Health inspection·March 21, 2024

F 0550 not in a privacy bag. Level of Harm - Minimal harm or potential for actual harm Observation on 03/20/24 at 11:31 AM revealed Resident #26 receiving care from LVN A. Resident #26 was asked if it bothered him that his foley catheter bag was not covered. Resident #26 shook his head yes to confirm it does in fact bother him that the catheter bag is not covered. Residents Affected - Few Interview on 03/20/24 at 11:34 AM LVN A stated that Resident #26 will shake his head yes or no for any question asked. LVN A was asked what a negative outcome would be for Resident #26's catheter bag not being covered, LVN A stated that it could lead to infection, no mention of privacy or dignity was mentioned in interview. Resident #48 Record review of Resident #48's clinical record revealed an [AGE] year-old male resident admitted to facility on 11/09/2022, with a diagnosis to include malignant neoplasm of prostate, acute embolism (blood clot in lung) and thrombosis of unspecified deep veins of lower extremity, bilateral (blood clots in both legs), acute kidney failure, unspecified, congestive heart failure. Record review of Resident #48's MDS assessment, dated 01/04/2024, revealed that Resident #48 had a BIMs of 12 and was assessed for an indwelling catheter. Record review of Resident #26's physician ordered revealed an order dated 03/03/2024 with the following: 16 fr foley catheter with 10 ml due to urinary retention. Change monthly with bag and prn for blockage or leaks every night shift starting on the 2nd and ending on the 2nd every month for urinary retention. Observation on 03/19/24 at 10:41 AM revealed Resident #48 was sitting in his recliner fully dressed ready for the day. Resident #48's foley catheter was hanging on resident's wheelchair next to resident's recliner. Catheter bag was not in a privacy bag. Interview on 03/19/24 at 10:42 AM Resident #48 was asked if it bothered him that his foley catheter bag was no in a privacy bag, Resident #48 stated It does bother me, but I am use to it. Observation on 03/20/24 at 11:53 AM of Resident #48 was in the dining room with foley catheter bag hanging from the bottom of his wheelchair with no privacy bag. Interview 03/20/24 at 3:11pm with DON revealed that foley catheter policy revealed no mention of a privacy bag for drainage bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 2 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 observation, interview, and record review the facility failed to provide residents with the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 (Resident #17 and Resident #4) of 20 residents reviewed for advance directives. Resident #17 had a DNR undated by the physician. Resident #4 had a DNR lacking the physician's printed name. These failures could place residents at risk of having their end of life wishes dishonored and having CPR performed against their wishes. Findings Included: 1. Record review of Resident #17's admission record dated [DATE] revealed an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), age related cognitive decline, 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), and type 1 diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system). The advance directive section of the admission record noted Resident #17 as DNR. Record review of Resident #17's quarterly MDS completed on [DATE] revealed a BIMS of 12 which indicated moderately impaired cognition. Record review of Resident #17's care plan completed on [DATE] revealed Resident #17 requested a code status of DNR. The focus area was initiated on [DATE]. One of the interventions listed was, Make sure code status is signed by appropriate parties and in the medical record. Record review of Resident #17's active orders dated [DATE] revealed an order for DNR with an order date of [DATE]. Record review of Resident #17's Standard Out-Of-Hospital Do-Not-Resuscitate Order revealed Resident #17 signed the document on [DATE] as did two witnesses. The physician signed the document, printed his name, and added his license number but did not date the document or sign the document at the bottom of the page in section three which read, ALL PERSONS WHO SIGNED MUST SIGN HERE .This document has been properly completed. 2. Record review of Resident #4's admission record dated [DATE] revealed a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of [DATE]. The admission record indicated she had diagnoses that included, but were not limited to, Alzheimer's (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and repeated falls. The advance directive section of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 3 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 admission record indicated Resident #4 was DNR. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's quarterly MDS completed on [DATE] revealed a BIMS of 11 which indicated moderately impaired cognition. Residents Affected - Few Record review of Resident #4's care plan completed on [DATE] revealed Resident #4 requested a code status of DNR. The focus area was initiated on [DATE] One of the interventions listed was, Make sure code status is signed by appropriate parties and in the medical record. Record review of Resident #4's active orders dated [DATE] revealed an order for DNR with an order date of [DATE]. Record review of Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order revealed resident #4 signed it on [DATE]. The physician's signature is illegible and is dated [DATE]. The physician did not print their name under the signature on the line provided. During an interview on [DATE] at 03:38 PM LVN B looked at Resident #17's DNR and stated she would honor it if she saw it in his chart. When asked what date the DNR became valid she noticed the physician had not dated the DNR and said she would not honor it because it was not valid without a date from a physician. During an interview on [DATE] at 03:40 PM DON looked at Resident #17's DNR and noted the physician did not date it. She stated there was always a negative outcome if a DNR was incompletely filled out. During an interview on [DATE] at 03:41 PM LVN B stated a possible negative outcome of a DNR being improperly filled out was if the facility followed the DNR the family could challenge them legally. During an observation and interview on [DATE] at 10:11 AM Resident #17 was sitting in his recliner with his eyes closed. He opened his eyes on hearing a knock at the door and when asked if he wanted to be DNR he nodded his head while saying, Mmmmhmmm. During an interview on [DATE] at 03:47 PM RN stated a DNR that is not filled out completely should not be followed as it is not valid. During an interview on [DATE] at 07:23 AM LVN A stated there was a negative outcome to residents if a DNR was not filled out completely. She said, Yes, because that is their wish, we are supposed to do what they want. She said a resident might end up suffering if their DNR was not followed due to being invalid. During an interview on [DATE] at 07:47 AM DON said a possible negative outcome of having a DNR that is incorrectly filled out was, It is not valid so family can come back and say they never signed it. Record review of facility policy titled Advance Directives and dated [DATE] revealed the following: . Advance directives will be respected in accordance with state law and facility policy. Record review of Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order Texas Department of State (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 4 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 Health Services Instructions for Issuing An OOH-DNR Order revealed the following: Level of Harm - Minimal harm or potential for actual harm . The original or a copy of a fully and properly completed OOH-DNR Order . shall be honored by responding health care professionals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 5 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a significant change in status assessment within 14 days after the facility determined or should have determined that a resident has a significant change in the resident physical or mental condition for 1 (Resident #14) of 20 residents reviewed for comprehensive resident assessments. Residents Affected - Few The facility failed to complete a significant change of condition assessment when Resident #14 was discharged from hospice. This failure placed residents at risk for not receiving an accurate assessment and could result in lack of care. Findings include: Record review of Resident #14's clinical records face sheet printed 3-19-2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypertension(a condition in which the force of the blood against the artery walls is too high), muscle weakness, and repeated falls. Record review of Resident #14's Significant change in status assessment MDS completed 9-9-2023 revealed he had a BIMS of 6 indicating he was severely cognitively impaired, and he had a functionality of requiring one to two-person assistance with most of his activities. Under Section O Special Treatments, Procedures, and Programs-K. Hospice Care-Resident #14 was marked for Hospice Care while a resident. Record review of Resident #14's MDS [NAME] revealed the following MDS's completed: Quarterly dated 3-9-2024. Quarterly dated 12-8-2023. Significant Change-dated 9-9-2023. (No noted Significant Change MDS completed for the discharge of hospice) Record review of Resident #14's Active Orders as of 3-20-2024 revealed the following order: Admit to hospice. Start Date: 9-9-2023, no discharge date provided. Record review of Resident #14's care plan with admit date of 6-24-2023, last updated 1-16-2024, printed 3-20-2024 revealed no care plans for hospice. During an interview on 3-20-2024 at 03:19 PM the DON verified that Resident #14 was not currently on Hospice. The DON reviewed Resident #14's chart and noted that Resident #14 was admitted to hospice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 6 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 9-9-2023 and was discharged from hospice on 11-6-2023 because Resident #14 no longer had a qualifying diagnosis. The DON did verify that Resident #14 currently had orders in his chart to be on hospice and reported that she would get those orders dc'd immediately. During an interview on 3-21-2024 at 08:38 AM the MDS Coordinator verified that Resident #14 was put on Hospice on 9-9-2023 and a significant change of condition MDS was completed to update Resident #14's condition. The MDS Coordinator reported that she was checking Resident #14's record because she was not aware that Resident #14 had been taken off hospice and at this time, she has not been able to determine when Resident #14 was discharged from hospice. The MDS Coordinator reported that Resident #14 did have a change of payor source on 11-7-2023 and she suspected that was when Resident #14 was discharged from hospice. The MDS Coordinator reported that she was going to complete a significant change of condition MDS today to update Resident #14's condition. The MDS Coordinator reported that a significant change of condition should have been completed when Resident #14 was discharge from hospice. The MDS Coordinator reported that if a significant change of condition was not completed when a resident is discharged from hospice that it would most likely not affect the residents care, but it could affect the care plan process which could affect a resident's care. The MDS Coordinator reported that they use the RAI manual to complete the MDS process. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 revealed the following: 03. Significant Change in Status Assessment (SCSA)An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 7 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 3 (Resident #17, Resident #37, and Resident #44) of 20 residents reviewed for preadmission screenings. Residents Affected - Few 1. Resident #17 had a PASRR performed 36 days after he was admitted to the facility. 2. Resident #37 had a PASRR performed 12 days after he was admitted to the facility. 3. Resident #44 had a PASRR with no assessment date in her EHR. These failures could place residents at risk of receiving inadequate care that could lead to deterioration in their health condition. Findings Included: 1. Record review of Resident #17's admission record dated 03/19/24 revealed an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), age related cognitive decline, 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), and type 1 diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system). Record review of Resident #17's quarterly MDS completed on 02/13/24 revealed a BIMS of 12 which indicated moderately impaired cognition. Section D of the MDS did not indicate any issues with mood. Section E of the MDS did not indicate any issues with behaviors. Section I of the MDS indicated Resident #17 had a diagnosis of depression. Record review of Resident #17's care plan completed on 03/10/24 revealed Resident #17 had depression but was not taking medication to treat the depression. The intervention listed was for staff to monitor Resident #17 for s/s of depression. Record review of Resident #17's PASRR revealed a date of screening of 05/26/23. 2. Record review of Resident #37's admission record dated 03/20/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's (a progressive disease that destroys memory and other important mental functions), 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), and abnormal weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 8 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #37's quarterly MDS completed 01/04/24 revealed a BIMS of 9 which indicated moderate cognitive impairment. Section D of the MDS indicated no issues with mood. Section E indicated Resident #37 rejected care on 1-3 of the 7 days of the look-back period. Section I of the MDS indicated no diagnosis of a mood or psychiatric disorder. Record review of Resident #37's care plan completed on 03/10/24 revealed no mention of a mood or psychiatric disorder. It did mention Resident #37 took an antianxiety medication related to the disease process of Alzheimer's. Record review of Resident #37's PASRR revealed a date of screening of 11/01/23. 3. Record review of Resident #44's admission record dated 03/20/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with more recent admit date s of 11/09/23 and 12/11/23. The admission record indicated diagnoses that included, but were not limited to, legal blindness, heart disease, and ovarian cancer. Record review of Resident #44's significant change MDS completed on 01/09/24 revealed a BIMS of 11 which indicated moderately impaired cognition. Section D of the MDS indicated Resident #44 felt lonely and isolated sometimes. Section E of the MDS revealed no issues with behavior. Section I of the MDS indicated a diagnosis of anxiety disorder. Record review of Resident #44's care plan completed on 02/16/24 revealed she used antidepressant medication related to depression and anti-anxiety medication related to anxiety disorder. Record review of Resident #44's PASRR revealed a blank line next to the date of screening. The PASRR further revealed Resident #44's date of last physical examination was 05/23/23. During an interview on 03/20/24 at 11:13 AM DON turned over the facility's PASRR policy and stated the facility had a PIP in place for PASRR because they did have someone who did not have one done timely. During an interview on 03/20/24 at 03:18 PM MDS LVN stated she was responsible for completing PASRRs for each resident. She stated if a PASRR is not completed at or prior to admission the facility might not be able to take care of their disability. When asked why Residents #17 and #37 had PASRRs completed after they were admitted she stated she did not know. During an interview on 03/21/24 at 07:23 AM LVN A stated she had been an LVN for 35 years. She stated a possible negative outcome of a resident not having a PASSR prior to admission was, We don't have all the information on the residents, and we need that. It is very important for their care. During an interview on 03/21/24 at 07:47 AM DON stated a PASRR needed to be done before a resident was admitted to the facility so the facility could be certain they could meet the needs of the resident. Record review of facility policy titled, Preadmission Screening and Resident Review (PASRR) Process revealed the following: . PASRR is a federally-mandated program that requires all states to pre-screen all people, regardless of payor source or age, seeking admission to a Medicaid certified nursing facility (NF). The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 9 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PASRR process for Texas is as follows: An initial PASRR Level 1 Screening (PL1) of every person applying for NF placement to identify people suspected of having ID, DD, or MI. Record review of facility PIP regarding PASRR dated 03/20/24 revealed a start date of 08/22/23 and a target end date of 02/17/24. The problem as stated on the PIP was PL1 [PASRR Level 1 Screening] are not getting put in timely manner. Supportive data on the PIP was, On some admits PL1 are not getting put in immediately. The root cause analysis on the PIP stated, PL1 not being sent from the hospital or being done if admitting from home. The PIP aim to have 100% PL1 competion [sic] rate was listed as delinquent as were the interventions of home admission and hospital completion. MDS LVN was listed as the owner of both interventions. The last page of the PIP indicated the PIP was closed with Achieved Desired Results listed as the reason for closure and all admissions continue to have pl1 before admission listed as the follow up plan. Event ID: Facility ID: 455551 If continuation sheet Page 10 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 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 2 (Resident #36 and #38) of 20 residents reviewed for comprehensive care plans. -The facility failed to include care plans for hospice for Resident #36. -The facility failed to include care plans for dialysis for Resident #38. This failure could place resident at risk of not receiving care and services to meet their needs. Finding include: Resident #36 Record review of Resident #36's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 2-23-2023 and readmitted on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), acute kidney failure disease of the kidneys leading to kidney failure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow, major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), hypertension (a condition in which the force of the blood against the artery walls is too high), fracture of the lumbar, and metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain). Record review of Resident #36's clinical record revealed a quarterly MDS completed 2-9-2024 with a BIMS of 5 indicating she was significantly cognitively impaired, and she had a functionality of being dependent on staff for all her activities. Section O-Special Treatments, Procedures, and Programs: K1 Hospice Care-Resident #36 was marked for having hospice care while a resident. Record review of Resident #36's Order Summary Report' with active orders as of 3-21-2024 revealed an order for Hospice to eval and treat Order Date: 12-28-2023. Record review of Resident #36's clinical record revealed a care plan with an admission date of 6-06-2023 and a last review date of 3-20-2024 with no care plan for hospice. During an observation and interview on 03-19-2024 at 02:29 PM Resident #36 was noted in bed under her covers. Resident #36 appeared in good condition but did appear confused throughout the interview. Resident #36 did report that her care had been good, her hospice care had been good, and she had no concerns. During an interview on 03-21-2024 at 08:42 AM, the DON verified that she was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 11 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 completing all care plans once the MDS's were completed. The DON reviewed Resident #36's chart and verified that Resident #36 did not have a care plan for hospice. Resident #38 Record review of Resident #38's clinical record revealed a [AGE] year-old female admitted to the facility originally on 10-11-2023 and readmitted on [DATE] with diagnoses to include fibromyalgia (a long-term condition that involves widespread body pain and tiredness), end stage renal failure(a medical condition in which persons kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant), Sjogren syndrome(an immune system illness that mainly causes dry eyes and dry mouth), diabetes(a chronic condition that affects the way the body processes blood sugar (glucose), major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), and anemia with chronic blood loss (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all throughout the body). Record review of Resident #38's clinical record revealed a quarterly MDS completed 12-29-2023 with a BIMS of 12 indicating she was moderately cognitively impaired, and she had a functionality of requiring substantial/maximal assistance with all activities. Section O-Special Treatments, Procedures, and Programs J1-Dialysis: Resident #38 was listed as having dialysis while a resident. Record review of Resident #38's Order Summary Report' with active orders as of 3-20-2024 revealed the following orders: -LCS diet Mechanical Soft texture, Regular/Thin Consistency-Active 11-20-2023 Sevelamer Carbonate Oral Packet 0.8 GM (Sevelamer Carbonate) Give 1.6 gram by mouth three times a day related to END STAGE RENAL DISEASE-Active 12-05-2023. Record review of Resident #38's clinical record revealed a care plan with most recent admission date of 1-18-2024 (noted care plans with initiation date of 11-25-2023) and a last review date of 3-19-2024 with no care plan for dialysis. Record review of Resident #38's progress notes revealed a progress note on 11-29-2023 with the following: - Took patient to dialysis this morning and patient was picked by 2:50 pm from dialysis this afternoon. During an observation on 03-19-2024 at 10:11 AM Resident #38 was in her room sleeping and awoke to knocking. Resident #38 did not respond to questions, but she did appear alert. Resident #38 did appear in good condition. During an interview on 03-20-2024 at 03:14 PM the DON verified that she was responsible for completing the care plans for the residents. The DON reported that she was aware that Resident #38 was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 12 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 dialysis and that she should have a care plan for the dialysis therapy. The DON reviewed Resident #38's care plan and determined that there was no care plan for dialysis and stated, I am going to add that care plan right now. It should have already been there. The DON reported that if all details of a resident's conditions and needs are not addressed in a resident's care plan then staff will not know how to address that residents need and therefore the resident care and condition could be affected. Residents Affected - Few Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the following: Policy Statement: A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: b. described the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 13 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and failed to ensure maintenance of bedrails for 4 (Resident #6, Resident #17, Resident #33, and Resident #53) of 20 residents reviewed for bedrails. Residents #6 and #33 had bedrails that were loose. Resident #17 had no consent for bedrails in his EHR or his paper chart. Residents #33 and #53 had bedrails the day they were admitted to the facility. These failures could place residents at risk of injury and/or entrapment. Findings Included: 1. Record review of Resident #6's admission record dated 03/19/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), acute kidney failure (sudden episode of kidney failure that happens in hours or days), acute pyelonephritis (sudden, severe inflammation of kidney due to bacterial infection), breast cancer, and complete traumatic amputation of left lower leg. Record review of Resident #6's quarterly MDS completed on 02/26/24 revealed a BIMS of 13 which indicated intact cognition. Section GG of the MDS indicated Resident #6 had a wheelchair and a lower extremity limb prosthesis. The section further indicated she required substantial/maximal assistance with transfers and moving from sitting to standing or from chair to bed. Resident #6 required partial to moderate assistance with putting on and taking off footwear and required supervision or touching assistance for toileting hygiene and walking. Across her other ADLs she was independent or needed only setup/clean up assistance. Section I revealed Resident #6's primary medical condition and primary reason for admission to the facility was amputation. Section J indicated Resident #6 had had falls since her admission to the facility. Section N indicated she was taking opioid medication. Section P of the MDS did not list bedrails as a restraint. Record review of Resident #6's care plan completed on 01/10/24 revealed she had an ADL performance deficit due to amputation and impaired balance. One of the interventions listed for this focus area was to use bedrails for safety and bed mobility. The care plan indicated Resident #6 had high blood pressure and should therefore be monitored for seizure activity. The care plan noted Resident #6 was a high risk for falls due to a history of falls as well as amputation of her left leg below the knee due to diagnosis of diabetes combined with a fall at home and subsequent foot infection. Record review of Resident #6's active orders dated 03/21/24 revealed an order for bedrails with an order date of 08/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 14 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #6's Consent for Use of Side Rails revealed it was signed by Resident #6 on 06/22/23 and indicated she wanted bedrails for positioning and mobility. Record review of Resident #6's Bed Rail Safety Review dated 03/07/24 revealed neither Resident #6 nor her representative expressed a desire for assistive devices to aid in bed mobility. It also revealed no alternatives to bed rails had been attempted because the bedrails promoted mobility and transfers. During an observation and interview on 03/19/24 at 10:14 AM Resident #6 was sitting in her room in her w/c. She was noted to have bilateral, football-shaped, metal bedrails in the upright position along the top sides of her bed. Resident #6 stated, I hated those bedrails because they move so much. I wish I had the more stable kind like my roommate has. I have not asked that they replace them, but I have asked that they tighten them which they do but they just keep loosening. 2. Record review of Resident #17's admission record dated 03/19/24 revealed an [AGE] year-old resident originally admitted to the facility on [DATE] with a recent admission date of 04/20/23. The admission record revealed Resident #17 had diagnoses that included, but were not limited to, heart failure, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), age related cognitive decline, 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), and type 1 diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system). Record review of Resident #17's quarterly MDS completed on 02/13/24 revealed a BIMS of 12 which indicated moderately impaired cognition. Section GG of the MDS revealed Resident #17 required partial/moderate assistance to substantial/maximal assistance across all ADLs except for eating and oral hygiene where he only required setup and clean up assistance. Section N of the MDS indicated Resident #17 was receiving opioid medication. Section P of the MDS did not indicate bedrails were being used as restraints. Record review of Resident #17's care plan completed on 03/10/24 revealed Resident #17 needed help with ADLs due to weakness associated with his diagnoses. One of the interventions listed noted side rails were used for bed mobility. This intervention was initiated on 05/10/23. The care plan indicated Resident #17 had high blood pressure and needed to be monitored for seizure activity. The care plan noted Resident #17 was a high risk for falls due to weakness and a history of falls at home. According to the care plan Resident #17 had impaired visual function. Record review of Resident #17's active orders dated 03/20/24 revealed an order for bedrails with an order date of 08/26/20. Record review of Resident #17's EHR under the assessments tab revealed a Bed Rail Safety Review dated 02/23/24. Record review of Resident #17's EHR revealed no consent for bedrails. Record review of Resident #17's paper chart revealed no consent for bedrails. During an interview and observation on 03/19/24 at 10:13 AM Resident #17 was sitting in his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 15 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recliner next to his bed. He stated he had been in the facility for 10 months. He appeared to have a hard time hearing and/or did not want to answer any other questions in that when questions were asked, he would lean forward cupping his hand around his ear and would not answer. His bed had bilateral bedrails in the upright position on the top sides of the bed. During an observation on 03/20/24 at 10:11 AM Resident #17 was seated in his recliner. His bed had bilateral bedrails on the top sides of the bed in the upright position. During an observation on 03/21/24 at 07:26 AM Resident #17 was asleep on his back on his bed under a blanket. Bilateral bedrails were in the upright position on the top sides of his bed. 3. Record review of Resident #33's admission record dated 03/20/24 revealed a sixty-one-year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), alcohol dependence with withdrawal, and personal history of traumatic brain injury (a head injury that causes damage to the brain by external force; can cause long term complications or death). Record review of Resident #33's quarterly MDS completed on 01/22/24 revealed a BIMS of 11 which indicated moderately impaired cognition. Section GG of the MDS indicated Resident #33 needed partial/moderate assistance in showering/bathing, and supervision in upper body dressing. Across the rest of his ADLs he was independent or just needed setup and clean up assistance. Section I of the MDS indicated Resident #33's primary medical condition and reason for admission was Other Neurological Conditions. Section P of the MDS did not list bedrails as restraints. Record review of Resident #33's care plan completed on 03/18/24 revealed he had an ADL performance deficit due to his diagnosis of dementia and history of traumatic brain injury. One of the interventions listed to address this deficit was Resident #33 used bedrails to maximize independence with turning and repositioning in bed. This intervention was initiated on 12/02/23. The care plan further revealed Resident #33 was taking an anticonvulsant medication. Record review of Resident #33's active orders dated 03/20/24 revealed an order for bedrails with an order date and start date of 12/01/24. Resident #33 had an order for an anticonvulsant medication to be given three times a day for seizures with a start date of 12/01/23. Record review of Resident #33's Consent For Use of Side Rails revealed the form was signed by Resident #33 on 12/01/23. Record review of Resident #33's Bed Rail Safety Review revealed it was signed on 12/01/23. It indicated that alternatives to bed rails had been attempted and the alternative was adjustable height low bed. During an observation and interview on 03/19/24 at 10:56 AM Resident #33 was seated on his made bed with his back resting against the headboard and his legs stretched out in front of him. His bed had bilateral, football-shaped, metal bedrails in the upright position on the top sides of the bed. He stated he did not know what the bed rails were for. He grabbed the one on his left side and it wiggled back and forth turning almost 180 degrees end to end. During an observation on 03/20/24 at 10:07 AM Resident #33 was seated on his made bed with his back against the headboard of the bed and his legs stretched out in front of him. His bed had bilateral, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 16 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some football-shaped metal bedrails in the upright position. Resident #33 demonstrated that the bedrail on his left was still loose and could turn 180 degrees. During an interview and observation on 03/20/24 at 03:24 PM MT looked at Resident #33's loose bedrail. He knelt down and looked at the base of the bedrail and said it could be made tighter, but he would have to drill another hole and put in a nut and bolt to keep it from twisting. During an observation on 03/21/24 at 07:29 AM Resident #33 was seated on his made bed with his back resting against the headboard of the bed and his legs stretched out in front of him. His bed had bilateral, football-shaped, metal bedrails in the upright position on the top sides of the bed. 4. Record review of Resident #53's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but were not limited to metabolic encephalopathy (problems in the brain from chemicals in the blood), cirrhosis of liver (impaired liver function caused by the formation of scar tissue), acute kidney failure (sudden episode of kidney failure that happens in hours or days), type 2 diabetes (insufficient production of insulin, causing high blood sugar), and repeated falls. Record review of Resident #53's quarterly MDS completed on 01/22/24 revealed a BIMS of 12 which indicated moderately impaired cognition. Section GG of the MDS revealed Resident #53 was independent across all ADLs except for eating where she required setup and clean up assistance and showering/bathing where she required supervision or touching assistance. Section N of the MDS indicated Resident #53 was taking opioid medication. Section P of the MDS did not list bedrails as restraints for Resident #53. Record review of Resident #53's care plan completed 01/17/24 revealed Resident #53 had limited physical mobility and would use a walker and bedrails to help her with mobility. She also had high blood pressure and was to be monitored for seizure activity related to said. Record review of Resident #53's active orders dated 03/20/24 revealed an order for bedrails with an order date of 10/07/24. Record review of Resident #53's Consent for Use of Side Rails revealed side rails were recommended at all times when resident was in bed for bed mobility and positioning. The consent was signed as given by telephone by Resident #53's family member. Record review of Resident #53's Bed Rail Safety Review dated 10/03/24 noted alternatives to bedrails had been attempted. The alternatives attempted were listed as Adjustable height low bed and Toileting Program. During an observation and interview on 03/19/24 at 10:48 AM Resident #53 was lying on her back in bed. She had bilateral bedrails in the upright position on the top sides of her bed. She stated she used the bedrails to get up out of bed. During an observation on 03/20/24 at 10:09 AM Resident #53 was lying in bed on her left side under a blanket with HOB raised slightly. Bilateral bedrails in upright position on the top sides of the bed. During an interview and observation on 03/20/24 at 02:55 PM MS and MT stated they do not routinely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 17 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some maintain bedrails. They said if nursing staff or residents tell them the bedrails are loose, they will check on them and if a new resident needs bedrails installed, they will do that. MT gestured toward one of the metal football shaped bedrails and stated, Those kind, the residents use them a lot and they don't stay, they break off and get loose. During an interview on 03/21/24 at 07:23 AM LVN A stated nurses fill out bedrail consents and assessments when residents are admitted . She said family usually want bedrails. She said a possible negative outcome of giving a resident bedrails before trying alternative options was, Sometimes they don't want them. I make sure to ask the resident. She stated loose bedrails could lead to residents being injured due to falls. She stated she had seen residents with broken bones due to loose bedrails in her 35 years of being an LVN. During an interview on 03/21/24 at 07:47 AM DON stated maintenance staff took care of bedrail maintenance. She said, So, if we see one is loose we notify them immediately and they fix it immediately. She said charge nurses are responsible for filling out bedrail consents. She said they do it but I follow up on that. DON said a possible negative outcome of a resident having a bedrail that was loose was, Patient can fall out or it can hit the patient and cause an injury. She could not think of a negative outcome of installing bedrails before trying alternative options. She said, most of the time when residents had bedrails it was because they choose them for their comfort. During an interview on 03/21/24 at 08:00 AM MT stated he did not have manufacturer's instructions regarding bedrails. Record review of facility policy titled Bed Safety and dated December 2007 revealed the following: . 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; . c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions . 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. The appropriate review and consent as specified above, side rails may be used at the resident's request . 8. Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 18 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for one of one facility reviewed for nursing services Residents Affected - Many The facility did not have an RN in the facility on 01/27/2024, 01/28/2024, 02/10/2024, 02/11/2024, 03/16/2024, and 03/17/2024. This failure placed residents at risk of not having supervisory coverage for RN specific nursing activities. Findings include: Record review of the facility's last 90 days of time sheets for RN coverage revealed that there was no RN coverage on 01/27/2024, 01/28/2024, 02/10/2024, 02/11/2024, 03/16/2024, and 03/17/2024. Interview on 03/20/24 at 2:27 PM with DON stated that she did not have that many days with no coverage. DON stated that agency did not cover that many days either. Interview on 03/20/24 at 2:32 pm with Regional DON said after she reviewed the last 90 days of time sheets for RN coverage, There was no coverage on 01/27/24, 01/28/24, 02/10/24, 02/11/24, there was no mention by Regional DON if there was RN coverage on 03/16/24, and 03/17/24 during interview. Unable to interview ADM, due to him not being available. Record review of policy titled CMA Manual System, dated 12/13/2013 revealed the following: 7014.1.1-Waiver of 7-day Registered Nurse (RN) Requirement for Skilled Nursing Facilities (Rev.97, Issued, 12-13-13, effective: 12-13-13, Implementation: 12-13-13) The requirements for long-term care facilities require that a skilled nursing facility provide 24-hour licensed nursing services, and RN for 8 consecutive hours a day, 7 days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing on a full time basis. The regional office, acting on behalf of the secretary, may waive the requirement in the following circumstances; The facility is located in a rural area and the supply of skilled nursing facility services is not sufficient to meet area needs; The facility has one full-time registered nurse regularly on duty 40 hours a week. This may be the same individual or part-time individuals. This nurse may or may not be the Director of Nursing and may perform some Director of Nursing and some clinical duties if the facility so desires; and either; The facility has residents whose physicians have indicated, through admission notes or physicians' orders, that the resident do not need RN or physician care for 48 hour period; or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 19 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 0727 Level of Harm - Minimal harm or potential for actual harm A physician or RN will spend the necessary time a t the facility to provide the care that residents need during the days that an RN is not on duty. This requirement refers to clinical care of the residents who need skilled nursing services. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 20 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to ensure dented cans were placed in the specified area to be returned. The facility failed to discard expired food. The facility failed to discard leftover food by use by date on the label. The facility failed to store food at least 6 inches off the floor. These failures could place residents at risk of food borne illness. Findings included: An observation on 03/19/24 at 09:21 AM of the refrigerator revealed the following: 8 single serve apple juice cups covered with original packaging foil lids sitting on a tray with an illegible label stuck to the tray. The label appeared to have become wet and the open and use by dates were black smudges. 5 single serve cartons of strawberry and chocolate shakes were in a box with no label or date. Bologna slices in the open original packaging were inside a resealable bag that was open to air. The resealable bag was labelled as opened 03/12 use by 03/19. A white, opaque, cylindrical tub with a lid labelled corn opened 3/12 use by 03/19 was sitting on a shelf approximately half full. A resealable bag of what appeared to be corn tortillas with no label or date was sitting on a shelf. 2 cardboard flats of 8 plastic boxes (with holes in the plastic) of strawberries were sitting stacked on one another. Two of the plastic boxes in the top flat and two of the plastic boxes in the bottom flat contained strawberries covered with a greyish white fluffy substance. A box of individual cranberry juice cocktails was open with no label or date. An observation on 03/19/24 at 09:31 AM of the freezer revealed an open box of bags of frozen broccoli on the floor. An observation on 03/19/24 at 09:32 AM a shelf outside the pantry was noted to contain dented cans and a sign directing dented cans to be placed on the shelf. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 21 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 An observation on 03/19/24 at 09:33 AM of the pantry revealed the following: Level of Harm - Minimal harm or potential for actual harm A bag of instant refried beans labelled use by 02/17/24 A 66.5 ounce can of tuna with a dent near the bottom seal of the can Residents Affected - Many A plastic gallon jug of soy sauce 3/4 full had no open date and was marked by the manufacturer refrigerate after opening for quality. The bottle had a yellow stamp near the top of the jug that read Best by January 18, 2024. A plastic gallon jug of teriaki sauce ½ full had an open date of 10/14/22 and was marked by the manufacturer as Refrigerate after opening. The jug had a yellow stamp near the top that read, Best by 2/27/23. A plastic gallon jug of soy sauce 1/8th full had an illegible open date and was marked by the manufacturer refrigerate after opening for quality. The jug had a yellow stamp near the top that read, Best by January 18, 2024. The sides of the jug were crusted with dry brown matter. A white, round, plastic tub with a red plastic lid was observed with no label. The tub was 1/3 full of a dry powdery substance and had a sticker indicating it was opened on 03/05/24. An observation on 03/20/24 at 08:12 AM of the refrigerator revealed the following: The white, opaque, plastic, cylindrical tub of corn labelled opened 3/12 use by 3/19 was still on a shelf in the refrigerator. The open, resealable bag of bologna slices in their original, open packaging labelled opened on 03/12 use by 03/19 was still on a shelf in the refrigerator. The two cardboard flats of 8 plastic boxes (with holes in the plastic) of strawberries were sitting stacked on one another in the refrigerator. Two of the plastic boxes in the top flat and two of the plastic boxes in the bottom flat contained strawberries covered with a greyish white fluffy substance. During an interview on 03/20/24 at 02:41 PM DS stated she had worked for the facility as DS for 5 or 6 years. She stated having expired food in the pantry and food past the use by date in the refrigerator could lead to residents getting sick. She stated the food could be contaminated and kitchen staff would not know how old it was. She stated her staff have been trained to date food when it comes into the kitchen in a box and if it comes out of the box to be sure it is dated. She stated the cooks are responsible for dating leftover food and she and the cooks are responsible for dating food as it comes into the kitchen. The DS stated she has trained her staff on labelling and dating food and on placing dented cans on the shelf outside the pantry to be returned. During an interview on 03/20/24 at 03:45 PM [NAME] stated she had worked for the facility for 9 years. She said all the cooks were responsible for labelling and dating food. She said if expired food was not thrown out residents would get sick. [NAME] stated if food was not labelled and dated correctly or dented cans were not removed from the pantry bacteria could grown and residents could get food poisoning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 22 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 Record review of facility policy titled Safe Food Handling and dated 5/1/2015 revealed the following: Level of Harm - Minimal harm or potential for actual harm . 5 Refrigerated Time/Temperature Control for Safety (TCS) leftover foods are properly covered, labeled and dated and marked with a use by date. TCS leftovers are discarded after 3 days unless otherwise indicated. 3. All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened. Residents Affected - Many Record review of facility policy titled Food Safety in Receiving and Storage and dated 10/2009 revealed the following: . 2. Store food in its original packaging as long as the packaging is clean, dry, and intact. 3. Place food that is repackaged in a leak-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with common name of the contents and date with the date it was transferred to the new container. 1. Store foods at least 6 off the floor . 2. Tightly seal opened packages to prevent contamination or place food in covered containers. 4. Clean exterior surfaces of food containers . of visible soil before opening . 12. Refrigerated, ready to eat PHF [potentially hazardous food] are properly covered, labeled, dated with a use-by date . 13. In the case of commercially processed food, the date marked by the facility may not exceed a manufacturer's use by date. Record review of an in-service on food storage and handling safety revealed a date of 12/13/23. It was taught by DS and Cook's name is on the attendance list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 23 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents Affected - Few -LVN failed to don gloves before administering an injectable medication to resident. - Facility failed to keep foley catheter bag off of the floor. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: Observation on 03/20/24 at 11:18 AM revealed foley catheter bag hanging from anonymous residents' bed, bottom of the catheter bag was touching the floor, there was no privacy bag on this catheter bag. Observation on 03/20/24 at 12:03 PM revealed LVN A administering insulin to a resident with no gloves on. HH was performed but donning gloves did not take place. Interview on 03/21/24 at 7:26 AM with LVN A was asked what a negative outcome is for not using gloves while administering an injectable medication. LVN A stated that it could lead to a finger stick and infection. Interview on 03/21/24 at 07:47 AM with DON stated that a negative outcome for not using gloves during an administration of an injectable medication it is not following universal precautions and have a higher chance of sticking oneself. Record review of facility provided policy titled Subcutaneous Injections dated revised March 2011 revealed the following: Steps in the Procedure 1. Perform hand antisepsis. 2. Put on gloves . . 17. Remove gloves and discard in designated container. Perform hand antisepsis. Record review of facility provided policy titled Handwashing/Hand Hygiene, dated revised August 2019 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 24 of 25 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 455551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072 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 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Level of Harm - Minimal harm or potential for actual harm 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Residents Affected - Few 10. Single-use disposable gloves should be used: a. Before aseptic procedures; b. when in contact with a resident, or the equipment on environment of a resident, who is on precautions. Record review of facility provided policy titled Catheter Care, Urinary, dated revised September 2014 revealed no mention of providing a foley catheter bag to keep foley catheter bag off of the floor to prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455551 If continuation sheet Page 25 of 25