Health inspection·June 3, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's face sheet revealed a [AGE] year-old male who was admitted to facility on 01/23/2025 with, but not limited to the following diagnosis: Type 2 diabetes mellitus with ketoacidosis without coma (where a lack of insulin causes harmful substances called ketones to build up in the blood), depression, essential (primary) hypertension (elevated blood pressure), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), acute kidney failure with tubular necrosis (a common lung disease causing restricted airflow and breathing problems). Record review of Resident #2's MDS, dated [DATE], revealed that Resident #3 had a BIMS of 14 and a functionality of maximal and moderate assistance is required in all care areas. Record review of Resident #2's MARs dated May1-31, 2025 revealed no discrepancies noted. During an interview on 06/03/2025 at 2:30PM Resident #2 stated that he has never gone without pain medication. When he requests it, he receives it. Resident #2 did not have any concerns at time of interview and stated that the staff was very good to him. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to facility on 07/12/2024 with, but not limited to the following diagnosis: Type 2 diabetes mellitus without complications (where a lack of insulin causes harmful substances called ketones to build up in the blood), mild cognitive impairment of uncertain or unknown etiology (when a person starts to have problems with their memory or thinking), right heart failure due to left heart failure. (LVN A) Record review of Resident #3's MDS, dated [DATE], revealed that Resident #3 had a BIMS of 13 and a functionality of maximal assistance needed in most care areas. Record review of Resident #3's MARs dated May1-31, 2025 revealed no discrepancies noted. During an interview on 06/03/2025 at 2:39PM Resident #3 stated I only get my pain medication when I really, really need it. It is not a scheduled medication, and I don't need it all of the time. Resident #3 stated I can request the medication when I need it. There was one nurse that came into my room and told me that I had asked for it, but I never did, I wasn't sure what she was talking about. During an observation on 06/03/2025 at 12:13pm revealed video evidence dated 05/23/2025, of LVN A opening the medication cart for Hall 400. LVN A opened the narcotic drawer and started to pop out medications out of random residents bubble packs. LVN A popped out what appeared to be approximately 14 pills. In the video it was unclear who the medications belonged to. LVN A then proceeded to take the medications in her hand and then place them in her mouth and consumed them. In the 2nd video dated 05/17/2025 LVN A went to the medication cart for 400 Hall and opened the medication cart and was seen getting in to the Narcotic drawer, LVN A took a medication cup and started to pop out medications from multiple different residents bubble packs. LVN A then placed the medications in her hand and went to speak to an unidentified CNA. LVN A and CNA spoke for an extended amount of time and during that time LVN A placed the medication in her right pocket. When a 2nd unidentified CNA came into view, LVN A proceeded to walk back towards the medication cart, pulled out her cell phone, placed it on the medication cart, and then walked behind a wall that concealed her from the CNA's but not the camera and she proceeded to take the handful of medications and walked to the back side of the nurses station desk while taking a drink from her personal drink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 2 of 4 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 06/03/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/03/2025 at 12:13pm ADM stated she did not have any suspicion until it was brought to her attention that Resident #1 was having pain and was not receiving medication for it. ADM stated that is when she started to review video footage and discovered LVN A was taking medications from the residents at the beginning of every shift that she worked. ADM stated that the narcotic counts were never wrong, and she (LVN A) never acted off. ADM stated that the police were called on the day LVN A was interviewed, and a police report was made and provided the incident #25-507802. ADM stated a Narcotic Detective came to the facility on the day of interview and while LVN A was being interviewed a UA drug panel was ran. LVN A came back positive for 12 out of the 15 drugs tested. LVN A was positive for amphetamine, barbiturates, benzodiazepines, buprenorphine, cocaine, marijuana, methadone, methamphetamine, ecstasy, oxycodone, phencyclidine, propoxyphene. During an interview on 06/03/2025 at 12:34pm LVN B stated she had suspicion on missing medications, due to when change of shift narcotic count was performed there were a lot of dropped or wasted medications with no second signature present of a witness nurse or MA. LVN B stated she noticed that residents were running out of medications more often and reported this to the DON. LVN B stated she had received re-education on ANE just in the past couple of days. LVN B stated the negative outcome for the residents not receiving their medication was an increase in pain for the resident and then not being able to provide medications due to it being documented that it had already been given when it had not been. During an observation on 06/03/2025 at 12:48pm of Hall 400 Narcotic log book revealed multiple choked, refused, and dropped narcotics with no 2nd signature for these wastes of medications. LVN A signature was the only signature present at time of incidents. During an interview on 06/03/2025 at 3:53pm ADON stated that LVN A never exhibited any behavior that would spike suspicion. ADON stated she and LVN A had worked the floor together and there was nothing that would have made the ADON suspicious. ADON stated she (ADON) is a part of the hiring process, and nothing came back on any background checks that were performed. On 06/03/2025 at 5:34pm attempted phone interview with Narcotic Detective, had to leave a voicemail with the State investigators phone number for officer to call back. No return call received. On 06/03/2025 at 5:46pm attempted phone interview with alleged perpetrator (LVN A), had to leave a voicemail with the State investigators contact information to call back. No return call received. During an interview on 06/03/2025 at 6:34pm LVN C stated she started noticing that she was having to order narcotics more frequently and thought that it was weird that these residents were going through meds so quickly. LVN C stated the negative outcome for residents was that the residents were complaining of pain and LVN C could not provide any pain medication due to it appearing to have been given already. During an interview on 06/04/2025 at 10:30am DON stated the negative outcome for residents would be that they would have an increase in pain, and lack of trust for the nursing staff. DON did state she was still performing re-education with nursing staff as they come in for their shifts. Inservices were stated on 05/29/2025, inservices included ANE, Quality of Care, signing out narcotics, medication administration, HIPPA, medicaid/medicare fraud, pharmacy. Record review of facility provided policy, titled, Abuse/Neglect, revised 11/15/2016, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 3 of 4 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 06/03/2025 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 0602 .9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455480 If continuation sheet Page 4 of 4