Health inspection·May 27, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lived without her own natural teeth for years before admitting to the facility. The FM stated that the resident admitted to the facility with dentures, and to her knowledge the facility does not help Resident #1 clean her dentures, she stated the resident has full top and bottom dentures. She stated Resident #1 took pride in her appearance and would rather not wear the dentures until the missing tooth was replaced, so she would fold her dentures up in a napkin and put them in her nightstand or backpack. The FM stated they had no concerns with the resident's diet and there had been no weight loss. In an interview on 05/27/2025 at 12:32pm with HA B she stated that she provided denture care to residents who needed it and that those tasks included: washing dentures, brushing them, putting the cleaning tablets in the denture cups. She also helped residents insert their dentures by rinsing them before putting in the resident's mouth, inserting them, asking residents how the placement was, and adjusting as needed. She stated that if someone was known for refusing to wear their dentures, the staff would tell the RN. She stated she was unsure if Resident #1 wore dentures. In an interview on 05/27/2025 at 12:39pm with the DON, she stated that she began working at the facility on 4/30/2025. She stated that the process for completing MDS assessments and care plans was that the MDSC would start their assessment and build into the comprehensive assessment. The nursing team would do acute care planning, and she stated that dentures should be care planned, additionally it should be noted if they refuse to wear them. She stated the CNA's were responsible for ensuring cleanliness and whereabouts of dentures, helping residents insert and remove the assistive devices, and proper storage. In an interview on 05/27/2025 at 12:51pm with CNA A revealed she began working at the facility in December 2024, she stated that Resident #1 had not worn her dentures since she began working there. She stated Resident #1 kept her dentures in her backpack, and that she probably had the cup in her backpack at that time. She said they document denture use on the EHR under tasks, and if a resident refused to wear them, it would be put under 'service not provided'. She stated that she would let the nurse know if Resident #1 did not want to wear her dentures. She stated that Resident #1 was on a regular diet and had no known issues chewing foods. She stated the help she provided to residents with dentures is that she would help take them out of their mouths at night, put them back in the morning, help with brushing, and using the cleaning tablets. She stated she was not aware of Resident #1's dentures being broken. She stated she offered to help Resident #1 with her dentures every day, but she refused to wear them , and that lately it was because she had a dentist appointment upcoming. In an interview on 05/27/25 at 01:18 PM with the MDSC revealed she started working at the facility 3.5 years ago. She stated that Resident #1 usually did not have dentures in. Her process for conducting MDS assessments was by going to see the residents. When asked how she would know if a resident had dentures if they don't normally wear them, she stated she would have to ask the staff. She stated that 'No natural teeth or tooth fragments' should have been marked for Resident #1 on the MDS. She said she would be responsible for care planning dentures as well. She stated that the facility was in the midst of auditing care plans due to the new DON's arrival at the facility. A negative impact on the resident could be nutrition issues and weight loss. Record review of undated Facility policy titled MDS Accuracy Guidelines dated last revised 10/24/2022, reflected, The purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 2 of 5 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 05/27/2025 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 0641 identify the specific needs of the resident in accordance with the RAI Manual. Level of Harm - Minimal harm or potential for actual harm All Sections of the MDS will be encoded and signed as accurate and completed as of the date the assessment or portion of the assessment is completed. Back dating is not allowed. Residents Affected - Few Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 3 of 5 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 05/27/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 7 residents (Resident #1) who were reviewed for care plans. The facility failed to develop a person-centered care plan for Resident #1's oral care needs related to denture use despite a dentists' visit and cleaning of her dentures on 4/21/25. This failure could place residents at risk of their needs going unmet, unintentional weight loss, and/or feelings of self-consciousness. Findings included: Record review of Resident #1's comprehensive MDS, dated [DATE], indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (memory loss), heart failure, depression (extreme sadness), cataracts, glaucoma, or macular degeneration (vision difficulties), lack of coordination, need for assistance with personal care, and problem related to life management difficulty. Resident #1 MDS reflected in Section L - Oral/Dental Status an 'x' in box 'Z. None of the above were present' when indicating if the resident had natural teeth, dentures, oral abnormalities, pain, or inability to examine oral cavity. Resident #1 had a BIMS score of 13 which indicated her cognition was intact. Record review of Resident #1's care plan dated last revised on 05/26/2025 reflected no indication the resident had dentures and/or wore or refused wearing them. Record review of Resident #1's dental note dated 4/21/2025 in her EHR reflected from the dental company that the resident's dentures were inspected for fit and occlusion, debris was removed from the dentures with dental tools and instruments. No pain or discomfort were noted by patient, and it was noted there was a tooth broken on her top denture, in the treatment plan notes it was stated they were to make a copy of the denture in order to replace the broken tooth. In an observation on 05/27/2025 at 12:34pm of Resident #1's bathroom revealed a denture toothbrush, and denture cleaning tablets in their sealed packages on her bathroom sink, his dentures were not visible in the bathroom. In an interview and observation on 04/30/2025 at 1:38pm of Resident #1's room revealed her teeth were in her backpack on the ground. Resident #1's dentures had a tooth missing on the top , and she stated those were the 6th pair of dentures she had received. She said she needed glue, but the dental company told her not to put them in. She asked if she looked bad without her dentures in because she takes pride in her appearance. Resident #1 was observed on multiple occasions without her dentures in, including during lunch. In an interview on 05/27/2025 at 11:57 AM with Resident #1's FM revealed that the resident had lived without her own natural teeth for years before admitting to the facility. The FM stated that the resident admitted to the facility with dentures, and to her knowledge the facility does not help Resident #1 clean her dentures, she stated the resident has full top and bottom dentures. She stated Resident #1 took pride in her appearance and would rather not wear the dentures until the missing tooth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 4 of 5 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 05/27/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was replaced, so she would fold her dentures up in a napkin and put them in her nightstand or backpack. The FM stated they had no concerns with the resident's diet and there had been no weight loss. In an interview on 05/27/2025 at 12:32pm with HA B she stated that she provided denture care to residents who needed it and that those tasks included: washing dentures, brushing them, putting the cleaning tablets in the denture cups. She also helped residents insert their dentures by rinsing them before putting in the resident's mouth, inserting them, asking residents how the placement was, and adjusting as needed. She stated that if someone was known for refusing to wear their dentures, the staff would tell the RN. She stated she was unsure if Resident #1 wore dentures. In an interview on 05/27/2025 at 12:39pm with the DON, she stated that she began working at the facility on 4/30/2025. She stated that the process for completing MDS assessments and care plans was that the MDSC would start their assessment and build into the comprehensive assessment. The nursing team would do acute care planning, and she stated that dentures should be care planned, additionally it should be noted if they refuse to wear them. She stated the CNA's were responsible for ensuring cleanliness and whereabouts of dentures, helping residents insert and remove the assistive devices, and proper storage. In an interview on 05/27/2025 at 12:51pm with CNA A revealed she began working at the facility in December 2024, she stated that Resident #1 had not worn her dentures since she began working there. She stated Resident #1 kept her dentures in her backpack, and that she probably had the cup in her backpack at that time. She said they document denture use on the EHR under tasks, and if a resident refused to wear them, it would be put under 'service not provided'. She stated that she would let the nurse know if Resident #1 did not want to wear her dentures. She stated that Resident #1 was on a regular diet and had no known issues chewing foods. She stated the help she provided to residents with dentures was that she would help take them out of their mouths at night, put them back in the morning, help with brushing, and using the cleaning tablets. She stated she was not aware of Resident #1's dentures being broken. She stated she offered to help Resident #1 with her dentures every day, but she refused to wear them , and that lately it was because she had a dentist appointment upcoming. Review of the facility's policy titled Comprehensive Care plans dated 2/10/2021 reflected, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment. alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676496 If continuation sheet Page 5 of 5