Health inspection·May 23, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach. The CNA stated she was working the 500 hall were Resident #2 resided but she did notice his call light on the floor. The CNA stated that it was everyone's responsibility to ensure that a residents call light was within reach. The CNA stated if a resident call light was not in reach, they would not be able to call for assistance if they needed something. An interview with the ADM on [DATE] at 2:45pm, the ADM stated that anyone that entered the resident's room would be responsible for ensuring that the call light was in reach. The ADM stated if a residents call light was not in reach, then the resident would not be able to call for assistance and the resident needs would not be met. An interview with the DON on [DATE] at 3:15pm, the DON stated that anyone that entered the resident's room would be responsible for ensuring that the call light was in reach. The DON stated that CNAs and HAs should be ensuring the residents call light was within reach when they made rounds. The DON stated if a residents call light was not in reach, then the resident would not be able to call for assistance. Review of the facility's Call Light Response policy, dated [DATE], reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff or centralized location to ensure appropriate response. Process 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.). 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 05/23/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment, for 1 of 7 residents (Resident #1) reviewed for residents' rights. The facility failed to keep Resident #1's room free of trash. This failure could lead to residents being harmed due to falls, feeling uncomfortable in their surroundings, or becoming sick due to spread of germs. Findings Included: Record review of Resident #1's face sheet dated 05/23/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included seizure disorder (uncontrollable shaking that is rapid and rhythmic, with the muscles contracting and relaxing repeatedly), gastrointestinal (the organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces), acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic or remembering information), and type 2 diabetes mellitus with diabetic nephropathy (a condition that could damage blood vessels in the kidney that filters waste from the blood). Record review of Resident #1's quarterly MDS completed on 05/01/24 revealed a BIMS score of 14 which indicated cognitively intact. During an interview and observation 05/23/24 9:40am Resident #1 had two clear trash bags with what appeared to be food and other items in them. One trash bag was tied to a bedside table to the left of Resident #1's bed and the other trash bag was in Resident #1's trash can. Resident #1 stated that her trash hasn't been taking out in two days. Resident #1 stated she has asked for the trash to be remove but staff haven't removed it. During an observation on 05/23/24 at 12:35pm Resident #1's trash was still located in the same area from the initial observation. During an observation on 05/23/24 at 2:35pm Resident #1's trash was still located in the same area from the initial observation. An interview with the ADM on 05/23/24 at 2:45pm, the ADM stated that CNAs and housekeepers were responsible for taking out the trash and the trash should be taken out once a shift or as needed. The ADM stated that he was not aware that Resident #1's trash hadn't been taken out. The ADM stated that the HD was responsible for ensuring the housekeepers are taken trash out daily. The ADM stated that if the trash was not taken out then that could be an infection control issues, insect issue, the room may smell and that wouldn't be sanitary. An interview with the DON on 05/23/24 at 3:15pm, the DON stated housekeeping was responsible for taking out residents' trash daily. The DON stated that housekeeping takes out trash at least once a (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 05/23/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few day or when needed. The DON stated that the HD was responsible for ensuring the housekeeper were taken out trash daily. The DON stated that if a resident's trash wasn't taken out then that could cause insects, infection control issues, and that would be unsanitary. An interview with the HD on 05/23/24 at 2:55pm, the HD stated that both the housekeepers and nurse take out the residents' trash daily. The HD stated that his expectations were that the housekeepers take trash out once in the morning and before they leave for the day. The HD stated he was not aware Resident #1 trash wasn't taken out. The HD stated if a resident's trash wasn't taken out then that could cause odors, insects, or the resident could get sick. Record review of facility policy titled Housekeeping Standards not dated reflected, 1. The facility will provide a clean and sanitary living environment for the physical and emotional well-being of the resident. The housekeeping program will address itself to upgrading the professionalism of housekeeping personnel and the prevention of the spread of disease and infection through proper and effective disinfection procedures. 2. The facility will provide a written quality control program that insures a clean safe, pleasant, and functional environment for residents, staff and visitors. The program will provide the following: A. Frequency scheduling - for every room, department, and area both inside and outside the facility. Frequencies based on the individual needs of each resident and facility condition . 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 05/23/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 7 residents (Resident #2) reviewed for physical environment. Residents Affected - Few The facility failed to ensure Resident #2 had a working call light in the room. This failure could place residents at risk of not being able to get assistance when needed. Findings included: Record review of Resident #2's face sheet dated [DATE], reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of edema (swelling caused by fluid trapped in your body's tissues), unspecified lack of coordination (coordination impairment or loss of coordination), muscle weakness (decrease in muscle strength), muscle wasting and atrophy(decrease in size and wasting muscle tissues), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic or remembering information). Review of Resident #2's Quarterly MDS Assessment, dated [DATE], reflected he had a BIMS score of 12 indicating moderately impaired. Resident #2's Quarterly MDS assessment also reflected he required substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear. Record review of Resident #2's care plan dated [DATE] reflected Resident #2 was care planned for impaired cognitive function, communication problem, and limited physical mobility. During an interview and observation [DATE] 9:50am Resident #2's call light was observed to be on the floor on the left side of his bed. Resident #2 stated that his call light was often on the floor and that his call light does not work . Resident #2 stated that he noticed his call light wasn't working on [DATE]. Resident #2 stated that the nurses was aware that his call light was not working. Resident #2 stated he would get in his wheelchair and go to the nurse's station for assistance or yell for help when a nurse passed his room. Resident #2 was observed pressing the call light and neither the light in his room or above his doorway illuminated when the call light was pressed. An interview with the ADM on [DATE] at 2:45pm, the ADM stated that all resident call lights should be functioning properly. The ADM stated he was not aware Resident #2 call light was not working. The ADM stated it was maintenance responsibility for ensure call lights were working properly. The ADM stated that he and the maintenance director replaced call light that were not working immediately. The ADM stated the facility had several call light replacements on hand if there were needed. The ADM stated that if a residents call light was not working then the resident would not be able to call for assistance and the residents needs would not be met. An interview with the DON on [DATE] at 3:15pm, the DON stated that all resident call lights should be functioning properly. The DON stated that maintenance was responsible for ensure the call lights were working. The DON stated that the maintenance director and the ADM replaced call lights that weren't working properly immediately. The DON stated the facility had call light replacements on hand. The DON stated that if a residents call light was not working then the resident would not be able to (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 05/23/2024 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 0919 call for assistance and the residents needs would not be met. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Call Light Response policy, dated [DATE], reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff or centralized location to ensure appropriate response. Residents Affected - Few Process 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 6 of 6