Health inspection·August 23, 2023

F 0575 construction since October 2022. Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 08/23/23 at10:27 AM with the DON, the DON stated that she felt that the residents could get to the Ombudsman information on the North side of the facility with assistance by staff members. Observed the DON walking through three closed double doors to the Ombudsman information. Two of the double doors were not handicap accessible. Observed the DON having difficulty with opening the second set of double doors which appeared to be stuck. The DON reiterated her statement that she felt that residents could access the Ombudsman information with the assistance of staff members. The DON also stated that residents in wheelchairs could also access the posting with the assistance of staff. Residents Affected - Many In an interview on 08/23/2023 at 10:45 AM with Admin-in-training, policy for required postings was requested. In an interview on 08/23/23 at 1:00 PM with Admin-in-training, he stated that the facility does not have a policy regarding required postings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 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 455480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (Rehabilitation Hall Cart) reviewed for medication storage. The Rehabilitation Hall Medication Cart contained an insulin pen that had no markings for which resident it was being used for and no date of when it was opened/accessed and when it would expire. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During an observation on [DATE] at 02:29 PM of the Rehabilitation Hall medication cart, noted was a Flex Touch Tresiba Insulin Pen which was one of eight insulin pens present in the cart. There were no markings on the Flex Touch Tresiba Insulin Pen for the resident it was being used for, the dose to be given, indications for use, strength, or route of administration. Also noted was no date of when the Flex Touch Tresiba Insulin Pen had been opened/accessed or when it was to expire. During an interview on [DATE] at 02:33 PM this surveyor observed RN A asked for assistance from RN B. RN B observed the Flex Touch Tresiba Insulin Pen, confirmed there were no resident markings (the resident's name, prescribed dose, strength, and route of administration), no open/access date, and no expiration date. RN B reported that 150 units of the 300 unit in the Flex Touch Tresiba Insulin Pen had been used. RN B reported that she knew which resident the pen was for but with no markings she could not be sure. RN B reported that this would be the issue with using an unmarked medication, that if it was used for a certain resident and it did not have any markings then it could be used on the incorrect resident which could affect the residents care and condition. RN B reported that with no marking of when the Flex Touch Tresiba Insulin Pen was opened/accessed and expiration date that a resident could receive an expired dose affecting their care. RN A confirmed that she agreed with the statements made by RN B. RN A also confirmed that the Flex Touch Tresiba Insulin Pen did not have any resident markings and no open/access or expiration date. During an interview on [DATE] at 03:20 PM the DON reported that she had started a training on the medications and how to store and mark them correctly. This surveyor observed the DON present a package that she reported was from the manufacturer and not the pharmacy. The DON verified that there was one Flex Touch Tresiba Insulin Pen in the package that originally contained 4 Flex Touch Tresiba Insulin Pens and that the remaining Flex Touch Tresiba Insulin Pen did not have any ancillary information on it (prescribed dose, strength, the resident's name, and route of administration). The DON reported that they would mark each pen in the future when put in use with the resident's ancillary information (prescribed dose, strength, the resident's name, and route of administration). The DON reported that she did not feel that this was an issue currently since there was only one resident on the rehabilitation unit that was on Flex Touch Tresiba Insulin and therefore that resident would be the only one to receive the Flex Touch Tresiba insulin. The DON did not feel that an error could occur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 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 455480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Record Review of the facility provided policy titled Storage of Medications 2003 Manual revealed the following: Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 1. The provider pharmacy dispenses medication in container that meet legal requirements, including requirements of good manufacturing practices where applicable .Only Pharmacist completes transfer of medication from one container to another. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 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 455480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure dented cans were not in circulation. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure the pantry was free from bugs. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 8/21/23 @ 8:20 AM revealed the following: 1. (1) 9X12 disposable foil pan with saran wrap loosely covering top, corners open to the air, with no label or date with what appeared to be a fruit cobbler. 2. (1) box of frozen pizzas, not sealed and open to air. Observation of the walk-in pantry on 8/21/23 at 8:26 AM revealed the following: 1. (1) 7 lb. can of banana pudding dented and stored with cans in circulation. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 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 455480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106 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 (1) open bag of Froot Loops cereal, ¼ full, open to air with no seal. Level of Harm - Minimal harm or potential for actual harm 3. Plastic bin of flour, loosely covered with plastic lid, bug observed in bin. Residents Affected - Many Observation of the freezer on 8/21/23 at 2:00 PM revealed the following: 1. (1) box of muffins loosely covered with saran wrap, open to the air with no label or date. In an interview on 8/21/23 at 11:22 AM with the DM. He stated the uncovered, unlabeled foil pan in the freezer was a cobbler. DM stated a possible negative outcome for uncovered and unlabeled food, was that it could get freezer burn. In an interview on 08/21/23 at 02:30 PM with the DM, policies on food storage, pureed foods, dented cans, and pest control were requested. DM stated that a possible negative outcome for dented cans would be bacteria and he would need to throw them away. In an interview on 8/22/23 at 08:57 AM, [NAME] A stated that if she saw a bug in the food or prep area, she would throw everything away. In an interview on 8/22/23 at 9:05 AM, [NAME] B stated if she found a bug in the food, she would throw it away and wasn't sure when she saw someone spray for bugs because she is not here every day. In an interview on 8/23/23 at 2:00 PM, Admin-in-training stated the facility does not have a policy on dented cans. Record Review of policy and procedure dated 2012 titled Dry Storage & Supplies revealed: Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Open packages of food are stored in closed containers with tight covers, and dated as to when opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 6 of 6