Health inspection·October 2, 2024

F 0550 revealed the following: Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Few Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Record review of policy for Dignity, dated revised February 2021, states: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; Record review of the facility provided policy titled, Texas State [NAME] of Rights of the Elderly, undated, revealed the following: In addition to other rights an elderly individual has, as a citizen, rights provided by this section. .3. An elderly individual should be treated with respect, consideration, and in recognition of the individual's dignity and individuality. An elderly individual should receive personal care and private treatment. Record review of the facility provided policy titled, Incontinent Care/Perineal Care with or without a Catheter, dated 12/2017 reveals no mention of a foley catheter bag privacy cover for residents indwelling foley catheters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 2 of 28 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 10/02/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #10) of 20 residents reviewed for advanced directives. Resident #10 had a DNR in her record with no date for the physician signature. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Resident #10 Record review of the clinical record dated 10/01/2024, for Resident #10 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with (acute) exacerbation, sleep apnea, lack of coordination, weakness, anemia, type 2 diabetes mellitus with elevated blood sugar, elevated calcium levels in the blood, and heart failure. Record review of the clinical record for Resident #10 revealed the last MDS dated [DATE] with a BIMS score of 12 indicting she was moderately cognitively impaired and a functional status indicating she required maximal assistance with the majority of activities. Record review revealed a DNR in Resident #10's clinical record dated 01/02/2024 with no date of signature by the physician in the Physician Statement section. An interview on 10/02/24 at 10:44 AM with ADON revealed that a negative outcome for not having the DNR dated makes the DNR not applicable and the resident would receive a full code and then we are in trouble. An interview on 10/02/24 at 02:09 PM with DON revealed that a negative outcome of not having the DNR dated essentially makes the form void, and we would not follow the final wishes of that resident. Record review of the facility provided policy titled ADVANCED DIRECTIVE GLOSSARY OF TERMS undated, revealed no information on the necessary signatures or/and dates on which the document would need to be valid. Record review of facility provided policy titled, Texas State [NAME] of Rights of the Elderly, undated, revealed the following: In addition to other rights an elderly individual has, as a citizen, rights provided by this section. .3. An elderly individual should be treated with respect, consideration, and in recognition of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 3 of 28 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 10/02/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm individual's dignity and individuality. An elderly individual should receive personal care and private treatment. .13. An elderly individual may participate in planning the individual's total care and medical treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 4 of 28 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 10/02/2024 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 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, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical and nursing needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #50) of 19 residents reviewed for care plans. The facility failed to update the wound care orders in Resident #50's care plan. This failure could put residents at risk of not receiving necessary care and treatment. Findings included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar), acquired absence of left leg below the knee, and acquired absence of right leg below knee. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's active orders revealed the following wound treatment order for his left leg amputation site with a start date of 08/21/24: Left BKA. Please soak with [brand name of wound cleanser] for 30 minutes prior to dressing change. Place [brand name of gauze used to promote wound healing] into wound bed then apply a thin layer of [brand name of antibiotic cream] to [brand name of absorbent dressing that helps with wound healing] cut to fit wound and apply. Cover with [absorbent pad] and secure with tape. Wrap localluwith (type-o for locally with) [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] secure with [brand name for elastic spiderweb-like bandage]. Every day shift every Mon, Wed, Fri for Left BKA. Record review of Resident #50's discontinued orders revealed the following wound treatment order for his left leg amputation site with a start date of 07/18/24 and an end date of 08/21/24: Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to peri-wound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze that promotes wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. every day shift every Mon, Wed, Fri for Left BKA Record review of Resident #50's care plan dated 09/03/24 revealed the following: . I have actual impairment to skin integrity r/t BKA I will have no complications r/t surgical wound through the review date. Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 5 of 28 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 10/02/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few periwound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze used to promote wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread over foam dressing used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. No mention was made of the new wound treatment order with start date of 08/21/24. During an observation and interview on 09/30/24 at 10:01 AM Resident #50 was seated in his w/c in his room. He stated staff do not change the bandage on his left leg amputation as often as ordered. During an observation and interview on 10/02/24 at 08:54 AM MDS LVN stated she was responsible for resident care plans. She stated when a resident received new orders she put them in (the care plan) the very next day. She stated there was a report she could run from PCC that would tell her each day what orders were new for which residents. MDS LVN stated, I run the report and see what orders were changed and I put them all into the care plans. When asked why the orders for Resident #50's wound care were not updated in his care plan she looked in PCC and said, I do see where it changed and I might have just overlooked this one. She stated a possible negative outcome of not having the orders in the care plan updated was, We don't have treatment properly documented. During an interview on 10/202/24 at 01:01 PM DON stated not documenting changed orders for Resident #50's wound care in his care plan could prolong his healing process and provide potential for more injury to the wound and of course infection. During an interview on 10/02/24 at 01:27 PM ADON B stated a possible negative outcome of not having a resident's orders updated in the care plan was, Treatment won't match. During an interview on 10/02/24 at 01:44 PM ADON A stated I need the care plan to match the orders. She said a possible negative outcome of not updating a resident's care plan with new orders was staff could not look at the care plan and know what is going on. Record review of facility policy titled Care Plans, Comprehensive Person-Centered and dated December 2016 revealed the following: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: . g. Receive the services and/or items included in the plan of care; . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 6 of 28 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 10/02/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive, person-centered care plan, and the resident's choices for 1 (Resident # 50) of 20 residents reviewed for quality of care. Residents Affected - Few The facility failed to provide wound care for Resident #50 as ordered. This failure could place residents at risk of poor healing, worsening infection, and increased pain. Findings Included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar), acquired absence of left leg below the knee, and acquired absence of right leg below knee. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's care plan dated 09/03/24 revealed the following: . I have actual impairment to skin integrity r/t BKA I will have no complications r/t surgical wound through the review date. Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to periwound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze used to promote wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread over foam dressing used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. No mention was made of the new wound treatment order with start date of 08/21/24. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's active orders revealed the following wound treatment order for his left leg amputation site with a start date of 08/21/24: Left BKA. Please soak with [brand name of wound cleanser] for 30 minutes prior to dressing change. Place [brand name of gauze used to promote wound healing] into wound bed then apply a thin layer of [brand name of antibiotic cream] to [brand name of absorbent dressing that helps with wound healing] cut to fit wound and apply. Cover with [absorbent pad] and secure with tape. Wrap localluwith (type-o for locally with) [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] secure with [brand name for elastic spiderweb-like bandage]. Every day shift every Mon, Wed, Fri for Left BKA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 7 of 28 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 10/02/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #50's TAR for the month of September 2024 revealed he did not receive wound care on Friday 09/13/24 or Wednesday 09/18/24. Record review of Resident #50's progress notes from 09/01/24 to 10/01/24 revealed no mention of Resident #50 having an appointment outside the facility on 09/13/24 or 09/18/24. There was one progress note on 09/13/24 and it did not pertain to wound care. There were no progress notes on 09/18/24. Record review of the dashboard (first page that opens for facility, where resident appointments were often documented, according to staff interviews below) in PCC from 03/01/24-10/02/24 revealed no appointment scheduled for Resident #50 on 09/13/24 or 09/18/24. During an observation and interview on 09/30/24 at 10:01 AM Resident #50 was seated in his w/c in his room. He stated staff do not change the bandage on his left leg amputation as often as ordered. During an interview on 10/02/24 at 08:27 AM DON stated the day nurse on duty on 09/13/24 was LVN F and the day nurse on duty on 09/18/24 was LVN M. During an interview on 10/02/24 at 08:50 AM LVN F stated ADON A was responsible for Resident #50's wound care on 09/13/24 because he was unhappy with her (LVN F). LVN F stated she found Resident #50 vaping in his room and his vape paraphernalia was taken from him; therefore, he was angry with her and ADON A took over wound care for a period. She stated a possible negative outcome of not providing wound care as ordered was the wound could get infected or get worse. During an observation and interview on 10/02/24 at 08:57 AM LVN F stated she remembered Resident #50 had appointments on 09/13/24 and did not return to the facility until 04:30 PM. She stated she remembered ADON A coming down the hall multiple times looking for Resident #50 to provide his wound care. When asked if she was certain the date she was remembering was 09/13/24, LVN F said she was certain. When asked if Resident #50's appointments and ADON A looking for Resident #50 on 09/13/24 were documented anywhere in his medical record LVN F stated she knew she documented that day. She sat down at a computer and began searching through progress notes for Resident #50 as well as through the dashboard of PCC where she stated sometimes resident's appointments were documented. She searched for approximately 4 minutes and concluded, I know I remember writing it down, maybe that was another day. She stated she was unable to find an appointment for Resident #50 noted on the dashboard in PCC. She stated nurses documented appointments in PCC most of the time. She continued, I know there was one day, it has to be that day (09/13/24) what she (ADON A) kept looking for him (Resident #50) so she could do it (wound care) and he was gone to an appointment, but I can't find anything in here (EHR). During an interview on 10/02/24 at 01:01 PM DON stated charge nurses were responsible for wound care. She stated Resident #50 was so unkind to our charge nurses that she had ADON A start doing his wound care, but the floor nurses were responsible to ensure it was performed. DON stated a possible negative outcome of not doing wound care as ordered was infection and a prolonged healing process. She stated if wound care was not performed as ordered the resident would not receive the care needed. DON stated if a resident had an appointment it should be in the progress notes. During an interview on 10/02/24 at 01:27 PM ADON B stated if wound care was not performed as ordered the wound could get worse and affect the healing process and/or possible infection. During an interview on 10/02/24 at 01:44 PM ADON A stated she was responsible for Resident #50's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 8 of 28 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 10/02/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound care for a period of time while he was needing a wound vac. She stated she was not responsible for his care on 09/13/24. She stated on that date the charge nurse was responsible for his wound care. ADON A stated staff were to document resident appointments on the dashboard of PCC. She stated Resident #50 did not experience a negative outcome due to not having his wound care performed as ordered. An attempted telephone interview on 10/02/24 at 02:17 PM with LVN M was unsuccessful. The phone was answered but no one spoke. Record review of facility policy titled Charting and Documentation and dated July 2017 revealed the following: . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. 2. The following information is to be documented in the resident medical record: . c. Treatments or services performed; . 7. Documentation of procedures and treatments will FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 9 of 28 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 10/02/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 7 staff (RN J) reviewed for nursing services. The facility failed to ensure the following: -RN J used proper hand hygiene when administering medications -RN J observed resident consume their medications at time of administration. -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J locked and secured medication cart during medication administration. -RN J used proper hand hygiene or donning of gloves before breaking a pill with her hands for Resident #57. This facility's failure placed residents receiving medications at risk for drug diversion, drug overdose, and decrease efficacy of medications. These failures could expose residents to a risk of contracting viral infections, secondary infections and other communicable diseases. Findings included: Observation on 09/30/24 at 08:35 AM revealed the medication cart on Hall 100 unlocked and unattended. Observation on 09/30/24 at 08:37 AM RN J came out of Resident #57's room and took the medication cart further down the hall. Observation on 09/30/24 at 08:39 AM revealed Resident #57 was lying on her back with her eyes closed, and a medication cup was observed on Resident #57's bedside table with several medications in it. Resident #57 opened her eyes and was asked if this was a regular occurrence with the medications just being left on her bedside table, Resident #57 stated that it was not, and she was really not sure why it happened today. Observation on 09/30/24 at 08:45 AM revealed Resident #10 with a medication cup on her breakfast tray with medications in it. When Resident #10 was asked why medications weren't taken with the nurse, Resident #10 stated because she can't take it with water and will put the pills in her oatmeal. Interview on 09/30/24 at 08:53 AM with CNA L who was working Hall 100 stated that the leaving of medications has been observed by her a few times. CNA L stated, It isn't supposed to, but yes it does happen regularly with this nurse and another nurse. CNA L stated that the negative outcome could be that another resident could get a hold of the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 10 of 28 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 10/02/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/30/24 at 12:12 PM of RN J assisting unidentified resident with her mid-day meal. RN J took her left thumb and scooped some of the unidentified resident's food back on to the plate of resident. RN J then proceeded to lick her thumb and continued to feed the unidentified resident. No hand hygiene was performed before, during, or after the assistance with the meal. Observation on 10/01/24 at 09:18 AM RN J came to room and provided Resident #57 with her medications. Resident #57 asked RN J to break a pill for her. RN J grabbed pill from resident and broke pill with bare hands. No gloves and hand washing took place before breaking pill for resident. Interview on 10/01/24 at 09:22 AM with Resident #57 was asked if the staff normally stayed in the room with her when she was taking her medication and she stated, Most of the time. Interview on 10/01/24 at 01:50 PM with RN J stated that a negative outcome for leaving the medication cart unlocked and unattended could be that someone could get into it. Interview on 10/01/24 at 01:51 PM with RN J stated that a negative outcome for leaving pills on the bedside table would be that someone else could get a hold of those pills. Interview on 10/01/24 at 2:11 PM with ADM stated that there was not a policy regarding the security of Medication carts. Interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome of having an incompetent nurse was it could lead to medication errors, inaccurate assessments and the overall care for residents could be lacking. Interview on 10/02/24 at 02:09 PM with DON stated that a negative outcome for having an incompetent nurse could lead to injury to resident, medication errors, and documentation errors. Record review of the facility in-service dated 03/13/2024 regarding medication carts, HIPPA, abuse and neglect, infection control, and meds at bedside. RN J did attend this in-service, signature was present on sign-in sheet. Record review of facility in-service dated 06/20/2024 regarding medication administration, med carts, med rooms, meds aat bedside, shower cabinets, disposal of razors, closets, narcotic waste documentation. RN J did attend this in-service, signature was present on sign-in sheet. Record review of RN J's coaching form, undated, revealed that coaching and re-education was provided on the following areas of concerns: 1. Medication cart will always be locked when out of sight of nurse. 2. No further medications will be left sitting on bedside tables, nurses will hand resident medication and stad by to ensure resident takes medication. 3. No further setting up medications prior to giving. 4. Review in 30 days. Dates of occurrences that these concerns were noted were June 18th, 25th, and July 8th, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 11 of 28 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 10/02/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Record review of personal file for RN J, revealed an Employee Disciplinary Review for RN J, dated 07/26/2024 revealed that on Various dates the medication cart was left unlocked. Record review of personal file for RN J, revealed an Employee Disciplinary Review for RN J, dated 10/01/2024 revealed that RN J was terminated from the facility due to multiple disciplinary reports. Residents Affected - Some Record review of the facility provided policy titled, Competency of Nursing Staff, revised October 2017, revealed the following: Policy Statement 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of resident, as identified through resident assessments and described in the plans of care. .4. Competency in skills and techniques necessary to care for residents' need includes but is not limited to competencies in areas such as: . .f. basic nursing skills; . .i. medication management; . .k. Infection control; . Record review of the facility provided policy titled, Hand Washing, undated, revealed no mention of when the appropriate times to perform hand hygiene would be. Record review of the facility provided policy titled, Crushing Medications, revised April 2007, revealed the following: .4. If a partial tablet is ordered, the nurse should break the tablet on the scored line. Hands must be cleaned before breaking the tablet. The other half tablet is to be discarded. (Note: The Vendor Pharmacist may be contacted to provide the half-tablet doses, thus eliminating the need for the nurse to split the tablets in half.) Record review of the facility provided policy titled, Storage of Medications, revised April 2007, revealed the following: .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 12 of 28 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 10/02/2024 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 0726 others. Level of Harm - Minimal harm or potential for actual harm .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 13 of 28 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 10/02/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #6) of 5 residents reviewed for unnecessary medication. Facility failed to ensure Resident #6's PRN order for psychotropic medication was limited to 14 days. This failure could place residents at risk of oversedation which could lead to falls and/or injuries as well as affect their quality of life. Findings Included: Record review of Resident #6's admission record dated 10/01/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), depression, and anxiety disorder. Record review of Resident #6's care plan completed 09/09/24 revealed she used antianxiety medications for anxiety disorder. The facility was to give the medications as ordered by the physician and monitor Resident #6 for side effects. Record review of Resident #6's annual MDS completed on 09/16/24 revealed the following: Section C: Resident #6 had a BIMS of 12 which indicated moderately impaired cognition. Section D: Resident #6 had felt down, depressed, or hopeless 2-6 of the 7 days in the look back period. Resident #6 felt lonely or isolated from those around her often. Section I: Resident #6 had a diagnosis of Anxiety Disorder. Section N: Resident #6 received anti-anxiety medication during the 7 days of the look back period. Record review of Resident #6's active order revealed an order for Alprazolam, an antianxiety medication, with the following directions: Give 1 tablet by mouth every 6 hours as needed for Anxiety. The order had a start date of 11/08/23. Record review of Resident #6's progress notes from 05/31/24-10/01/24 revealed no progress note from physician indicating need for continued PRN order for antianxiety med. Record review of Resident #6's EHR under the MISC tab revealed 4 physician's notes from the last 4 months with dates of 06/06/24, 07/10/24, 09/05/24, and 09/20/24. Record review of Resident #6's physician's note dated 06/06/24 indicated her anxiety disorder was Stable on current treatment. Has low dose [Brand name of antianxiety medication] PRN. There was no mention of duration of the PRN order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 14 of 28 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 10/02/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #6's physician's note dated 07/10/24 indicated her anxiety disorder was Stable on current treatment. Has low dose [Brand name of antianxiety medication] PRN. There was no mention of duration of the PRN order. Record review of Resident #6's physician's note dated 09/05/24 indicated her anxiety disorder was Stable on current treatment. There was no mention of the PRN order or its duration. Record review of Resident #6's physician's note dated 09/20/24 indicated her anxiety disorder was Stable on current treatment. There was no mention of the PRN order or its duration. Record review of Resident #6's MAR for June 2024 revealed she was given her PRN antianxiety medication 5 times that month on the following dates 06/09, 06/13, 06/14, 06/18, and 06/19. Record review of Resident #6's MAR for July 2024 revealed she was given her PRN antianxiety medication 5 times that month on the following dates 07/09, 07/21, 07/25, 07/26, and 07/31. Record review of Resident #6's MAR for August 2024 revealed she was given her PRN antianxiety medication 12 times that month on the following dates 08/06, 08/08, 08/09, 08/13, 08/15, 08/19, 08/20 (she was given the medication two times on this date), 08/22, 08/24, 08/27, and 08/28. Record review of Resident #6's MAR for September 2024 revealed she was given her PRN antianxiety medication 11 times that month on the following dates 09/03, 09/04 (she was given the medication two times on this date), 09/05, 09/06, 09/10, 09/12, 09/17, 09/18, 09/20, and 09/25. During an interview on 10/02/24 at 01:06 PM DON stated PRN orders for psychotropic drugs were good for 14 days. She stated for a PRN order for psychotropic drug to be extended past 14 days the physician would have to write that a change in the medication might cause adverse reaction in the resident. She stated a possible negative outcome of a PRN order for a psychotropic drug extending past 14 days was over sedation, dependance. DON stated she did not know why Resident #6 had a PRN antianxiety medication order that had not been discontinued after 14 days. During an interview on 10/02/24 at 01:32 PM ADON B stated PRN orders for psychotropic medications were limited to 14 days. She stated nurses who input PRN orders for psychotropic medications were to put them in for 14 days. She said a possible negative outcome of PRN orders for an antianxiety medications being continued past 14 days was dependent on the case, the resident's response to the medication, as well as on how long the resident had been on the medication as PRN at home prior to admission. During an interview on 10/02/24 at 01:48 PM ADON A stated PRN orders for psychotropic medications should have a stop date when put in to the EHR by nurses. She said a possible negative outcome of a PRN order for antianxiety medication extending past 14 days was sedating them (residents) too much. Record review of facility policy titled Psychotropic Drugs and dated 10/25/17 revealed the following: . The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, . and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: . (iii) Anti-anxiety . The facility must ensure that- . 4. PRN orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 15 of 28 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 10/02/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN Orders for Psychotropic . Medications In certain situations, psychotropic medications may be prescribed on a PRN basis, such as while the dose is adjusted, to address acute or intermittent symptoms or in an emergency. However, residents must not have PRN orders for psychotropic medications unless the medication is necessary to treat a diagnosed specific condition. The attending physician or prescribing practitioner must document the diagnosed specific condition and indication for the PRN medication in the medical record. Event ID: Facility ID: 455480 If continuation sheet Page 16 of 28 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 10/02/2024 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 - Some 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. Based on observations, interviews, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall 100 medication cart and Hall 400 medication cart) of 3 medication carts reviewed for medication storage. -Hall 100 medication cart left unlocked and unattended. -Hall 100 medication cart revealed 4.5 lose pills in the bottom of medication drawers. -Hall 100 medication cart had insulin for Resident #41 with no open date on her Humulin N insulin. -Medication was left on beside table for Resident #57 by RN J -Medication was left on beside table for Resident #10 by RN J -Medication was left on bedside table for Resident #7 by LVN F -Hall 400 medication cart revealed expired control solutions for calibration of the glucometer machine. The facility's failure placed residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings included: Observation on 09/30/24 at 08:35 AM revealed the medication cart on Hall 100 unlocked and unattended. Observation on 09/30/24 at 08:39 AM revealed Resident #57 was lying on her back with her eyes closed, and a medication cup was observed on Resident #57's bedside table with several medications in it. Resident #57 opened her eyes and was asked if this was a regular occurrence with the medications just being left on her bedside table, Resident #57 stated that it was not, and she was really not sure why it happened today. Observation on 09/30/24 at 08:45 AM revealed Resident #10 with a medication cup on her breakfast tray with medications in it. When Resident #10 was asked why medications weren't taken with the nurse, Resident #10 stated because she can't take it with water and will put the pills in her oatmeal. In an interview on 09/30/24 at 08:53 AM with CNA L who was working Hall 100 stated that the leaving of medications has been observed by her a few times. CNA L stated, It isn't supposed to, but yes it does happen regularly with this nurse and another nurse. CNA L stated that the negative outcome could be that another resident could get a hold of the medications. Observation on 09/30/24 at 09:31 AM revealed Resident #7 with a medication cup on her bed side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 17 of 28 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 10/02/2024 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 - Some table and several medication cups stacked on the nightstand. Resident #7 stated staff leave meds with her 60-75% of the time to take on her own. Resident #7 stated staff did not do that when she first got here. Observation on 09/30/24 at 09:37 AM revealed 4.5 lose pills found in the drawers of Hall 100 medication cart. 1 pill identified as Lorazepam 0.5mg was discovered in the Narcotic lock box. All other pills were unidentified by RN J. Insulin for Resident #41's Humulin N did not have an open date on it. According to manufacturer insert it should be discarded after 31 days of opening. In an interview on 09/30/24 at 09:40 AM with RN J, she was asked what the process was when medications are found in the medication cart. RN J stated that she takes them to her DON. RN J then took pills to the DON's office. In an interview on 09/30/24 at 09:51 AM with DON stated that the medications would be reconciled with the Narc count. DON asked RN J if the count was correct this morning. RN stated that it was. The count was confirmed and accurate. The Resident that the medication belonged to passed away last week. DON stated that nurses were responsible for the order and cleanliness of the carts that were use. In an interview on 09/30/24 at 09:55 AM RN J stated that a negative outcome for lose medications in the medication carts would be that someone was missing a medication and with the Lorazepam it could lead to increased anxiety for the resident. Observation on 09/30/24 at 10:05 AM revealed a blood glucose control solution that was dated 07/27/2023 in Hall 400 medication cart. LVN F was asked if this was used today. LVN F stated that it was used this morning to calibrate the glucometer for the day. In an interview on 09/30/24 at 10:16 AM LVN F was asked what a negative outcome was for using controls that were expired. LVN F stated that the reading could be too high or too low for the calibration. In an interview on 09/30/24 at 12:10 PM Resident #7 stated when staff left her pills with her she originally thought they were trusting her but now she thinks they were being lazy because it would not take long to stand and watch me swallow them. And there are people in here who have poor memory and I don't think it is safe for them. In an interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome for leaving the medication cart unlocked was We do have residents that wander both with and without dementia and they could get a hold of the medications in the carts. ADON stated that the negative outcome for leaving medications at the bedside was the resident could choke, hoard them for later and the medications would not be effective or therapeutic. ADON stated that the negative outcome for having lose medications and expired medications was that residents could go without a dose of medications which could lead to medication errors. The expired medications would not be effective. In an interview on 10/02/24 at 02:09 PM with DON stated that a negative outcome for leaving the medication cart unlocked was other residents or individuals could walk by and get into the cart. DON proceeded to give the negative outcome for having medications left at bedside could lead to the wrong person taking the medications and the resident choking on the medication. DON stated that the undated medications could not be effective because it could be out of date. In regard to the lose pills it could lead to a medication error and a missed dose for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 18 of 28 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 10/02/2024 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 Record review of the facility provided policy titled, Storage of Medications, revised April 2007, revealed the following: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Residents Affected - Some .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the facility provided policy titled, Administering Medications, revised December 2012, revealed the following: .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. .16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 19 of 28 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 10/02/2024 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 professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. Cooks C, D, and E failed to perform hand hygiene appropriately when preparing foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: In an observation and interview on 9/30/24 at 11:30 am, [NAME] C was observed washing hands and putting gloves on. [NAME] C touched various kitchen surfaces in the kitchen. [NAME] C touched the prep counter, picked up a bag of ham chunks, attempted to open the bag, put the bag on the counter, and went to another area of the kitchen. [NAME] C opened the drawers in the kitchen and closed them then went to a different area of the kitchen, picked up the scissors and walked back to the preparation table. [NAME] C cut the bag of ham chunks open, then took disposable individual plastic serving cups and lids out of the packages. [NAME] C arranged the disposable individual serving cups in a line and picked up the bag of ham. [NAME] C attempted to pour the ham into the serving cups. [NAME] C then put her gloved hand inside the bag of ham chunks and took a handful of ham out and placed the ham into the individual serving cups. [NAME] C reached into the bag again with her gloved hand and filled more containers with ham. [NAME] C was asked if she realized she had changed tasks and had touched various kitchen surfaces then touched the food with contaminated hands. [NAME] C said, I forgot to change my gloves? [NAME] C continued to pick up ham with her gloved hand and place ham into the container cups. [NAME] C then picked up a pen and began making labels for the ham. [NAME] C snapped lids on the cups and carried the cups of ham to the salad bar in the dining room. In an observation and interview on 9/30 /24 at 11:55 am, [NAME] E was observed in the kitchen preparing dessert cups for the noon meal. [NAME] E was observed washing hands and putting on fresh gloves. [NAME] E touched various kitchen surfaces. [NAME] E touched the pans of desserts on the edges of the pan. [NAME] E picked up a knife and cut the dessert into slices touching the edges of the pan to turn it around. [NAME] E placed dessert cups onto the preparation table and unstacked the dessert cups. [NAME] E began plating the dessert and while attempting to put the dessert into the dessert cups with her spatula, [NAME] E used her gloved hand to swipe the dessert off the spatula into the dessert cup. [NAME] E was also observed using her gloved hand to push the dessert down into the dessert cups. [NAME] E said, So do I need to wash and change my gloves? [NAME] E stated she was not aware she had touched the food with her gloved hands. She stated she should have used a serving spoon to plate the dessert and should not have touched the desserts. She stated residents could get sick from contaminated food. In an observation and interview on 9/30/24 at 12:30 pm, [NAME] D washed his hands and changed his gloves. [NAME] D touched various kitchen surfaces then picked up a plate and a serving utensil. [NAME] D plated two enchiladas and used his fingers to push the enchiladas onto the plate off the serving spatula. [NAME] D picked up a plate cover, placed the plate cover on the plate then picked up a clean plate. [NAME] D picked up the serving spatula and placed 2 enchiladas on the plate. [NAME] D used his fingers to push the enchiladas off the serving spatula onto the plate. [NAME] D stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 20 of 28 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 10/02/2024 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 should not have touched the food with his hand and should have washed his hands and changed his gloves. He stated not changing gloves and touching food could cause food borne illness to the residents. During an observation and interview on 9/30/24 at 12:25 am, [NAME] C was observed touching the prep table and various kitchen surfaces while cutting the lunch dessert into squares. [NAME] C touched the edges of the dessert pans, the serving utensils and various surfaces in the kitchen. [NAME] C was observed getting dessert cups from the shelf and went back to the prep table. [NAME] C picked up dessert cups and placed them on a serving tray in single order filling up the tray. [NAME] C picked up the serving cups and one by one began filling the cups with the dessert. [NAME] C began using her hands to push the dessert into the cups and used her hands to scoop up the dessert out of the pan into the dessert cups. [NAME] C did not change her gloves or wash her hands during this task. During an interview on 9/30/24 at 2:50 pm, the DM stated she was responsible for training staff in all kitchen areas. She stated she does frequent reminders about washing hands and changing gloves. The DM stated she was aware Cooks C, D, and E did not wash their hands or change gloves between tasks. The DM stated they should have washed their hands and changed their gloves when switching tasks. She stated all kitchen staff should have used utensils to serve and prepare the food and should not have touched the food with their hands. The DM stated not changing gloves and washing hands could cause food borne illness. The DM stated she trained the staff in hand washing techniques and glove use. Record review of an undated facility policy titled, Dietary Department Glove Standard Protocol, revealed, in part: there will be no bare hand to food contact in the kitchen. Use of tongs, spatulas, or deli tissue paper will be used whenever possible to avoid touching a ready to eat food item with a bare hand. If a glove must be used, hands will be washed prior to putting on the glove and immediately after removing it. Gloved hands are considered a food contact surface that can get contaminated. Failure to change gloves can contribute to cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 21 of 28 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 10/02/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communication diseases and infections for 3 (Resident #15, Resident #22, and Resident #57) of 17 Residents. Residents Affected - Some The facility failed to ensure the following: -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J used hand hygiene and donning of gloves before breaking a pill with her hands for Resident #57. -CNA H perform hand hygiene during incontinent care of Resident #15. -CNA I perform hand hygiene during incontinent care of Resident #22. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Observation on 09/30/24 at 12:12 PM of RN J assisting unidentified resident with her mid-day meal. RN J took her left thumb and scooped some of the unidentified resident's food back on to the plate of resident. RN J then proceeded to lick her thumb and continued to feed the unidentified resident. No hand hygiene was performed before, during, or after the assistance with the meal. Observation on 10/01/24 at 09:18 AM RN J came to room and provided Resident #57 with her medications. Resident #57 asked RN J to break a pill for her. RN J grabbed pill from resident and broke the pill with bare hands. No gloves or hand washing took place before breaking the pill for the resident. Observation on 10/01/24 at 01:45 PM of incontinent care for Resident #22 performed by CNA H and CNA I. Both CNA's performed hand hygiene before starting incontinent care with foley catheter care for Resident #22. CNA I was the primary and cleaned Resident #22 in an appropriate manner, clean to dirty. When CNA I went to change her gloves, she did not perform hand hygiene and donned new gloves and concluded catheter care and incontinent care for Resident #22. Hand hygiene was performed after the resident was placed into a comfortable position. Observation on 10/01/24 at 02:29 PM of incontinent care for Resident #15 performed by CNA H and CNA G. Both CNA's performed hand hygiene before starting foley catheter and incontinent care for Resident #15. CNA H was the primary and cleaned Resident #15 in an appropriate manner, clean to dirty. However, when Resident #15 was turned to the right side so that her buttocks could be cleaned CNA H still had soiled gloves on and proceeded to touch Resident #15's skin to assist CNA G in the turning process. CNA H proceeded to clean the backside of Resident #15, CNA H changed her gloves, but did not perform hand hygiene, and then proceeded to place the resident in a comfortable position. Hand hygiene was performed after the resident was covered and the room was being cleaned by CNA H and CNA G. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 22 of 28 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 10/02/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 10/01/24 at 02:42 PM with CNA I stated that a negative outcome for not performing hand hygiene when glove changes took place could lead to cross contamination and infection for the resident. Interview on 10/01/24 02:46 PM with CNA H stated that a negative outcome for not performing hand hygiene when glove changes take place could lead to cross contamination. Residents Affected - Some Interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome of not washing hands during incontinent care could lead to cross contamination between one resident and another. Interview on 10/02/24 at 02:09 PM with DON stated that the negative outcome for not washing hands during incontinent care could lead to cross contamination and a risk for increased infection. Record review of the facility provided policy titled, Incontinent Care/Perineal Care with or without a Catheter, dated 12/2017 revealed the following: Policy It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity, and ensures not cross contamination. .3. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes. Cover resident, provide safety measures and wash hands with soap and water. 4. Cover resident with sheet or bath blanket. Raise cover to expose perineum. 5. Sanitize hands and put on gloves 6. Proceed with perineal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 23 of 28 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 10/02/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (Resident #18 and Resident #60) of 20 residents reviewed for environment and 2 of 2 resident refrigerators. The facility failed to remove expired and rotten food from both resident refrigerators and failed to maintain them in sanitary condition. This failure could place residents at risk of contracting foodborne illness and/or feeling uncomfortable or degraded in their living environment. Findings Included: Record review of Resident #18's admission record dated 10/01/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), mild intellectual disabilities (lower intellectual function leading to struggles with abstract thinking and social skills), and type 2 diabetes (insufficient production of insulin, causing high blood sugar). Record review of Resident #18's quarterly MDS completed on 09/16/24 revealed a BIMS of 14 which indicated intact cognition. Record review of Resident #18's care plan revealed it was completed on 09/09/24. Record review of Resident #60's admission record dated 09/30/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #60's admission MDS completed on 07/30/24 revealed a BIMS of 12 which indicated moderately impaired cognition. Record review of Resident #60's care plan revealed it was completed on 07/25/24. During an observation and interview on 09/30/24 at 09:53 AM Resident #18 was seated in his w/c in his bedroom opening his mail. He stated his only concern or complaint was the ice box near the entrance. He stated it needed to cleaned as it is a mess. During an interview and observation on 09/30/24 at 12:15 PM Resident #60 was seated on the edge of his bed. He stated the common fridge for residents was in poor shape. He said the refrigerator was kept in a storage closet near the nurses' station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 24 of 28 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 10/02/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm During an interview and observation on 09/30/24 at 01:45 PM Resident #60 was pushing a female resident in her w/c near the nurses' station. He pointed out the storage closet that contained the common refrigerator for residents. The door had a sign on it that said Storage and the door knob had a key pad. When asked how residents accessed the refrigerator, Resident #60 pointed to ADON B and said, She can let you in. Residents Affected - Few During an interview and observation on 09/30/24 at 01:47 ADON B opened the door to the storage closet and had the door to a mini refrigerator open as well. She stated the refrigerator was for residents to store food. She stated residents could not access the refrigerator unless staff let them into the storage closet. She stated nursing staff knew the code to open the door of the storage closet. There is a sign taped to the door of the refrigerator containing temperatures for each day of September. There is a handwritten sign above the refrigerator which says Please Keep Clean and was signed by LVN F. On the shelf above the refrigerator is a large spot the size of a dinner plate where the paint has peeled and bubbled and the wood underneath the paint is a dark brown rust color and is chipping up in shards. An observation on 09/30/24 at 01:49 AM of the resident mini refrigerator revealed the following: A small thermometer hanging inside the refrigerator on the top shelf of the door. A small freezer compartment with no door that was frosted over to the extent that it was 1/3 it's normal size. It was full of frozen water bottles. 2 mini water bottles less than half full labelled with Resident #18's name no date. 1 mini water bottle containing approximately 1/3 cup of milky white liquid labelled with Resident #18's name no date, and no identifying label. 1 partial carton of health shake labelled use by 09/29/24 no name. 1 large bottle of water partially empty no name, and no date. 1 large bottle of ketchup with date of 12/26 written on tape on the lid and an expiration date of 01/22/25 printed on the bottle. 1 jar with honey label containing what appears to be hot sauce. Labelled with a resident's name but no date. 1 clear plastic to go container of salad labelled with a resident's name and with the date 09/03. The lettuce was dark green, almost black, limp and appeared to be slimy. There were ice crystals hanging from the top of the container down into the lettuce. 1 sandwich in a resealable plastic bag labeled with a resident's name and dated 09/24. There were ice crystals in the bag and the top slice of bread was soggy. 4 small bottles of water labelled with Resident #18's name. 1 foil envelope drink unopened labelled with Resident #18's initials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 25 of 28 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 10/02/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm A plastic bag bearing the name of a Mexican food restaurant handles tied. Inside the bag were several napkins, two long black hairs, ice crystals, a bean burrito and a receipt dated 07/17/24. Black plastic to go box labelled with a resident's name and dated 07/17/24. Inside was what appeared to be a baked potato covered in a fuzzy green substance. Residents Affected - Few 2 medium to go drink cups with straws through the lids 90% full of a pink liquid labelled with a resident's name but no date. Small clear plastic to go container of what appears to be tartar sauce, no label or date. The bottom of the refrigerator had brown and pink smears over 90% of its surface with smaller patch of black smear toward the front. A plastic grocery bag with a coconut cake inside with a best by date of 10/02/24 labelled night shift. The outside of the refrigerator had a temperature log taped to the front of the door with temperatures written in for each day in September. During an interview on 10/01/24 at 02:01 PM CNA G stated she had worked for the facility for a month. She stated she knew the code to the storage closet where the resident refrigerator was kept. She stated residents could ask staff and staff would open the door for them to access the refrigerator. She stated housekeeping was responsible for cleaning the refrigerator. CNA G stated a possible negative outcome of the refrigerator containing rotting or expired food was residents could be poisoned or get an infection. During an interview on 10/01/24 at 02:08 PM LVN F stated she was the one who wrote the sign in the storage closet asking others to keep the area clean. She stated the rehabilitation hall has a refrigerator for residents to keep their personal food in as well. LVN F stated CNAs, nurses, and housekeeping staff were able to open the door to the storage closet for residents to access the refrigerator. She stated housekeeping staff were responsible for cleaning the refrigerator and nursing staff were responsible to read the thermometer inside the refrigerator and write the temperature each day on the sheet taped to the door of the refrigerator. LVN F stated a possible negative outcome of not throwing out rotten or expired food from the residents' refrigerator was food poisoning. During an interview on 10/01/24 at 02:12 PM HSK stated she was the housekeeping supervisor and has worked for the facility since May of 2024. She stated, regarding cleaning the residents' refrigerator, I was informed that is CNAs job. She stated she could not remember who told her that, but she knows it was when she first started working for the facility. During an observation and interview on 10/01/24 at 02:15 PM LVN K stated the rehabilitation wing did have a refrigerator for residents to use. She walked to a small apartment size refrigerator and stated it was not behind a locked door and residents were free to put items in and take them out at will. She stated nursing staff kept an eye on the residents and if they were confused staff would step in to assist them in finding their own items in the refrigerator. An observation on 10/01/24 at 02:19 PM of the resident refrigerator freezer on the rehabilitation wing revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 26 of 28 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 10/02/2024 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 0921 A single serve package of sherbet in the freezer with no name and no date. Level of Harm - Minimal harm or potential for actual harm A clear plastic, lidded container of what appeared to be an ice cream sundae with no name, date, or label. What appeared to be 1 pink stick popsicle with no label, name, or date. Residents Affected - Few What appeared to be 1 red popsicle with no label, name, or date. 1 medium to go cup with plastic lid open to air due to straw hole full of frozen peach-colored liquid no label, name, or date. An observation on 10/01/24 at 02:24 PM of the resident refrigerator on the rehabilitation wing revealed the following: One carton of health shake mostly full, with a date of 10/01/24. One partially used individual size protein shake with no name. 2 4-count packs of individual serving pudding no name. 1 resealable quart bag of 4 individual servings of sour cream. 2 have best by dates of July 1, 2024, 1 has best by date of August 25, 2024, and one has best by date of September 30, 2024. 5 resealable quart bags and one sandwich bag of individual servings of mayonnaise, mustard, and ketchup with no dates. 1 brown plastic bowl from the facility with disposable lid and date of 09/30 scratched into the lid. No name, label, or date. 1 small water bottle almost full of milky white liquid. No name, date, or identifying label. 1 bottle of purple drink partially gone no name. Large jar labelled as strawberry preserves containing what appears to be hot sauce no date or identifying label. 2-quart plastic bottle of ginger ale half gone no name and no date. 1 resealable gallon bag of individual servings of ketchup, mayonnaise, mustard, and relish dated 07/27/24. The bottom shelf and top shelf of the refrigerator are sticky in patches. The bottom shelf has a long brown hair stuck to the shelf in something sticky. During an interview on 10/02/24 at 01:08 PM DON stated the nurses kept track of the temperatures of the resident refrigerators and housekeeping cleaned them. She stated having spoiled or expired food in the resident refrigerators could cause an infection control issue and residents might experience GI (gastrointestinal) distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 27 of 28 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 10/02/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/02/24 at 01:23 PM ADON B stated, regarding cleaning of resident refrigerators, Well it is supposed to be housekeeping but I would say it has been confusing because residents go to CNAs or nurses to put something in there (the refrigerator), no housekeeping. She stated residents could get sick if expired and/or rotten foods were left in the refrigerators. During an interview on 10/02/24 at 01:38 PM ADM stated nursing staff were responsible for cleaning out the resident refrigerators. During an interview on 10/02/24 at 01:49 PM ADON A stated housekeeping was responsible for cleaning out the resident refrigerators. She stated CNAs and nurses were responsible for giving residents access to the refrigerators. She stated a possible negative outcome of the resident refrigerators containing expired and rotten food was contamination, foodborne illness. Record review of page 13 of facility admission packet titled Statement of Resident Rights revealed the following: . You have a right to: . 2. Safe, decent and clean conditions . Record review of page 15 of facility admission packet titled Texas State [NAME] of Rights of the Elderly revealed the following: . 17. An elderly individual may retain personal . possessions as space permits. The number of personal possessions may be limited for health and safety reasons which are documented in the patient's medical record. The number of personal possessions may be limited for the health and safety of other patients. Record review of facility policy titled Food Safety and dated 2006 revealed the following: . Food shall be handled in a safe manner. 7. Do not keep potentially hazardous food in refrigerator past the labeled expiration date. Record review of facility policy titled Storage Refrigerators and dated 2006 revealed the following: . All Storage Refrigerators shall be maintained clean . 4. Food must be covered when stored, with a date label identifying what is in the container. 5. Refrigeration equipment is to be routinely defrosted . Record review of facility policy titled Homelike Environment and dated May 2017 revealed the following: . Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible. 1. Staff shall provide person-centered care that emphasized the resident's comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment. Record review of facility policy titled Foods Brought by Family/Visitors and dated February 2014 revealed the following: . 2. Perishable foods must be stored properly . 4. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth .) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 28 of 28