Health inspection·June 29, 2023

F 0776 Level of Harm - Minimal harm or potential for actual harm areas will resolve without complication by review date. Interventions: Check range of motion, educate resident to inform staff immediately of falls, medication review, neuro checks per facility protocol, PT consult for strength and mobility. Review of Resident #70's incident report created by LVN A, dated 06/20/23, revealed the following: Residents Affected - Some Incident Description: Resident informed [me] that she fell in her bathroom. Resident wheeled self to the station and stated, [I fell in my bathroom and my left wrist and left hip hurt, I did not hit my head.] Immediate Action Taken: Resident taken to her room and head to toe assessment completed for injuries' no swelling or bruising noted to either area, ice applied to left wrist, v/s taken, neuro check initiated, MD notified order received to x-ray left wrist, and left hip. Administered PRN Norco 10/325 d/t c/o pain 9/10. Resident own POA, notified ADON and DON. Awaiting xray. Review of Resident #70's physician order, dated 06/20/23 at 9:55 AM, revealed an order for X-ray hand, left wrist and left hip due to recent fall and pain. Review of Resident #70's progress note, documented by LVN A on 06/20/23 at 10:44 AM revealed: Resident in w/c stated; I fell in the bathroom and now my wrist hurts an hip, left hand wrist and left hip, resident given pain pill per her request, MD notified DON and ADON notified Family member [NAME] notified, ice pack applied to left hand, wrist, [wew] order to x-ray left hand, wrist and left hip, X-ray Dept notified. Review of Resident #70 progress note, documented by LVN A on 06/20/23 at 12:06 PM revealed: Resident up in wheelchair wheeling self, waiting on X-ray Dept. Review of Resident #70's progress note, documented by LVN B on 06/20/23 at 5:06 PM revealed: Resident had a fall this morning in her bathroom, and stated that she landed on her left hip and left wrist. This nurse received in report that X rays were ordered for these this AM. Resident complained to this nurse of increased pain to the left hip of 9/10 and this nurse administered a PRN Norco per orders to this resident, as well as a PRN Flexural. Upon reevaluation resident stated that her wrist is more swollen and that her thumb and fingers are feeling numb. This nurse notified the resident provider and received an order to send resident out to the Emergency room, for further evaluation. Resident stated to this nurse that she felt lightheaded and dizzy, while standing in the bathroom texting her family and fell to the floor catching herself with the left wrist and landing on her hip. Resident denies hitting her head when she fell. This nurse noted that resident left wrist is even more swollen that it was at the start of the shift. Resident is normally up walking in the hall during the shift, and today resident is noted to be in a wheelchair. Resident denies feeling lightheaded at this time. Resident has reduced movement in her left hand and fingers at this time. Resident complains that pain is moving up the arm to the elbow at this time. Resident able to notify family of the transfer to the hospital. Review of Resident #70's hospital records, dated 06/20/23, revealed reason for visit fall and diagnoses broken arm. Observation and interview on 06/27/23 at 10:58 AM of Resident #70 revealed she was sitting in her wheelchair, observed Resident #70 to have a cast on her left hand. Resident #70 stated last Tuesday (06/20/23) at around 9:00 AM she had a fall in her bathroom. She stated she was on her phone and felt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 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 676496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation & Healthcare of Burleson 275 SE John Jones Drive Burleson, TX 76028 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 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dizzy and fell to the floor. Resident #70 stated she got up by herself and noticed she had pain to her left wrist and hip. She stated she was able to get up and got in her wheelchair. She stated she wheeled herself to the nurses' station and informed her nurse at approximately 9:20 AM, she stated her nurse was LVN A. She stated LVN A assessed her and provided her with an ice pack, pain meds and ordered x-rays. Resident #70 stated around 12:00 PM she asked LVN A about her x-rays and LVN informed her they were still waiting. Resident stated she was having pain. Resident #70 stated at around 2:00 PM before shift change, she asked LVN A again about the status of the x-rays and LVN A informed her that the order was put in and they were waiting on the x-ray department. Resident #70 stated at around 4:20-4:30 PM she talked to the DON about her fall. She stated that the DON was unaware of her fall, and she informed the DON that she was having pain to her left wrist and hip. Resident #70 stated between 5:00-6:00 PM EMS arrived and was taken to the hospital. Resident #70 stated she only sustained a fracture to her left wrist. Resident #70 stated she was in pain; however, she was provided with her pain medication to reduce the pain. Resident #70 stated her hand was swollen and she felt her fingers were getting numb. Resident #70 stated she did not understand why the x-rays took a long time to arrive. Resident #70 stated if she would not have gone to the DON and informed her about her fall and being in pain, she would have still been waiting for the x-ray department to come by. Interview on 06/29/23 at 11:31 AM with LVN A revealed Resident #70 had an unwitnessed fall in her bathroom the morning of 06/20/23. LVN A stated Resident #70 wheeled herself to the nurses' station and informed her about her fall. She stated she conducted a head-to-toe assessment and range of motion. She stated Resident #70 complained of pain to her left wrist, she stated upon assessment resident hand was straight, no swelling and no deformity noted. LVN A stated she provided Resident #70 with an ice pack and pain medication. She stated she contacted the doctor and x-ray orders were provided approximately at 10:00 AM. LVN A stated x-ray department did not make it out during her shift or evening shift, she stated Resident #70 was sent to the hospital. LVN A stated the x-ray orders were ordered as a regular order and not STAT. She stated if the order was placed as STAT the x-ray department had four hours to respond. LVN A stated she did not order the x-ray STAT because she did not see any swelling and Resident #8 was able to move her fingers. She stated if Resident #70 hand would have been swollen or disfigured, she would had sent her out to the hospital. Interview on 06/29/23 at 2:16 PM with the DON revealed on 06/20/23 at around 4:00-4:30 PM Resident #70 came to her and informed her that she had a fall and had pain to her left wrist. The DON stated she observed Resident #70 wrist to have a raised area but no deformity. She stated Resident #70 was unable to move her fingers and that was what prompted her to send resident out to the hospital immediately for further evaluation. The DON stated Resident #70 did complain of pain; however, Resident #70 was given an ice pack and pain medication through-out the day. The DON stated Resident #70 sustained a fracture to her left wrist. The DON stated she was notified that morning 06/20/23 of Resident #70 fall and that x-rays were ordered; however, she was not aware that the x-rays were not ordered STAT. She stated the order should had been STAT due to resident expressing pain. The DON stated every morning she conducts an order summary report from the day prior and will review any x-ray orders. She stated there was no risk to the resident from not obtaining STAT orders because Resident #70 was still propelling around the facility in her wheelchair and was receiving pain medication. Interview on 06/29/23 at 3:09 PM with LVN B revealed she worked the 2:00-10:00 PM shift and was the nurse for Resident #70 on 06/20/23. LVN B stated the morning of 06/20/23 Resident #70 had a fall. She stated in the evening unknown of the exact time Resident #70 informed her that she was in pain 9/10 pain scale. She stated she assessed Resident #70 and noted resident's left hand to be swollen, she stated resident was able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 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 676496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation & Healthcare of Burleson 275 SE John Jones Drive Burleson, TX 76028 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 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some move her fingers but not a lot. LVN B stated Resident #70 complained of pain and stated her fingers were going numb. LVN B stated she provided Resident #70 with a pain pill. She stated she reviewed Resident #70 physician orders and noted that an x-ray order had already been ordered; however, the orders were not STAT. LVN B stated Resident #70 was able to verbalize how she fell and was able to express the pain she had which should have prompt them to obtain STAT orders. LVN B stated Resident #70 was sent to the hospital for further evaluation and returned same day. She stated Resident #70 sustained a fracture to her left wrist. 2. Review of Resident #8's Face Sheet, dated 06/29/23, revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnosis included pain in left knee. Review of Resident #8's quarterly MDS Assessment, dated 05/02/23, revealed Resident #08 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #8 required extensive assistance with ADLs, including toilet use. Resident #8 had not had any falls or experience any pain. Review of Resident #8's care plan, 02/20/23, revealed: The resident had pain r/t left knee pain, chronic back pain with presence of spinal cord stimulator. Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions: Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Further review of the care plan revealed Resident has a terminal prognosis. Goal: The resident's comfort will be maintained through the review date. Interventions: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Observed and interview on 06/27/23 at 2:07 PM of Resident #8 lying in bed. Resident #8 stated she was concerned about right knee being swollen. Resident #8 stated about three weeks ago while being changed she heard her knee pop and she informed her hospice nurse about the pop and being in pain. Resident #8 could not recall the aides who assisted her. Resident #8 stated her hospice nurse had informed her that she was going to request x-rays to be completed. Resident #8 stated the hospice nurse was the only person she informed of her knee popping. Resident #8 stated as of today she was still waiting for x-ray to be completed. Resident #8 stated she was in pain but did get pain medication upon request. Interview on 06/27/23 at 2:51 PM with LVN B revealed she was the nurse for Resident #8. LVN B stated she was just notified today by Resident #8 of having knee pain. LVN B stated she was going to notify hospice about the resident's new complaint of knee pain. Review of Resident #8 physician orders, dated 06/28/23 at 12:45 PM, revealed Resident #8 had an order for an x-ray of the right knee due to an increase in pain. Follow-up observation and interview on 06/28/23 at 1:50 PM of Resident #8 lying in bed. Resident #8 denied having any pain. Resident #8 stated she was still waiting on x-rays to be completed for her knee. Interview on 06/28/23 at 1:58 PM with LVN B stated she had contacted hospice nurse yesterday evening; however, there was no response. LVN B stated the hospice staff contacted LVN A earlier today (06/28/23) and x-ray orders had been obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 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 676496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation & Healthcare of Burleson 275 SE John Jones Drive Burleson, TX 76028 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 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/28/23 at 2:00 PM with LVN A stated Resident #8 had not complained of pain to her. She stated she received a text message earlier today (06/28/23) from hospice nurse informing her about obtaining x-ray orders for Resident #8. LVN A stated they were waiting for x-ray department to arrive. LVN A stated this was the first time being notified of any x-ray orders. Interview on 06/28/23 at 3:12 PM with the Hospice Nurse revealed last week on 06/22/23 Resident #8 notified her that one of the aides had turned her and she felt like her knee had popped. She stated resident complained of pain and swelling. She stated she assessed the resident; however, Resident #8 had a history of edema and swelling to her legs. She stated Resident #8 does complain of pain when getting assistance. She stated after her visit with Resident #8 on 06/22/23 she verbally notified LVN A to order x-rays for Resident #8. The Hospice Nurse stated LVN A knew about the request regarding the x-rays. The Hospice Nurse stated, the ball was dropped, when asked what that meant, The Hospice Nurse stated she had to follow-up with LVN A today (06/28/23) regarding Resident #8's x-rays. She stated the hospice aide visited Resident #8, and Resident #8 notified the hospice aide she was still waiting on x-rays to be completed. The Hospice Nurse stated she sent a text message to LVN A today 06/28/23 at 11:41 AM asking her to order the x-rays for Resident #8. By 12:45 PM, LVN A responded stating x-rays were ordered. The Hospice Nurse stated she communicated with facility staff by verbal communication before and after her visits and by phone. The Hospice Nurse stated depending on the x-ray results there could be a delay in treatment due to Resident #8 stating she heard a pop. Review of Resident #8 x-ray report, dated 06/28/23 6:06 PM, revealed no fracture identified. Interview on 06/29/23 at 11:18 AM with LVN A revealed the x-ray department came to complete the x-rays yesterday (06/28/23) evening. LVN A stated x-ray results were negative for any fractures and hospice had been notified of results. LVN A stated she was informed recently by Hospice aid and the Hospice Nurse to obtained x-rays for Resident #8. LVN A stated prior to yesterday (06/28/23) she was asked to obtained orders for Resident #8. LVN A stated she could not recall the exact date; however, Hospice Nurse reminded her yesterday about the x-rays due to resident complaining of pain. LVN A stated Resident #8 had not informed her of having any knee pain or her knee popping. She stated hospice staff communicated with her verbally or by phone. LVN A stated she might had forgotten to obtain x-ray orders for Resident #8. LVN A stated there was no risk to the resident for not obtaining x-ray on 06/22/23 due to Resident #8 not having a fracture. However, there was a risk of delay in treatment if results were different. Interview on 06/29/23 2:02 PM with the DON revealed her expectation was for her nurses and hospice staff to communicate and for her staff to keep management informed of any events. The DON stated hospice staff and facility staff communicated via phone or in-house. The DON stated her nurses were keeping her up-to-date with any change in condition regarding residents. The DON stated she was not aware of any x-rays being ordered on 06/22/23 for Resident #8. She stated she was only aware about the x-rays ordered yesterday 06/28/23. The DON stated her expectation was for her nursing staff to follow-up with any orders requested from hospice. Review of the facility's Notification of Changes policy, revised 02/10/21, revealed the following: To provide guidance on when to communicate acute changes in status to MD, NP, and / responsible party. The facility will immediately inform the resident; consult with the resident's physician, and if known, notify the resident's legal representative or appropriate family member (s) of the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 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 676496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation & Healthcare of Burleson 275 SE John Jones Drive Burleson, TX 76028 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 0776 1. An accident resulting in injury to the resident that potentially requires physician intervention. Level of Harm - Minimal harm or potential for actual harm 2. An emergency response situation that require EMS involvement. 3. A significant change in the physical, mental or psychosocial status of the resident. Residents Affected - Some 4. The need to significantly alter the resident's treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 6 of 6