysis A revealed Resident #70 was currently at dialysis center getting dialysis. She stated in the past Resident #70's dialysis communication sheet had been provided and Resident #70's last dialysis communication sheet was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 9 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 01/3/24 located in her bag today. She stated Resident #70 was not provided pre dialysis communication sheet information so dialysis would know about resident's assessment prior to dialysis. She stated the facility did not provide medication information to dialysis center so they could know which medications resident was administered prior to dialysis. Follow up Interview on 01/31/24 at 3:40 PM with LVN I revealed she was the charge nurse for Resident #70 today. She stated she got busy and today she was unable to complete Resident #70's communication sheet for pre dialysis information which included assessment of dialysis site and vitals. Interview on 02/01/24 at 10:10 AM with Agency LVN N stated she did not work with residents on dialysis at the facility. She stated she was an agency nurse and was provided orientation by charge nurse who she took over about residents. She stated she would round with charge nurse to familiarize herself with residents. She stated she only worked at facility 2 times so far. She was not in-serviced about facility policy about dialysis and was unaware about dialysis communication sheets. Interview on 02/01/24 at 10:45 AM with DON revealed she expected charge nurse to complete pre dialysis part of the dialysis sheet and give it to Resident #70 to take with her to dialysis so dialysis center can be aware of resident's condition prior to dialysis. She stated she expected charge nurse to ask Resident #70 after she returns from dialysis for dialysis communication sheet that was filled out by dialysis center and assess Resident #70 including vitals and dialysis site . She stated when facility nurses were not completing the dialysis communication sheets it can put residents at risk of not ensuring resident was stable for dialysis. She stated when facility nurses are not reviewing Resident #70's dialysis communication sheets they were unaware of resident's condition from dialysis. She stated facility nurses were in-serviced about two months ago about completing dialysis communication sheets but the facility did not complete in-service sheets to provide which nurses were in-serviced. She stated she expected nurses to complete pre and post dialysis weights on Monday, Wednesday and Friday as ordered. She stated she expected Resident #70's vitals to be done right before dialysis so nurse would have a baseline and assess if resident was stable for dialysis. She stated the facility did not have a dialysis policy. She stated agency nurses were not specifically in-serviced on dialysis . She stated about 2 months ago nurses were inserviced by ADON about completing dialysis communication sheets and started using the dialysis communication sheets she had. DON stated she expected charge nurses to complete pre and post dialysis part of the dialysis communication sheet on Resident #70's dialysis days. Observation and Interview on 02/01/24 with 11:25 AM revealed Resident #70 was sitting in her wheelchair in therapy room. She stated she went to dialysis yesterday and the charge nurse in the evening when she returned from dialysis did not ask her for the dialysis communication sheet. Resident #70 stated she did not get a dialysis communication sheet yesterday from charge nurse to provide to dialysis center. She stated she did not have consistent charge nurse on the evening shifts and nurse did not ask her for dialysis communication sheets to review. She did not have any dialysis communication sheets with her. Interview on 02/01/24 at 12:22 PM Agency LVN M revealed she worked on evening shift when Resident #70 returned from dialysis on her hall. LVN M stated she would check Resident #70's vital signs when she returned from dialysis in the evening and would ensure Resident #70 was given her meal. She stated Resident #70 would usually return about 6:30 pm or right before 7 pm on her shift. She stated Resident #70 did not provide her any documentation from dialysis. She was not aware of dialysis communication sheets for dialysis residents and had not been in-serviced on completing dialysis sheet. She stated she had been working at facility for about two months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 10 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 The facility did not have a policy on dialysis per DON. The facility did not submit a policy at the date and time of exit from the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 11 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Residents Affected - Many 1. The facility failed to ensure low temperature dish machine met minimum of 120 F temperature for wash and rinse cycles. 2. The facility failed to ensure fryer was covered when not in use. These failures could place residents at risk for food-borne illness and food contamination. Findings included : 1. Observation on 01/30/24 at 9:48 AM revealed the facility had low temperature dish machine in use. The low temperature dish machine was 100 degrees F for wash and 102 F for rinse cycles. The low temperature dish machine was ran again revealing temperature went up to 105 F for wash and 110 F for rinse. Interview on 01/30/24 at 9:50 AM with Dietary Manager revealed the hot water temperature did fluctuate. He stated the low temperature dish machine was not meeting the minimum of 120 degrees F. He stated he will contact the representative for dish machine to have them come out and will speak with Maintenance about temperature. He stated the water temperature for dish machine this morning was at least 120 F. Interview on 01/30/24 at 9:56 AM with Dietitian revealed the facility would stop using the dish machine until it was looked at to ensure it met the minimum hot water temperature. She stated the facility would use Styrofoam products for meals until dish machine was working properly. 2. Observation on 01/30/24 at 9:41 AM revealed fryer was uncovered with dark brown grease. Interview on 01/30/24 at 9:51 AM with Dietary Manger revealed the fryer was not in use and the grease should be covered by a sheet pan. He stated the Dietary [NAME] changed it weekly but was not sure when it was last changed. Interview on 01/30/24 at 9:53 AM with Dietary [NAME] revealed she had filtered the grease yesterday and the grease was due to be changed weekly. She stated the grease was only changed weekly. She stated the grease should be covered by sheet pan when not in use. Interview on 02/01/24 at 11:09 AM with Dietary Manger revealed he had no prior issues with low temperature dish machine's hot water temperatures. He stated the low temperature dish machine not meeting minimum hot water temperatures placed dishes at risk of not getting the soiled food off. He stated they have in-serviced dietary staff to ensure to run the low temperature dish machine at least 3 times prior to use to ensure it was meeting hot water standards of 120 F. He stated the fryer had been drained and cleaned along with new oil. He stated the grease in fryer not being covered placed at risk of items falling into it and can attract pests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 12 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 0812 The facility did not have policies on dish machine and fryer per the Administrator. The facility did not submit a policy at the date and time of exit from the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 13 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 five (Resident #70, Resident #80, Resident #09, Resident #65, and Resident #56) of nine residents reviewed for infection control. Residents Affected - Some 1. LVN C failed to perform hand hygiene after providing an Insulin injection to Resident #70. 2. LVN D failed to prevent cross contamination of a bottle test strips used to obtain glucose levels when she carried the bottle into Resident #80's room and returned it to the top of the medication cart. 3. LVN D failed to prevent cross contamination when she opened the bottle of test strips previously carried into Resident #80's room and retrieved test strips to obtain the blood sugar readings for Resident # 9. 4. RN A failed to prevent cross contamination of a bottle test strips used to obtain glucose levels when she carried the bottle into Resident #65's room and returned it to the medication cart. RN A failed to perform hand hygiene after removal of her gloves after completion of obtaining a fingerstick blood sugar test on Resident #65. 5. RN A failed to prevent cross contamination of a bottle test strips used to obtain glucose levels when she carried the bottle into Resident #56's room and returned it to the medication cart. RN A failed to perform hand hygiene after removal of her gloves after completion of obtaining a fingerstick blood sugar test on Resident #56. Theses failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #70's face sheet, dated 02/01/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #70 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 01/30/24 at 11:00 a.m. revealed LVN C at the medication cart preparing to obtain a fingerstick blood sugar test on Resident #70. LVN C entered the resident's room and obtained the blood sugar reading and determined the resident would require Insulin by sliding scale. LVN C performed hand hygiene, retrieved the resident's insulin pen from the medication cart and dialed in the required amount of insulin. LVN C performed hand hygiene and put on gloves and entered the resident's room and administered the insulin. LVN C returned to the medication cart, removed her gloves and without performing hand hygiene placed the insulin back in the medication cart. In an interview on 01/30/24 at 11:10 AM with LVN C, she stated she was supposed to perform hand hygiene anytime she removed her gloves. She stated failing to do this could spread infection. 2. Record review of Resident #80's face sheet, dated 02/01/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #80 had a diagnosis which included type 2 diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 14 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 mellitus. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's face sheet, dated 02/01/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnosis which included diabetes mellitus due to underlying condition. Residents Affected - Some Observation during medication pass on 01/30/24 at 11:15 a.m. revealed LVN D preparing to obtain fingerstick blood sugar for Resident #80. LVN D pulled a glucometer, a bottle of test strips, a lancet and an alcohol wipe from the medication cart and entered the resident's room. LVN D placed the supplies on the resident's over the bed table without sanitizing the table or placing the supplies on a clean barrier. LVN D entered the resident's bathroom, washed her hands, and put on gloves and proceeded to obtain the blood sugar reading. LVN D gathered the glucometer, lancet and used alcohol wipe and disposed the lancet in the sharps container and carried the glucometer with her to the resident's bathroom and laid it on the sink, removed her gloves and washed hands. LVN D wrapped the glucometer in a paper towel, retrieved the bottle of test strips from the Resident's bedside table and returned to the medication cart. LVN D placed the glucometer and bottle of test strips on top of medication cart. LVD D then put on gloves and cleaned glucometer with a germicidal wipe but did not clean the bottle of test strips. LVN D then opened the medication cart and retrieved the Resident's insulin pen and dialed in the required amount of insulin per sliding scale. LVN D put on gloves and entered the Resident's room and administered the insulin. LVN D removed her gloves, performed hand hygiene, and returned the insulin to the medication cart. LVN D then moved her medication cart to the next residents with the bottle of test strips still on top of medication cart. Continuation of medication observation and interview with LVN D on 01/30/24 at 11:15 a.m. revealed her outside of Resident #9's room. A sign posted outside of Resident #9's room revealed she was in droplet isolation. LVN D stated Resident #9 was positive for COVID. LVN D performed hand hygiene and put on gloves. LVN D retrieved the glucometer, alcohol wipe, a lancet and then opened the unsanitized bottle of testing strips (which had been in Resident #80's room) and retrieved one test strip. LVN D placed the test strip in the glucometer and placed it on top of the medication cart and put on a N-95, gown and gloves and entered the resident's room to obtain the fingerstick blood sugar. LVN D then ungowned and gloved, sanitized hands, cleaned the glucometer with a germicidal wipe, but not the bottle of test strips or the top of her medication cart. LVN D placed the bottle of test strips back in the cart and pulled out the residents' insulin pen and dialed the amount of insulin required per sliding scale. LVN D put on full PPE and re-entered Resident #9's room and administered her insulin. LVN D ungowned and gloved and performed hand hygiene and returned the insulin pen back into the medication cart. In an interview with LVN D on 01/30/24 at 11:30 a.m. she stated she should not have carried the full bottle of test strips into Resident #80's room, stating it was multi resident use supplies and would be considered contaminated at that point. She stated she had no idea why she carried it in and stated she just got flustered. She stated she should have cleaned the top of her medication cart as well. She stated the risk of not properly sanitizing was spreading germs and cross contamination. 3. Record review of Resident #65's face sheet, dated 02/01/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #65 had a diagnosis which included type 2 diabetes mellitus. Record review of Resident #56's face sheet, dated 02/01/24, reflected an [AGE] year-old female who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 15 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 Residents Affected - Some was admitted to the facility on [DATE]. Resident #56 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 01/30/24 at 11:35 a.m. revealed RN A preparing to obtain fingerstick blood sugar for Resident #65. RN A pulled a glucometer, a bottle of test strips a lancet and an alcohol wipe from the medication cart and entered the resident's room. RN A placed the supplies on the residents over the bed table without sanitizing the table or placing the supplies on a clean barrier. RN A obtained the fingerstick blood sugar reading, gathered her supplies, and placed the used glucometer with test strip in the same hand with the bottle of test strips and returned to the medication cart and laid the dirty glucometer and bottle of test strips on top of the cart. RN A disposed of the lancet and test strip and removed her gloves and checked the computer for insulin dosage then performed hand hygiene. RN A then put on gloves and sanitized the glucometer with a germicidal wipe, but not the bottle of test strips. RN A stated the resident did not require insulin according to her sliding scale. RN A then proceeded down the hall to the next resident, who was not in her room. RN A proceeded down the hall to the dining room and located the resident. RN A then placed the bottle of unsanitized testing strips into the medication cart and took Resident # 56 back to her room to obtain her fingerstick blood sugar. Continuation of medication observation with RN A on 01/30/24 at 11:40 AM revealed her outside of Resident #56's room. RN A retrieved the bottle of test strips (which had been carried into Resident #65's room), glucometer, alcohol wipe and lancets and entered resident's room. RN A placed the bottle of testing strips and glucometer on the roommates over the bed table without sanitizing the table or placing a barrier down for the supplies. RN A obtained the fingerstick blood sugar, left the room and disposed of the test strip and lancet, leaving the bottle of test strips on the bedside table in the resident's room. RN A removed her gloves and without performing hand hygiene checked the computer to determine the required amount of insulin. RN A then performed hand hygiene, gloved, and cleaned the glucometer with a germicidal wipe. RN A removed her gloves and without performing hand hygiene, opened the medication cart and retrieved the resident's insulin pen and dialed the amount of insulin needed. RN A put on gloves and entered Resident #56's room and administered the insulin and retrieved bottle of test strips. RN A removed her gloves, performed hand hygiene, and placed the bottle of strips and the insulin pen back in the medications cart. In an interview with RN A on 01/30/24 at 11:45 a.m. she stated she should have placed a barrier on the bedside table before laying the supplies on the table. She stated she should not have carried the whole bottle of test strips from room to room due to risk of cross contamination and spreading of germs and she was supposed to perform hand hygiene after glove removal. She stated did not realize she had not performed hand hygiene before touching her computer. In an interview with the DON on 01/30/24 at 11:40 a.m. she stated staff were to only carry in the necessary supplies needed to perform the fingerstick blood sugar. She stated if they had to place equipment or supplies on a surface in the resident's room then they needed to clean the surface and place a barrier down for their supplies. She stated the bottle of test strips should never be taken in the resident's room because once in the room it is considered contaminated. She stated staff were to preform hand hygiene after glove removal. She stated failure to follow the proper procedure could result in infections and spreading of germs from resident to resident. Record review of the facility's policy, Obtaining a Accucheck/Fingerstick Glucose level, dated December 2022, reflected .The following equipment and supplies will be necessary when performing this procedure .alcohol wipe(s), Disinfected blood glucose meter( glucometer) with sterile lancet .test (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 16 of 17 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 676488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hollow Rehabilitation Center 5011 North US Hwy 75 Sherman, TX 75090 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 strips .personal protective equipment .Place the equipment on the bedside stand or overbed table .Wear clean gloves .Obtain a blood sample .Dispose of the lancet in the sharps disposal container .discard disposable supplies in the designated containers .Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .remove gloves and discard into designated container .Wash hands Residents Affected - Some Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2015, reflected, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .for the following situations .After contact with blood or bodily fluids .after contact with objects (e.g., medical equipment) .After removing gloves .Hand hygiene is the final step after removing and dispose of personal protective equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676488 If continuation sheet Page 17 of 17