Inspection·May 27, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In a group interview on 05/25/2023 at 11:15 a.m., Resident #69 and several other residents verbalized feelings that they do not believe it was right or fair that smokers are not treated equally at the facility. Resident #69 revealed that residents who transferred from an Assisted Living were allowed to keep their cigarettes and lighters with them and smoke at times other than the posted times. Resident #69 shared that all smokers who have lived at this facility, even those identified as safe smokers must wait for smoking times and were not allowed to keep their items on themselves. During an observation of the 1:30 PM smoking break on 05/25/2023, Resident #69 and five other smokers were present on the patio. Resident #103 had brought his cigarettes out with him and was smoking, while the five others waited for the staff assigned to supervise break to arrive. Several of the residents stated frustration over policy of not being able to keep their cigarettes the same as others in the facility were allowed. Resident #69 stated she felt it was unfair because she was a safe smoker and does not require any type of assistance or supervision however was not allowed to keep her smoking items and must wait for smoking breaks and staff. While the residents continued to wait for the staff to supervise, a nurse came out to bring medications to Resident #103 and the other residents quickly insisted, can you find someone for our break? and added no one even showed up yesterday. Resident #41 arrived with her cigarettes/lighter as the nurse left and started smoking, standing away from the group. The residents were asked if they could recall a smoking evaluation/assessment to discuss if they were able to keep their paraphernalia or not. All residents present stated they were not aware of any type of assessment. Housekeeper J arrived at 1:39 p.m. for the smoking break, issued each resident 2 cigarettes and lit the cigarettes for all residents. In an observation and interview with Housekeeper J on 05/25/2023 at 1:48 p.m., Housekeeper J revealed that none of the smokers present had any special supervision needs or safety concerns. She stated if any of them did the nurses would share those with her prior to smoke break. In an interview with Resident #103 on 05/27/2023 at 1:14 p.m., Resident #103 revealed he transferred to this facility from an Assisted Living and has been allowed to keep his smoking paraphernalia with him. Resident #103 revealed he was told if he can find a staff member on break in a smoking area, he was allowed to go out and smoke with them between the regular posted times. In an interview with the Administrator on 05/27/2023 at 2:29 p.m., the Administrator revealed she knew there was a lot of frustration between the smokers due to the transition of the two facilities. She stated she had tried to make the move for those transferring as smooth as possible, but it had caused problems for those who were used to having smoke breaks more supervised. The Administrator further revealed the smoking policy had been expanded to allow residents who keep paraphernalia to only allow electronic lighters however staff continue to find regular lighters and must educate residents on policy. The Administrator stated she had not found a solution at this time but would make it a priority. Record review of the facility's policy, included in the admission Packet, titled, Smoking Policy - Residents, dated 9/2022, revealed, This facility shall establish and maintain safe resident smoking practices. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 12. Residents who have independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Record review of a second policy, provided by the Director of Clinical Operations, titled, Smoking Policy Residents, revised July 2017, revealed, This facility shall establish and maintain safe resident smoking practices. 2. Smoking is only permitted in designated resident smoking areas, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 2 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete are located outside of the building. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. Record review of the facility's policy titled, Resident Rights, revised February 2021, revealed, 1. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the residents right to: (e). self-determination and (i). exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. Event ID: Facility ID: 455628 If continuation sheet Page 3 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 1 of 1 resident council group whose minutes were reviewed. Residents Affected - Some The facility failed to address the groups grievances presented since February 2023. This deficient practice could affect residents in attendance and result in feelings of worthlessness. The findings were: Review of the Resident council minutes from February 2023 to May 2023 revealed the following concerns: February 2023 Dietary Concerns: Menus were not being presented to residents prior to the scheduled meal. Residents did not know their meal choices for the day and or the kitchen did not always serve food items according to the menu. Condiments were not provided for all meals and some food were served repetitively. Housekeeping Concerns: The floors on the E wing were not getting cleaned especially in the resident bathrooms. March 2023: Dietary Concerns: Daily menus were not posted; staff was not taking daily meal orders; and the quality of food had worsened. The same foods were served alot of the time and there was no variety of foods. The DM was invited to the group to address stated issues. Nursing Concerns: Residents were not receiving all scheduled medications from agency staff. The nurses were not holding CNA's accountable for completing assigned tasks. April 2023: Nursing concerns: The facility was short staffed on weekends. Dietary Concerns: The kitchen was still running out of sugar and jelly. Housekeeping Concerns: The dining room was not cleaned after meals and left dirty. Resident bathrooms were not being cleaned properly. May 2023: Dietary Concerns: Daily menus were not posted; staff was not taking daily meal orders; and the same foods were served over and over (too much chicken). There were not enough desserts made for everyone and or desserts were not posted on the menu. Residents did not know what dessert they would receive. Residents were not offered a meal of the month. Housekeeping Concerns: Housekeeping staff was still not cleaning the floors and floor technician was not moving the resident furniture to clean underneath. The trash was not picked up off the floors. Nursing Concerns: Staff was not passing out medications to the right resident. Nursing staff was not wearing their name tags. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 4 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0565 Level of Harm - Minimal harm or potential for actual harm Maintenance Concerns: Resident had ongoing problems with not being able to access specific TV channels and the remotes were often lost. Observation from 05/24/23 to 05/27/23 revealed there were no grievance forms in the basket located at the designated place on the entry hallway. Residents Affected - Some Interview on 05/25/23 at 11:15 AM revealed 12 Residents attended the group meeting. Residents expressed the following concerns: Dietary: The quality of the food was not good and they were served certain items like chicken and ham all the time. They were served items they did not like even after telling staff multiple times they did not like the specific food item. Daily menus were not always posted and desserts were never posted on the menu. Residents were not always served what was on the menu and they often ran out of food such as milk and condiments such as sugar and salt. On this date: 5/24/23 there was no milk, One Resident was offered syrup for his cereal and previously had been offered chocolate milk because there was no regular milk. Dietary staff always used the excuse the supplier did not provide all food items as ordered, but they did not see Dietary staff making any efforts to go to the store to buy items that were not received. Sometimes 2nd helpings were not available. Residents stated they had been patient and wanted to give staff an opportunity to make improvements because there were many new administrative staff as of January 2023. The Residents stated that staff was not addressing their concerns after council meetings. They further stated the AD would review the concerns for the previous month during each meeting and every month the same concerns would come up. Residents stated they felt staff was not listening and did not care about their concerns. Residents also mentioned there were multiple residents recently admitted to the facility after another facility closed down. The new residents were allowed to have cigarettes and lighters on them and smoke at liberty because they lived in the ALF at the previous facility. However, all smokers who had been in the facility including safe smokers had to wait to smoke at allotted smoking times and were not allowed to have cigarettes and lighters on them. Residents stated they did not believe it was right or fair. Residents stated they had the same housekeeping concerns as mentioned on the resident council minutes. Staff did not clean their bathrooms very well; did not mop the resident floors, did not pick up trash in the resident rooms or clean the dining room. Residents were not able to vote during the last major election season. The AD quit and the Activity Assistant did not follow up with it. Residents also stated they were very upset the facility decided to convert the Chapel into a rehabilitation gym without telling them or giving them an opportunity to express their position. Interview on 05/26/23 at 1:30 PM with the AD revealed the previous AD explained the process of assisting Residents to vote for local and statewide elections. She stated the previous AD left before the last major election and was not sure if she assisted the Residents to vote. The AD stated she took over after the election and was not sure whether or not the residents were able to vote. Interview on 05/27/23 at 06:24 PM with the Administrator revealed the AD would address council grievances during morning meetings. She stated she would assign concerns to Department heads. She expected staff to reach a resolution within 48 hours. The Department Manager would be responsible for talking with the Resident about the outcome. The Administrator stated the AD should write resident council concerns on a grievance form for every individual concern after council meetings. The Administrator stated the AD should have provided her with a copy of the minutes, but was not doing it. However, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 5 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Administrator stated as the person in charge of the grievance process, she should have also reminded the AD to provide her a copy. The Administrator stated she did not recognize all the concerns brought up during the resident council meetings from February 2023 to May 2023 as she reviewed the minutes. She stated she was aware not all grievances were being addressed. She stated concerns with agency staff, staff not wearing name badges and rooms not being cleaned regularly and thoroughly had been addressed. However, she would not be able to provide anything in writing to support staff's efforts. The Administrator confirmed grievance forms had not been available until after today when the basket was filled. Review of facility policy titled, Grievances/Complaints, Filing, revised 2017, read partly as follows: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances for the satisfaction of the resident and/or representative. 1. Any resident, family members, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 3. All grievances, complaints or recommendations stemming from resident or family groups, concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including a rationale for the response. 7. Upon receipt of a grievance and or complaint, the grievance officer will receive and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. 11. The resident or person filing the grievance and/or on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 6 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 - Some 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 interview and record review the facility failed to ensure the right to refuse and/or discontinue treatment and to formulate an advance directive for 4 of 24 Residents (Resident #28, #53, #69 and #324) whose records were reviewed for DNR status. 1. The facility failed to ensure Resident #28's DNR include his date of birth making it an invalid document. 2. The facility failed to ensure Resident #53's DNR contained two witness signatures twice on the document. 3. The facility failed to ensure Resident #69's OOH-DNR was valid. 4. The facility failed to ensure Resident #324's DNR had a licensed physician signature. The DNR was signed by a nurse practitioner. These failures could place residents at-risk for having their end of life wishes dishonored. The findings were: 1. Review of Resident #28's admission sheet, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses to include unspecified Dementia mild, with anxiety, unspecified Atrial Fibriliation and Heart Failure. Further review revealed Resident #28 had a family member named as the reponsible party Review of Resident #28's quarterly MDS assessment, datd [DATE], revealed his BIMS was 12 out of 15 reflecting some cognitive impairment. Review of Resident #28's Care Plan, initiated [DATE], revealed he had a DNR in place. The goal was to honor Resident #28's wishes and some of the interventions included follow living will and to obtain Advance Directive with physician order and resident/responsible party signature. Review of Resident #28's OOH DNR, signed [DATE] revealed the Resident's date of birth was not provided/filled in on the document. Interview on [DATE] at 9:30 AM with the ADM and Regional RN revealed they had audited all Resident's code status on [DATE] and had reviewed all DNR documentation making corrections as needed. The Regional RN stated a DNR required a resident's date of birth in order for it to be valid. The Regional RN stated they did not know Resident #28's birth date was not on his DNR. 2. Record review of Resident #53's admission records, dated [DATE], revealed an admission date of [DATE] and diagnoses that included syringomyelia (a neurological disorder in which a fluid-filled cyst (syrinx) forms within the spinal cord. The syrinx can get big enough to damage the spinal cord and compress and injure the nerve fibers that carry information to and from the brain to the body) and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Further review revealed resident #53 was their own responsible party and under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 7 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 section titled Advanced Directive stated Do Not Resuscitate. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #53's quarterly MDS assessment, dated [DATE], revealed the resident had a BIMS score of 15 indicating intact cognition. Residents Affected - Some Record review of Resident #53's care plan, date initiated [DATE], revealed Resident #53 choose to die with dignity and my wish is to be kept free from any artificial interventions that would prolong my life including CPR, tube feeding, and IVs. I choose a DNR code status and have a OOH-DNR on file. During an interview on [DATE] at 10:38 a.m. the administrator stated the DNR was missing the witness signatures at the bottom of the document. The administrator stated the DNR was not valid and would need to be redone. Record review of Resident #53's OOH-DNR, signed [DATE] by the resident, revealed the section for all persons who have signed above must sign below, did not contain the two witness signatures. 3. Record review of Resident #69's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE], with diagnoses that included: chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), epilepsy (a neurological condition that causes unprovoked, recurrent seizures) and essential hypertension (high blood pressure). Further review of Resident #69's face sheet revealed under the section ADVANCE DIRECTIVE: Do Not Resuscitate - DNR. Record review of Resident #69's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. Record review of Resident #69's Care Plan, last review date [DATE], revealed a focus: Patient has an advance Directive as evidenced by: Do not Resuscitate. Patient's wishes will be honored. Record review of Resident #69's OOH-DNR, dated [DATE], revealed Resident #69 had not signed the OOH-DNR. Resident #69's family member had signed in Section C as nearest living relative and I am qualified to make this treatment decision under Health and Safety Code 166.088. During a record review and interview with the Administrator on [DATE] at 10:56 a.m., the Administrator confirmed the OOH-DNR would not be valid with the family member's signature since Resident #69 remained cognitively intact and could sign for herself. The Administrator stated she would have a conversation with Resident #69 to determine the resident's wishes and provide Resident #69 assistance with the completion of a new OOH-DNR if needed in order to ensure her wishes were honored. 4. Record review of Resident #324's entry MD, dated [DATE], revealed, readmission date of [DATE] and an initial admission date of [DATE]. Record review of Resident #324's OOH-DNR, singed [DATE] by Resident #324, was signed by a nurse practitioner in the section Physician's Statement and on the bottom line for attending physician's signature. During an interview on [DATE] at 10:38 a.m. the Administrator stated it looked like a nurse practitioner had signed resident #324's OOH-DNR and it was probably not correct. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 8 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 the DNR was not valid and they would fix it immediately. Level of Harm - Minimal harm or potential for actual harm Record review of the Texas Health and Human Services webpage, www.dshs.texas.gov/emstraumasystems/dnr.shtm, titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: Filling out the Out-of-Hospital Do-Not-Resuscitate Form. Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. Further review revealed, Can a physician's assistant or nurse practitioner sign the physician's statement? No. Only the attending physician can sign in this section. Residents Affected - Some Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (6) places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician. (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed. Record review of the facility's policy titled, Do Not Resuscitate Order, revised [DATE], revealed, 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 9 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide notice to residents of the change as soon as was reasonably possible. where changes in coverage were made to items and services covered by Medicare for 2 of 3 Residents (Resident #87 and Resident #277) whose records were reviewed for Medicare eligibility. Residents Affected - Few 1. The facility failed to provide Resident #87 with a beneficiary protection notification before skilled services were terminated. 2. The facility failed to provide Resident # 277 with a beneficiary protection notification before skilled services were terminated. These deficient practices could affect residents whose covered status changed and could result in residents not having sufficient time to consider their options. The findings were: 1. Review of Resident #87's admission record, dated 5/27/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (causes the brain to shrink and brain cells to eventually die, CVA (ischemic stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and Hemiplegia (partial paralysis. Review of Resident #87's annual MDS assessment, dated 3/18/23, revealed her BIMS was coded as severely impaired. Review of Resident #87's Notice of Medicare Non-Coverage, revealed skilled services would be terminated on 2/6/23. Further review revealed the SW left a detailed message on 2/3/23 for Resident #87's family member. Review of Resident #87's progress notes for February 2023 did not reveal any documentation reflecting the SW followed up with Resident #87's family member about termination of skilled services 2. Review of Resident #227's admission record, dated 5/27/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Hypertension (high blood pressure), anxiety and depression. Review of Resident #277's discharge MDS assessment, dated 3/16/23, revealed her BIMS was 15 reflecting she was cognitively intact. Review of Resident #277's Notice of Medicare Non-Coverage, revealed skilled services would be terminated on 3/16/23. Further review revealed Resident #277 form was blank. Interview on 05/27/23 at 05:10 PM with the BOM confirmed Residents #87 and #277 were not provided with notification of termination of skilled services. She stated the SW who was responsible for providing notifications was no longer employed at the facility. She stated she had been providing the notifications and to her knowledge staff was to provide residents with at least a 2 day notice before skilled services were terminated. This would allow the residents time to decide whether or not to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 10 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0582 continue with services or to appeal for continued services. The BOM stated leaving a message for a famiy member was not sufficient notification and multiple attempts should be made to reach the family member. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 11 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 have physician orders for the resident's immediate care at the time the resident was admitted for 1 of 8 (Resident #274) residents whose records was reviewed for physician orders in that; Residents Affected - Few The facility failed to obtain a physician order for Resident #274's CPAP machine. This failure could place residents at-risk of inadequate monitoring of medical conditions and not receiving the correct amount of oxygen while sleeping. The findings were: Record review of Resident #274s face sheet, dated 05/27/2023, revealed an admission date of 05/12/2023 with diagnoses that included: rheumatoid arthritis (a chronic inflammatory disease that affects the joints), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. Record review of Resident #274's admission MDS, dated [DATE], revealed the resident's BIMS score was 14, which indicated the resident's cognition to be intact. Further review in Section O, Special Treatments, Procedures, and Programs, revealed Resident #274 had received Non-Invasive Mechanical Ventilator (BiPaP/CPAP) while a resident of this facility and within the last 14 days and an additional diagnosis of respiratory failure with hypoxia (decreased level of oxygen in all or part of your body, such as your brain). Record review of Resident #274's care plan, last dated 05/26/2023, revealed no focus area for the CPAP machine. Record review of Resident #274's active orders, dated 05/27/2023, revealed no orders for a CPAP. In an observation and interview with Resident #274 on 05/23/2023 at 12:45 p.m., Resident #274 revealed the CPAP machine, on the shelf behind her, belonged to her and she had used it every night since admission. She stated she was able to put it on herself but had to have nursing assistance at times. In an interview with the DON on 05/27/2023 at 3:45 p.m., the DON revealed the CPAP machine should have been on the physician's orders so the nursing staff would know the settings that need to be closely monitored. The DON stated the nursing staff should have ensured there were orders in place for Resident # 274's CPAP and did not know why the CPAP orders had not been included. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 12 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 4 of 16 residents (Residents #1, #18 and #116) whose assessments were reviewed. Residents Affected - Some 1. The facility failed to accurately assess Resident #1's diagnosis of UTI after returning from the hospital. 2. The facility failed to accurately assess Resident 18's fall history on her quarterly assessment. 3. The facility failed to accurately assess Resident #116's cognition status on his admission assessment. These failures could lead to the residents' not receiving the care and services they needed based on their assessment. The findings were: 1. Review of Resident #1's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Neuromuscular dysfunction of bladder (disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and unspecified Dementia (general name for a decline in cognitive abilities). Review of progress note, dated 4/9/23, revealed Resident #1 complained of abdominal pain. Resident #1 was transferred to the hospital where he remained until 4/14/23. Further review revealed, one of his diagnosis while at the hospital included UTI. Review of Resident 1#1's quarterly MDS assessment, dated 4/19/23, revealed his BIMS was 13 of 15 indicating minimal cognitive impairment. Further review revealed a diagnosis of UTI was not coded under Section I., Active Diagnosis. Interview on 05/27/23 at 04:39 PM with MDS Coordinator F revealed she did not capture Resident #1's UTI diagnosis on his quarterly MDS, dated [DATE]. She stated a diagnosis of UTI was included for the previous 30 days. from the completion of the assessment. MDS Coordinator F stated it was important to include the Resident's most current medical condition because staff had access to the resident's electronic record which included the resident's care needs. 2. Review of Resident #18's admission record, dated 5/24/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Multiple Sclerosis (potentially disabling disease of the brain and spinal cord [central nervous system], Aphasia (disorder that results from damage to portions of the brain that are responsible for language), and Other Seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Review of the incident/accident log from [DATE] to May 2023 revealed Resident #18 had an unwitnessed fall on 3/20/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 13 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of incident report, dated 3/20/23, revealed Resident #18 slid out of bed while CNA was giving her a bed bath while turning her. Slid onto floor mat. CNA guided her to floor mat. Assessment completed and no injuries noted. Review of Resident #18's quarterly MDS assessment, dated 3/21/23, revealed it did not reflect a fall history since re-entry, 9/17/21. Interview on 05/27/23 at 04:17 PM with MDS Coordinator F revealed Resident #18's fall was not coded in her assessment and it should be included. MDS Coordinator F stated it was important to include the Resident's most current medical condition because staff had access to the resident's electronic record which included the resident's care needs. She stated regional staff provided training and they used the RAI for guidance. 3. Review of Resident #116's face sheet dated 05/23/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included emphysema (a lung condition that causes shortness of breath) and aphasia following cerebral infarction (a disorder that affects how you communicate, affecting speech and possibly the way you write and understand both spoken and written language; it usually happens after a stroke or head injury). Review of Resident #116's admission MDS dated [DATE], Section C: Cognitive Patterns, revealed under the heading, C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? The code 0 was entered, indicating, No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status. Review of Resident #116's BIMS assessment dated [DATE] by the facility's social worker revealed a score of 9, indicating the resident's cognition was moderately impaired. A note at the end of the assessment stated, Resident #116 is unable to communicate verbally, and this assessment was modified for him to communicate using his hand to repeat numbers back to this clinician. Review of Resident #116's electronic health record revealed an initial progress note dated 03/25/2023, 10:10 a.m. stating: Alert and oriented x 2-3. Has some difficulty communicating verbally at times due to aphasia related to previous stroke but was able to make needs known most of the time. Denies pain or discomfort when asked. Review of progress note dated 05/21/2023, 9:38 a.m., revealed: Alert and oriented x 3. Transfer and toilet with assist. Feeds himself. Denies pain at this time. Tolerating therapy services well. Interview with Resident #116 on 05/23/2023 at 2:45 p.m. revealed Resident #116 could not speak clearly; however, he was able to answer the surveyor's questions by nodding his head to indicate yes or no and using hand gestures. Interview on 05/27/2023 at 4:07 p.m. with MDS Coordinator G revealed she coded Resident #116 as No is rarely/never understood on his Admission/5-day MDS dated [DATE], and this was an inaccurate assessment of the resident's cognitive status; she should have coded him as not assessed because the resident was able to communicate. MDS Coordinator G stated that at the time this assessment was due, the facility's social worker had left the position full time and she had to submit the assessment to get it in on time. The social worker would later return to work for the facility on a part-time basis, completing MDS assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 14 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Interview on 05/27/2023 at 5:05 p.m. with the DON revealed Resident #116 was able to communicate and should not have been coded in his assessment as though he was rarely/never understood. The DON stated she knew the resident and his family from before his admission to the facility, she communicates with him on a regular basis, and would assess his cognition as moderately intact. The DON stated she was responsible for overseeing the MDS' for accuracy. Residents Affected - Some Review of facility policy Resident Assessments Revised March 2022 revealed, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: (1) admission Assessment (Comprehensive); (2) Quarterly; (3) Annual Assessment (Comprehensive); 4 Significant Change in Status Assessment (Comprehensive) .3. A 'comprehensive assessment' includes a. completion of the Minimum Data Set (MDS); b. completion of the care area assessment (CAA) process; and c. development of the comprehensive care plan. Surveyor: [NAME], [NAME] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 15 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #274) reviewed for baseline care plan, in that: The facility failed to ensure Resident #274's baseline care plan included information related to resident's use of a CPAP. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #274s face sheet, dated 05/27/2023, revealed an admission date of 05/12/2023 with diagnoses that included: rheumatoid arthritis (a chronic inflammatory disease that affects the joints), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. Record review of Resident #274's admission MDS, dated [DATE], revealed the resident's BIMS score was 14, which indicated the resident's cognition to be intact. Further review in Section O, Special Treatments, Procedures, and Programs, revealed Resident #274 had received Non-Invasive Mechanical Ventilator (BiPaP/CPAP) while a resident of this facility and within the last 14 days and an additional diagnosis of respiratory failure with hypoxia (decreased level of oxygen in all or part of your body, such as your brain). Record review of Resident #274's care plan, last dated 05/26/2023, revealed no focus area for the CPAP machine. Record review of Resident #274's active orders, dated 05/27/2023, revealed no orders for a CPAP. In an interview with Resident #274 on 05/23/2023 at 12:45 p.m., Resident #274 revealed the CPAP machine belonged to her and she had used the CPAP every night since she moved into the facility. In an interview with the DON on 05/27/2023 at 3:45 p.m., the DON revealed the CPAP machine should have been on the baseline care plan so nursing staff would know the settings that need to be closely monitored. The DON stated she did not know why the CPAP orders had not been included. In a record review and interview with MDS Coordinator G on 05/27/2023 at 4:53 p.m., MDS Coordinator G confirmed the resident's CPAP needs were not indicated on the care plan and should be for nursing staff to know how to care for Resident #274's needs. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised March 2022, revealed, Resident care plans are developed according to the timeframes and criteria established by 483.21. Further reference of the policy revealed the reference, 483.21(a) Baseline Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 16 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0655 Plans. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 17 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 8 Residents (Resident #116) reviewed for care plans.: The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #116 to address the resident's communication problem. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were: Review of Resident #116's face sheet dated 05/23/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included emphysema (a lung condition that causes shortness of breath) and aphasia following cerebral infarction (a disorder that affects how you communicate, affecting speech and possibly the way you write and understand both spoken and written language; it usually happens after a stroke or head injury). Review of Resident #116's BIMS assessment conducted on 04/02/2023 by the facility's social worker revealed a score of 9, indicating the resident's cognition was moderately impaired. A note at the end of the assessment stated, Resident #116 is unable to communicate verbally, and this assessment was modified for him to communicate using his hand to repeat numbers back to this clinician. Review of Resident #116's comprehensive care plan dated 03/09/2023 revealed there was not a care plan addressing the resident's communication problem. Interview on 05/27/2023 at 4:07 p.m. with MDS Coordinator G revealed Communication deficit should have been addressed in Resident #116's care plan, stating, I didn't do a good job. MDS Coordinator G stated that if this deficit were not addressed in the resident's care plan, staff members would not be aware of it and would therefore not understand the best way to communicate with him and ensure his needs were met. MDS Coordinator G further stated there was a regional coordinator who provided training every other week. Interview on 05/27/2023 at 5:00 p.m. with the DON revealed she was aware that Resident #116 had a communication deficit and this deficit should have absolutely been addressed in the resident's comprehensive care plan. She did not know why it was omitted, and its omission could potentially have a negative effect on the resident by not identifying ways for staff members to communicate with the resident by means other than language. The DON stated she was responsible for overseeing accurate and timely completion of care plans. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2021, revealed, 8. The comprehensive, person-centered care plan will: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 18 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 psychosocial well-being and j. Reflect the resident's expressed wishes regarding care and treatment goals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 19 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #1 & #24) for care plan revisions, in that: 1. The facility failed to ensure Resident #1's Care Plan was revised to include his most recent hospitalization, diagnoses while in the hospital and referral for skilled services. 2. The facility failed to ensure Resident #24's care plan was revised to include oxygen therapy and nebulizer treatments. These failures could place residents at risk for not receiving care according to their needs. The findings included: 1. Review of Resident #1's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Neuromuscular dysfunction of bladder (disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and unspecified Dementia (general name for a decline in cognitive abilities). Review of progress note, dated 4/9/23, revealed Resident #1 complained of abdominal pain. Resident #1 was transferred to the hospital where he remained until 4/14/23. Further review revealed Resident #1's diagnoses while at the hospital included osteomyelitis of pressure wound, sepsis, and UTI. Review of Resident #1's Care Plan, last revised on 4/17/23, did not reveal a focused area that Resident #1 was hospitalized and diagnosed with osteomyelitis of pressure wound, sepsis, and UTI. Interview on 05/27/23 at 04:39 PM with MDS Coordinator F confirmed she did not include Resident #1's hospitalizations and diagnoses including osteomyelitis of pressure wound, sepsis, and UTI. MDS Coordinator F stated a resident's Care Plan was a continuous reflection of their status and it was important that all care areas were included because it directed the care of the resident. MDS Coordinator F further stated Resident #1 was referred for skilled services and received OT as a result of his hospitalization. She stated this should have also been included in his Care Plan as a focused area. 2. Record review of Resident #24's face sheet dated 05/23/2023 revealed an initial admission date of 03/15/2017 with a most recent admission of 02/13/2023 and diagnoses which included: primary osteoarthritis (degenerative joint disease from breakdown of joint cartilage and underlying bone) of left hip, diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 08, which indicated moderate cognitive impairment. Further review revealed the assessment indicated Resident #24 had not received oxygen therapy within the last 14 days. Record review of Resident #24's care plan, last review date 04/03/2023, revealed no focus area for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 20 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0657 oxygen therapy or nebulizer treatments. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #24's active orders, dated 05/26/2023, revealed an order for oxygen 2-4 liters to keep sats above 90% PRN. Every 24 hours as needed, with a start date of 03/06/2023. Further review revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer, with a start date of 05/04/2023. Residents Affected - Few In an interview with RN H on 05/23/2023 at 12:05 p.m., RN H reviewed Resident #24's orders in the electronic medical record and confirmed Resident #24 remains on nebulizer treatments and oxygen. In a record review and interview with the DON on 05/27/2023 at 3:45 p.m., the DON confirmed neither the oxygen nor nebulizer treatments for Resident #24 were on the care plan and stated they should be so that nursing would have the instructions needed to provide care to the resident. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 11. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: (a) when there has been a significant change in the resident's condition; (b) when the desired outcome is not met; (c) when the resident has been readmitted to the facility from a hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 21 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 24 Residents (Resident #76) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #76, who had a DNR in place, CPR, after the resident choked and became unresponsive, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 05/26/2023. While the IJ was removed on 05/27/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical and psychological health and result in serious injury and or death. Review of Resident #76's admission record, dated 5/23/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Dementia (is a progressive brain condition that can cause issues with thinking, behavior, and memory) in other Diseases Classified Elsewhere, Moderate with Agitation, Parkinson's Disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and Dysphagia, Oropharyngeal Phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). Review of Resident #76's admission MDS assessment, dated 3/10/23, revealed her BIMS was 01 of 15 reflecting severe cognitive impairment and she required extensive assistance by 1 or 2 persons for ADL's including eating. Review of Resident #76's Care Plan, revised on 3/10/23, revealed she had a diet alteration related to Resident and family wishes. Resident and family wish for Regular diet, regular texture. The interventions included: Educate patient on nutrient restriction in relation to medical condition/Dx, Diet as ordered, Monitor lab data as available, Monitor meal consumption daily, Notify physician and family/responsible party of weight change, Obtain and update food/beverage preferences. Resident also had an advance Directive as evidenced by DNR. Interventions included: Follow facility protocol for identification of code status. Follow Living Will. Obtain Advance Directive with physician order and resident/responsible party signature. Review of Resident #76's of physician orders for May 2023 revealed she had an order for regular diet, thin regular consistency, dated 3/6/23; and an order for DNR, dated 4/13/23. Review of Resident #76's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) revealed it was signed on 4/21/21. Review of a cheat sheet with resident's code status observed in rooms 1 to 13 revealed Resident #76's code status was not included. Review of progress note, dated 5/25/23, at 18:51 (6:51) PM, read as follows: Event Type: Pt choked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 22 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on chicken and rice at lunch time and then went into cardiac arrest requiring CPR to be performed. Date of Event: 5/25/2023 Time of event: 1215 Detailed description of event (how, when, where, vitals, symptoms): Pt assessed choking on food at lunch time in dining room. Pt not moving air at all and not coughing just showing signs of a blocked airway. Had CNA and LVN try to pull patient out of chair to attempt to do Heimlich maneuver and 3-4 thrusts given but pt could not stay upright so we lowered pt to ground. 911 called. LVN gave 4-5 Heimlich maneuver thrusts which did move food a little bit but pt was still choking. At this time pt became unresponsive, carotid pulse palpated with no pulse detected and pt with no respirations. Then CPR was initiated. 2-3 compressions given per [name], LVN, which caused a big inspiratory gasp and pt opened her eyes then. Pt having shallow respiration but is moving air. Placed pt on right side in the rescue position and continued to attempt to remove what was in her airway. Some chicken and rice were removed. EMS arrives and takes over code. Pt leaves building on stretcher at 1245 with EMS. Patients' description of event: Pt unable to describe event due to dementia. Full Range of Motion Assessment findings (i.e. wnl for resident, or describe abnormal findings): wnl for resident. MD Notification (Date, Time, Method of communication): 5/25/23 at 1300 (1:00 PM) Responsible Party Notification (Date, Time): [LVN B] notified at 1300 (1:00 PM) Interventions (should address any abnormal assessment findings): Pt transferred to [hospital] ER per EMS. If Fall note-injury, how patient was found, environment, footwear, last toileted, FSBS if diabetic: NA. Review of progress note, dated 5/25/23 at 18:16 PM (6:16 PM), revealed Resident #76 was admitted to the ICU at a local hospital. Observation at 05/25/23 in the dining room, on hall B at 12:22 PM, revealed multiple staff (RN A, LVN B and CNA C) with Resident #76. LVN B and CNA C were holding Resident #76 up and she was slumped forward. It looked like the Resident was going to throw up. RN A conducted multiple abdominal thrusts and then told the other staff, We are going to have to lay her down. LVN B and CNA C laid Resident #76 on the floor on her right side. LVN B opened Resident #76's mouth and stated something was stuck in the back of the Resident's throat. She turned Resident #76 on her back and completed multiple rapid abdominal thrusts. She removed some food particles, but LVN B stated the airway was still obstructed. RN A noted Resident #76 was non-responsive, was not able to find her carotid pulse, then instructed LVN B to start CPR. LVN B started performing chest compressions on Resident #76. Resident #76 took a deep breath after about 3 to 5 minutes. RN A then instructed CNA E to call 911 which he proceeded to do from the nurse's station at 12:30 PM. Further observation revealed EMS arrived about 10 to 15 minutes later. Interview on 05/25/23 at 12:32 PM with a family member revealed she saw Resident #76 choking and told CNA E about it. She stated CNA E walked up to the Resident, asked if she was choking, walked away into room [ROOM NUMBER]. The family member stated it did not have to get this far and the situation could have been prevented had CNA E told someone. Interview on 05/25/23 at 12:33 PM with CNA E revealed he denied a family member spoke with him. He stated he saw Resident #76 was red and had her hands on her chest. She put her hands down and he asked if she was ok, and she said Yes. CNA E stated he walked into room [ROOM NUMBER] and told CNA C something was going on with Resident #76. CNA C went to check on Resident #76. Interview on 05/25/23 at 12:41 PM with CNA C revealed she was walking towards the dining room and saw Resident #76 put her hands on her chest. She looked closer and saw Resident #76 was not breathing and looked like she was choking. She told RN A who was standing by the food cart that Resident #76 was not breathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 23 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 05/25/23 at 2:15 PM with CNA E stated he was agency staff and had worked at the facility for 10 months. He stated he had been a CNA since 1996. CNA E was asked what was the first thing he should do in an emergency situation. CNA E stated he had been in this situation before and knew what to do. CNA E stated he told CNA C something was going on with Resident #76 because she was the first staff he saw. He stated CNA C looked at Resident #76 and commented Resident #76 was choking and not breathing. CNA E was asked if he reported the incident to a nurse? He changed the subject and said the nurses were passing out trays. He stated they were supposed to stay in the dining room but were not there. CNA E stated CNA C let the nurses know what was going on. He stated he called 911 after RN A told him, but he did not know how to reach the DON because he did not know how to use the phone at the nurse's desk. He stated he started walking down the hall towards the main offices and flagged the DON down when he saw her. Interview on 05/25/23 at 02:25 PM with RN A revealed her and LVN B were normally in the dining room to supervise the residents during mealtime. RN A stated Resident #76 was eating during lunch time. She stated she had her back to the Resident and was cutting another resident's meat. RN A stated CNA C commented Resident #76 was choking and not breathing. She turned around and saw Resident #76 was turning colors. She stated she responded and tried to perform abdominal thrusts while CNA C and LVN B were holding Resident #76. Resident #76 was slumped over, and flopped down. RN A stated she could not get the technique right because the Resident was slumped over so she told the other staff to lie her down. At that point LVN B tried to conduct abdominal thrusts while the Resident was in supine position. LVN B also tried to dislodge the food by doing a finger sweep. She stated LVN B got some rice and a small piece of chicken out but could not clear Resident #76's throat. RN A stated she looked over at Resident #76 and noted she was blue. She checked for the Resident's carotid pulse but could not find one. RN A stated Resident #76 had agonal breathing (labored, gasping breaths that occur because of insufficient oxygen), and she instructed CNA E to call 911. She stated she checked Resident #76 before she left and had a good bounding (heart is beating faster than normal) caranda pulse but staff and the EMT's could not get a reading on the Resident's O2 saturations. Interview on 05/25/23 at 3:05 PM with RN A revealed she should have called 911 right away or had another staff to call 911 upon responding to Resident #76's choking. She stated she did not know Resident #76's code status and did not check before or after responding to Resident #76 choking incident. She stated she found out Resident #76 was a DNR when gathering paperwork for the EMT's. She stated they should not have performed CPR with a DNR in place. However, she stated she believed they did what they had to do in responding to the emergency situation. She stated they moved from performing the Heimlich Maneuver to providing CPR because Resident #76 had no pulse. RN A identified at the point she could not find a pulse might have been the deciding factor not to pursue CPR. She stated she was not sure about it. RN A stated she would have to talk with the DON and maybe the physician for clarification. RN A stated staff had to look in PCC to get Resident #76's code status and was not sure if the resident's charts were color coded to alert staff about their code status. She stated she tried calling the DON while LVN B was performing abdominal thrusts, but the DON did not answer her phone. RN A stated once LVN B resuscitated Resident #76, she used the phone at the nurse's desk and paged the DON STAT to hall B. Interview on 05/25/2023 at 3:47 PM with the DON revealed she stated RN A and LVN B did not perform CPR after responding to Resident #76 choking. She stated they only performed the Heimlich Maneuver. Surveyor clarified, per observation, nursing staff performed CPR when RN A and LVN B were not able to clear Resident #76's airway. The DON stated if the Resident was choking, My position is for them to perform CPR, because that's a horrible death. The DON was asked if staff knew Resident #76 had a DNR should they have performed CPR. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 24 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated, that would be something we have to look into because I don't agree that anyone should have to die like that. The DON stated in an emergency situation staff should assess the resident and call 911 after establishing it was an emergency. The DON stated staff carried a sheet of paper with the resident's code status and other care needs so they should know when to call 911. The DON stated the resident's DNR status was also on a report sheet at the nurse's station and in PCC. Interview on 05/25/23 at 4:51 PM with the DON revealed she interpreted the policy as I still would have done it. (DON read policy that stated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect.) The DON was informed the Heimlich was unsuccessful and RN A was unable to find a carotid pulse. The DON stated I'm aware that she coded and had no pulse. I see it, she was still choking. I see the chicken in her throat as affecting her having no pulse. I consider someone dead when they have no apical pulse. The DON further stated staff was to check for a DNR right away in the resident's electronic medical record that is my expectation. Interview on 05/25/23 at 04:52 PM with LVN B revealed she did not know Resident #76's code status when she started CPR. She stated she should not perform CPR when a DNR was in place, and she should have checked Resident 76's code status prior to performing CPR. LVN B stated she did not check. She stated she was not sure about whether or not she should have performed CPR because initially she responded to Resident #76 choking. She performed CPR when she was not able to dislodge the food from the Resident's throat and after RN A could not find a pulse. LVN B stated she thought about the fact she did not know Resident #76's code status when performing CPR. She sated everything happened so fast and she was focused on helping Resident #76. LVN B became tearful during the conversation. LVN B stated would have to look in PCC for the resident's code status. LVN B was not aware of anywhere else she could find a resident's code status during an emergency situation. Interview on 05/25/23 at 5:15 PM with CNA C revealed she was walking towards the dining room and noticed Resident #76's color was off. She stated CNA E approached her and said he did not know if Resident #76 was having a problem breathing. She stated she walked up to Resident #76, looked at her closer and it looked like she was choking and could not breath. She stated RN A was standing by the food cart and responded right away. CNA C stated LVN B walked around the corner. Then she and LVN B were holding Resident #76 up from her arms because she was not bearing weight. She stated RN A performed some abdominal thrusts, but the Resident was slumped over, so RN A asked them to lie the Resident down. CNA C stated LVN B then tried to do the abdominal thrust again and could not get the food out. LVN B then started CPR when RN A could not find Resident #76's pulse. CNA C stated she did not know Resident #76 code status and could find it in the red book at the nurses station. She stated it was their emergency book. CNA C walked to the nurses station and could not find the red book. She one of the nurse's on assignment and the nurse told CNA C she did not know anything about a red book. Interview on 5/26/23 at 12:40 PM with Resident #76's family member revealed she talked with facility staff about Resident #76's choking incident which ended up with staff performing CPR. The family member stated she was ok with staff providing CPR because she did not want Resident #76 to choke. The family member did not understand Resident #76 lost consciousness and nursing staff could not find her pulse and then staff performed CPR. The family member did not know facility policy read that nursing staff could not perform CPR once a resident lost consciousness and or could not find a pulse. In addition, the facility CPR policy provided options when addressing other emergency situations for residents who had a DNR in place. The family member stated nursing staff had not discussed any options with her. She stated Resident #76 was placed on what looked like a puree diet when she was initially admitted to the facility and remained on it for a couple of days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 25 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Then she asked the facility to put Resident #76 back on a regular diet because she was refusing to eat the puree food. The family member stated facility staff had not talked with her about the results of a completed ST evaluation. She stated it would have helped her in determining the best diet plan for Resident #76 and wondered if Resident #76 would benefit from eating chopped foods. She stated another family member questioned why staff performed CPR because Resident #76 had a DNR in place. The family member stated she was not sure how she would feel if the Resident was in a coma as a result of having CPR. She stated she would be talking to the other family member about Resident #76's DNR code status and would call the facility. Interview on 05/26/23 at 03:10 PM with Dr. T (MD who signed the DNR), stated Resident #76 had been with their care team since 05/2021 and the last note was entered by an NP, one of the team members. He stated Resident #76 had lost 10% of her body weight and was at end stage Parkinson's, and end stage Dementia. Dr. T stated the team was planning on placing her on hospice soon. He stated the incident with Resident #76 choking and then staff performing CPR was an odd situation and staff could potentially get a resident back if the food was dislodged. He stated he would not start CPR with someone with end stage disease. Dr. T commented, Me personally I wouldn't have started CPR. I can see why the facility started it because she was choking, but she did not have a good quality of life. He stated he would have stated CPR on a patient who was robust. Dr. T wondered how well staff knew Resident #76 and stated it was a tough question; whether or not to perform CPR after a choking incident. He stated almost universally all the patients and families who they talked with and had a DNR did not want CPR even if the patient was choking. Interview on 05/26/2023 at 10:00 AM with the ADM and Regional RN revealed they audited all nursing staff's CPR status and discovered that many of the staff did not have a CPR certification including RN A, LVN B and CNA C. Review of CPR certification status for RN A, LVN B and CNA C revealed they did not have a CPR certification at the time LVN B performed CPR on Resident #76. Review of facility policy, Do Not Resuscitate Order, revised March 2021), read in part; Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a (Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident medical record. 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: c. Medical Orders for Life-Sustaining Treatment. e. Clinical Orders for Life Sustaining Treatment. 5. Do Not Resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. Review of a facility policy, Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, read in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on 05/26/2023 at 12:34 PM and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 26 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 Administrator was notified at 12:34 PM. The Administrator was provided with the IJ template on 05/26/2023. Level of Harm - Immediate jeopardy to resident health or safety The following Plan of Removal was accepted on 05/26/2023 at 6:48 p.m. Residents Affected - Few LETTER OF CREDIBLE ALLEGATION POR FOR REMOVAL OF IMMEDIATE JEOPARDY Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws Verification Plan of Removal: 1. Director of Nursing/designee completed immediate education with RN A, LVN B and CNA C, who were in attendance to emergency on proper response to emergency situation, when to initiate CPR on a resident and include the following steps for emergency response. 1. Staff was trained on 05/25/2023 at 2:15 p.m.; copy of in-service report and sign in sheet provided. 2. Administrator/designee verified status of Resident #76 and was determined by the hospital to be stable and returning to facility on 05/26/2023. 2. The resident's status at the hospital was verified and a fax from the hospital was provided to the survey team. The fax indicated that the resident was alert and awake and in no acute distress, and was initially on a face mask but was being titrated down. returned to the facility on [DATE]. Her diet order had changed to mechanical soft texture. She was observed by the survey staff on 05/26/2023 between 2:00 p.m. to 3:00 p.m. and also on 05/27/2023 at 3:00 p.m. sitting in her wheelchair by the nursing station. She looked well, her eyes were clear and her pallor was good. Per interview on 05/27/2023 at 3:00 p.m. with the charge nurse, when asked if she had choked on some chicken, her response was, Oh, no, that was my daughter. 3. Director of Nursing/designee validated all resident current Code status was up to date and in EHR, including care planned and on direct care [NAME] on 05/26/2023. 3. Verified; however, the survey team discovered that a total of four (4) OOH-DNR forms were invalid. This was brought to the attention of the Administrator and Regional nurse. They acknowledged the deficiency, and this deficient practice will be cited. 4. The Corporate Clinical Resource completed education with the Director of Nursing regarding requirements on Emergency Response, including following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on 5/26/2023. 4. Verified via interview on 5/27/2023 and signed in-service roster. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 27 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 5. The Corporate nurse completed education with nurse management on requirements to follow resident wishes regarding Code status and CPR, regardless of situation or personal feelings. Level of Harm - Immediate jeopardy to resident health or safety 5. Verified via interviews on 5/27/2023 and signed in-service roster. Residents Affected - Few 6. Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on 5/26/2023. Class scheduled to update all certification needed on 06/03/2023 at facility with certified instructor. 6. Verified via list of all licensed staff and their status, and email from instructor indicating she will be at facility at 9:30 a.m. on 6/03/2023. Also received copy of invoice and proof of payment of $1037.50 for 15 students (two 4-hour sessions) and mileage 7. Identification of all others affected: The DON/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff [NAME] care record on 5/26/2023. 7. Verified by visually inspecting hard charts, which all had a divider indicating FULL CODE in neon green/yellow or DNR in red, and also checking EHR's. 8. The DON will complete education with all staff on proper procedures to follow in case of Emergency, including initiation of Emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aide in support areas, such as initiating 911, validating code status, etc. Education will be initiated on 5/26/2023 to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status prior to performing life sustaining measures to avoid violating the resident's wishes. This education will be ongoing with all staff prior to working their next scheduled shift. 9. DON/designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. This education will be ongoing with all staff prior to working their next scheduled shift. 8/9. Verified through record review of sign in sheets of training and also in-person interviews of the following staff members: 1. LVN V 2. HR W 3. CNA X 4. CNA Y 5. CNA Z 6. LVN AA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 28 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0678 7. LVN BB Level of Harm - Immediate jeopardy to resident health or safety 8. CNA CC Residents Affected - Few 10. CNA EE 9. LVN, ADON DD 11. CNA FF 12. LVN GG 13. CNA student HH 14. Dietary Manager 15. LVN R 16. RN II 17. Director of Rehabilitation 18. Maintenance Assistant JJ 19. CNA KK 20. LVN LL 10. Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure -Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on 5/26/2023 at 3:00 p.m. 10. Verified by record review, signed by administrator, medical director (via telephone), DON, both ADON's, and Director of Clinical Operations. A root cause analysis was conducted by the PIP to determine WHY the event occurred. On 5/27/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. The Administrator was informed the Immediate Jeopardy was removed on 05/27/2023 at 10:00 AM. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 29 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 1 facility and that each resident received adequate supervision to prevent accidents for 2 of 24 residents (Residents #41 and #103) reviewed for accidents/supervision, in that: 1. Resident #41 had a lighter and package of cigarettes on her bed. 2. Resident #103 was smoking unsupervised prior to assigned smoking times. 3. The metal receptacle in the smoking area for ashes, marked no trash, contained a can and cigarette package. These failures could place residents at risk for smoking-related injuries. The findings were: 1. Record review of Resident #41's face sheet, dated 05/27/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), metabolic encephalopathy (a medical term used to describe a disease that affects brain structure or function. It causes altered mental status and confusion), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #41's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. Further review revealed the resident's level of assistance with ADLs of walking on and off the unit at a supervised level with no physical assistance of staff and personal care and dressing at an independent level with set up help only. Record review of Resident #41's Care Plan, last review date 05/02/2023, revealed a focus area Patient is a smoker. Interventions included, Resident continues to have cigarettes and lighter in room even after multiple interventions to let nurses lock up supplies, She is alert and oriented x4 and has never smoked in her room, determine safety of patient independently smoking (see smoking assessment). Record review of Resident #41's Smoking Evaluation dated 04/28/2023, revealed the resident had no history of smoking related incidents, did not exhibit signs of confusion, had no visual or dexterity deficits, was able to hold a cigarette safely without a device, safely extinguish a cigarette and did not require any adaptive equipment. Further review revealed staff had reviewed the smoking policy with the resident. Record review of the Smoking Policy - Residents, Rev. 210401-TX, dated 01/10/2023 and signed by Resident #41 revealed 12. Residents who have independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. 2. Record review of Resident #103's face sheet, dated 05/27/2023, revealed the resident had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 30 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initial admission date of 01/06/2023 and re-admission on [DATE], with diagnoses that included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life Record review of Resident #103's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. Further review revealed the resident's level of assistance with ADLs of mobility, using an electric wheelchair on and off the unit and personal care at an independent level with no physical help from staff. Record review of Resident #103's Care Plan, initiated and revised on 05/05/2023, revealed a focus area Cognitive impairment as evidenced by memory impairments/recall issues and interventions that included, reassure resident as needed if confused and reorient resident to situation as needed. Further review revealed an additional focus area, initiated, and revised on 05/05/2023 Patient is a smoker with a goal of Patient will only smoke in designated areas daily until next review. Interventions initiated and revised 05/05/2023 included determine safety of patient independently smoking, patient educated to appropriate smoking areas, if safety becomes a concern involve IDT team and resident for reevaluation of smoking needs. Further review revealed care plan was revised on 05/27/2023 with an initiation of intervention dated 05/25/2023, following surveyor's observation of smoke break and interviews to include Resident continues to smoke outside w/o supervision. Administer has even explained smoking policy to resident and he continues. Record review of Resident #103's Smoking Evaluation dated 04/10/2023, revealed the resident had no history of smoking related incidents, did not exhibit signs of confusion, had no visual or dexterity deficits, was able to hold a cigarette safely without a device, safely extinguish a cigarette and did not require any adaptive equipment. Further review revealed staff had reviewed the smoking policy with the resident. Record review of the Smoking Policy - Residents, Rev. 210401-TX, dated 01/06/2023 and signed by Resident #103 revealed 12. Residents who have independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Observation during initial tour on 05/23/2023 at 12:56 p.m., revealed Resident #41 sitting in her recliner and a package of cigarettes and a lighter on her bed. Resident #41 revealed she had already had lunch and was waiting for the next smoking break. She further revealed she was allowed to keep her cigarettes and lighter because she was a safe smoker. In a group interview during Resident Council, residents revealed some residents are allowed to keep their cigarettes and lighters with them and smoke at times other than the posted times. Observation of the 1:30 PM smoke break on 05/25/2023 at 1:24 p.m., six smokers were present on the patio. Resident #103 had brought his cigarettes out and began to smoke before staff assigned to supervise break arrived. Observation at 1:31 p.m., Resident #41 arrived with her cigarettes and lighter and began to smoke. Housekeeper J arrived at 1:39 p.m. to supervise the smoking break. Observation and interview with Housekeeper J on 05/25/2023 at 1:48 p.m., Housekeeper J revealed she was not aware of any of the smokers who were present had any special supervision needs or safety concerns. She stated, if so the nurses would share those concerns with her prior to smoke break. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 31 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0689 Level of Harm - Minimal harm or potential for actual harm 3. Observation and interview with Housekeeper J on 05/25/2023 at 1:57 p.m., of a tall red metal receptacle on the patio of the smoking area revealed a sign, no trash. Upon attempt to open the metal receptacle the foot pedal would not lift the lid. Housekeeper J revealed the lid to the receptacle gets stuck sometimes and opened the container which revealed a soda can and cigarette pack. Housekeeper J stated, that's not supposed to be in there. Residents Affected - Some In an interview with Resident #103 on 05/27/2023 at 1:14 p.m., Resident #103 revealed he transferred to this facility from an Assisted Living and has been allowed to keep his smoking paraphernalia with him. Resident #103 revealed he was told if he can find a staff member on break in a smoking area, he was allowed to go out and smoke with them between the regular posted times. In an interview with the Administrator on 05/27/2023 at 2:29 p.m., the Administrator revealed she knew there was a lot of frustration between the smokers due to the transition of the two facilities. She stated she had tried to make the move for those transferring as smooth as possible, but it had caused problems for those who were used to having smoke breaks more supervised. The Administrator further revealed the smoking policy had been expanded to allow residents who keep paraphernalia to only allow electronic lighters however staff continue to find regular lighters and must educate residents on policy. The Administrator stated she had not found a solution at this time but would make it a priority. The Administrator further confirmed the metal receptacle should not contain trash in order to keep the community and residents free of hazards. Review of a list of residents who smoke, undated, provided by the facility on 05/23/2023, revealed (13) residents in the facility smoked cigarettes. Record review of the facility's policy, included in the admission Packet, titled, Smoking Policy - Residents, dated 9/2022, revealed, This facility shall establish and maintain safe resident smoking practices. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 12. Residents who have independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Record review of a second policy, provided by the Director of Clinical Operations, titled, Smoking Policy Residents, revised July 2017, revealed, This facility shall establish and maintain safe resident smoking practices. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 32 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 4 of 16 residents (Residents #24, #37, #55 and #274) reviewed for respiratory care, in that: Residents Affected - Some 1. Resident #24's nebulizer mask was unbagged and resting on top of the resident's bedside table. 2. The water reservoir attached to Resident #37's oxygen concentrator was empty and was not replaced in accordance with the facility's changing schedule. 3. Resident #55's nebulizer mask was unbagged and resting on top of the cabinet behind the resident's bed. 4. Resident #274's CPAP mask was unbagged and resting on top of the cabinet behind the resident's bed. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. The findings were: 1. Record review of Resident #24's face sheet, dated 05/23/2023, revealed an admission date of 02/13/2023 with diagnoses that included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 08, which indicated moderate cognitive impairment. Further review revealed the assessment indicated Resident #24 had not received oxygen therapy within the last 14 days. Record review of Resident #24's care plan, last review date 04/03/2023, revealed no focus area for nebulizer treatments. Record review of Resident #24's active orders, dated 05/26/2023, revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer, with a start date of 05/04/2023. Observation during initial tour on 05/23/2023 at 11:46 a.m., revealed Resident #24's nebulizer mask lying on the resident's bedside table unbagged. The nebulizer machine however was not insight. Resident #24 was not in the room at the time for interview however LVN I was walking in the hall and asked if the nebulizer mask belonged to Resident #24. LVN I confirmed the mask did belong to Resident #24. LVN I revealed when a mask was not in use it should be in a plastic bag and dated. LVN I revealed bags are changed out weekly and dated. LVN I further stated he did not know if Resident #24 was still taking treatments or not and exited the room with the mask. In an interview with RN H on 05/23/2023 at 12:05 p.m., RN H reviewed Resident #24's orders in the electronic medical record and confirmed Resident #24 remained on nebulizer treatments. RN A further confirmed nebulizer machines are assigned to residents until their orders are discontinued so it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 33 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unknown why the resident's machine was not with the mask. At this time RN H stated all oxygen masks should have been in a plastic bag to protect them from cross contamination. 2. Record review of Resident #37's face sheet, dated 05/23/2023, revealed an admission date of 01/06/2023 with diagnoses that included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (the heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood), and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated intact cognition. Record review of Resident #37's care plan, last review date 04/28/2023, revealed a focus area, Potential for impaired gas exchange related to COPD. The goal was: Resident will participate in treatment regimen and have no untreated episodes of shortness of breath daily through next 90 day review. One intervention listed was: O2 per order Oxygen at _3_L/min via NC - Continuously. The focus area, goal and intervention were all dated 01/15/2023. Record review of Resident #37's active orders, dated 05/27/2023, revealed an order for Oxygen at _3_L/min via NC - Continuously. Start date: 01/06/2023. Observation on 05/23/2023 at 2:20 p.m. revealed the water reservoir attached to Resident #37's oxygen concentrator was empty. Further observation revealed the date written on the water reservoir was 05/18, indicating when it had been opened or replaced. During an interview on 05/23/2023 at 2:22 p.m. with Resident #37, the resident stated he was on oxygen all the time, and he rarely left his room. He stated he used a portable oxygen tank when in his wheelchair and the concentrator when he was in bed. Resident #37 stated he did not know how often the staff checked or changed the water reservoir. During an interview with LVN K on 05/23/2023 at 2:35 p.m., LVN K acknowledged that the water reservoir attached to Resident #37's oxygen concentrator was empty, and the date written on it was 05/18, indicating when it had been opened or replaced. LVN K stated the staff working the Monday night shift was responsible for checking the water reservoirs and replacing them as needed. During an interview on 05/27/2023 at 5:00 p.m., the DON confirmed that the oxygen concentrators were supposed to be checked by the weekly by the nursing staff working the night shift. 3. Record review of Resident #55 face sheet, dated 05/27/2023, revealed an admission date of 12/08/2022 with diagnoses that included: hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins in the blood) and atherosclerotic heart disease (condition that causes arteries to narrow, restricting healthy blood flow). Record review of Resident #55's admission MDS, dated [DATE], revealed the resident's BIMS score was 10 which indicated moderate cognitive impairment. Further review in Section I, Active Diagnosis, revealed Pulmonary had been selected. Record review of Resident #55's care plan, last review date 03/22/2023, revealed a focus area for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 34 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Alteration in Respiratory Status, and interventions that included, administer medications as ordered. Observe labs, response to medication and treatments. Record review of Resident #55's active orders, dated 05/27/2023, revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3ml inhale orally every 4 hours as needed for Dyspnea (shortness of breath) via nebulizer, with a start date of 12/08/2022 and an additional order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 3ml inhale orally two times a day for COPD, with a start date of 12/28/2022. Observation during initial tour on 05/23/2023 at 2:13 p.m., revealed Resident #24's nebulizer mask resting on top of the cabinet behind the resident's bed was unbagged. Resident #55 was asleep and unable to be interviewed. LVN I had been observed leaving the room prior to observation but no longer in the hallway therefore RN H accompanied surveyor back to the room. RN H confirmed nebulizer mask was not in a plastic bag and stated, it was just here, as the resident awoke. RN H asked Resident #55 if he knew where the plastic bag was for his nebulizer mask and the resident responded, I don't know what you are talking about. RN H stated the nebulizer masks should have been in a plastic bag to keep it clean. 4. Record review of Resident #274's face sheet, dated 05/27/2023, revealed an admission date of 05/12/2023 with diagnoses that included: rheumatoid arthritis (a chronic inflammatory disease that affects the joints), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. Record review of Resident #274's admission MDS, dated [DATE], revealed the resident's BIMS score was 14, which indicated the resident's cognition to be intact. Further review in Section O, Special Treatments, Procedures, and Programs, revealed Resident #274 had received Non-Invasive Mechanical Ventilator (BiPaP/CPAP) while a resident of this facility and within the last 14 days and an additional diagnosis of respiratory failure with hypoxia (decreased level of oxygen in all or part of your body, such as your brain). Record review of Resident #274's care plan, last dated 05/26/2023, revealed no focus area for the CPAP machine. Record review of Resident #274's active orders, dated 05/27/2023, revealed no orders for a CPAP. An observation and interview with Resident #274 on 05/23/2023 at 12:45 p.m., revealed Resident #274's CPAP mask was unbagged and resting on top of the cabinet behind the resident's bed. Resident #274 revealed the CPAP machine belonged to her and she had used it every night since admission. In an interview with RN H on 05/23/2023 at 1:32 p.m., RN H confirmed the CPAP mask should have been bagged and dated. In an interview with the DON on 05/27/2023 at 3:53 p.m., the DON confirmed all respiratory masks should be placed in a plastic bag and dated when not in use to prevent infections. Record review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, revealed, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 35 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents and staff. Infection control considerations related to medication nebulizers/continuous aerosol: 1. Obtain equipment (i.e., administration set-up, plastic bag, gauze sponges.2. Use distilled water for humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after twenty-four (24) hours. 5. Check water level of any pre-filled reservoir every forty-eight (48) hours. 6. Change pre-filled humidifier when the water becomes low. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set-up every seven (7) days. Event ID: Facility ID: 455628 If continuation sheet Page 36 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 provide or obtain laboratory services to meet the needs of its residents. The facility failed to ensure its own its own laboratory services met the applicable requirements for laboratories in that: Residents Affected - Some The facility did not have a current CLIA certificate of waiver. This deficient practice placed residents' laboratory tests at risk of not meeting certain quality standards due to lack of oversight from CMS. The finding was: Record review of the binder provided by the facility that contained its contracts revealed there was no CLIA certificate waiver present. Interview on [DATE] at 7:30 p.m. with the Administrator revealed that she had taken over the position of Administrator in [DATE] and discovered that the facility's CLIA waiver had expired [DATE] while reviewing documents left by the previous administrator. The administrator acknowledged that this waiver must be renewed and maintained in the facility to ensure the laboratory testing performed in the facility was not subject to CMS inspection and certification. Record review of policy Lab and Diagnostic Test Results - Clinical Record revised [DATE] provided on [DATE] at 8:00 p.m. by the Regional Nurse Consultant revealed the policy did not cover testing performed in the facility and the requirement for the facility to have a CLIA waiver and no additional policy was provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 37 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 1 of 6 Residents (Resident #77) whose records were reviewed for food preferences. Facility staff failed to ensure Resident #77 received substitutes for foods he did not like. This deficient practice could result in residents not being satisfied with meal service when served foods they disliked. The findings were: Review of Resident #77's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Cerebral Palsy and Cognitive Communication Deficit. Review of Resident #77's quarterly MDS assessment, dated 4/19/23,, revealed his BIMS was 15 of 15 reflective he was cognitively intact, he required supervision by 2 staff for eating and he was on a therapeutic meal plan. Review of Resident #77's Care Plan, revised on 3/8/23 revealed he preferred to eat in his room and preferred staff set up his lunch and place it on the floor. Observation and interview on 5/23/23 at 2:26 PM revealed Resident #77 lying on his abdomen on top of a sheet on the floor. There weree multiple personal items and 2 mattresses side by side also on the floor. Resident #77 stated it was easier for him to move around and access personal items. Resident #77 stated his primary concern was he was often served eggs for breakfast which he absolutely hated, and chicken was served all the time. He stated he was so tired of eating chicken, and it was usually baked chicken. Resident #77 stated he had talked with multiple staff; CNA's and nurse's and let them know he did not want to be served either item. He stated usually someone reviewed the menu and alternative of the day and he would choose what he wanted to eat. However, staff did not do this consistently; therefore, he would often receive eggs and chicken even though he did not like them. He stated he was so frustrated about having to talk to staff about the same food concerns. Observation on 05/25/23 at 11:59 AM revealed food cart parked in the hall upon entering hall B. Observation on 05/25/23 at 12:02 PM revealed CNA's started passing out trays. Observation and interview on 05/25/23 at 12:05 PM revealed CMA T handed the DM Resident #77's lunch tray and stated Resident #77 requested the enchilada casserole. Interview with CMA T stated Resident #77 was a very picky eater and did not like all food items. She stated Resident #77 received baked chicken which he did not like to eat. CMA T stated she had told Dietary staff the Resident did not like chicken. She stated baked chicken was often served and Resident #77 returned his meal tray back to the kitchen every time. Observation on 05/25/23 at 12:08 PM revealed Resident #77 received baked chicken. He stated it happened all the time. Resident #77 stated staff did not review the menu of the day and was not provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 38 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with a choice between the main meal and the alternate. Resident #77 stated he requested the enchilada casserole which was the alternative meal of the day. Observation and interview on 05/25/23 at 12:10 PM revealed the DM handed Resident #77 the alternate tray. She reviewed Resident #77's menu ticket and the only dislike listed was gravy. Further review revealed Resident #77's preferences and other dislikes were not listed on his menu ticket. Interview on 5/27/23 at 5:20 PM with the DM revealed either she or other Dietary Staff had established the resident likes and dislikes on halls A and D but not on halls B and C. She confirmed they had not established Resident #77's (who was on hall B) likes and dislikes. She stated she did not know Resident #77 did not eggs and did not want to receive baked chicken. She stated she took over her position during January 2023 and was in the process of learning all resident's preferences. She stated it was important residents received the foods they liked and enjoyed it for their satisfaction. Review of facility policy, Resident Food Preferences, revised July 2017, read in part: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team, Modification to diet will be ordered with the resident's or representative's consent. 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the Dietician or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtime. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 39 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 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 for review: Residents Affected - Many 1. DA L had facial hair and was not wearing a facial hair restraint while engaged in food preparation. 2. There were frozen omelets, pizza crusts, pie crusts and garlic bread that were improperly stored in the reach-in freezers. 3. There was an opened carton of thickened orange juice and an opened carton of thickened sweet tea without labels indicating the dates they were opened. 4. There was a case of frozen fish fillets and a case of frozen carrots that were improperly stored in the walk-in freezer. 5. CNA S touched Resident #36's sandwiches with her bare hands while cutting them on his plate. These failures could place residents who received meals and/or snacks from the kitchen and who were assisted with their meals at risk for the spread of diseases and food borne illness. The findings included: 1. Observation on 05/23/2023 at 11:05 a.m. revealed DA L had hair along his jawline and on his chin that was approximately 1/4 long. Further observation revealed DA L was not wearing a facial hair restraint. At the time of the observation, Dietary Aide L was standing in front of the juice dispenser and pouring juice and tea in glasses for the lunch meal. Interview on 05/23/2023 at 11:30 a.m. with the DM revealed she observed DA L had facial hair and was not wearing a facial hair restraint. The DM stated all staff had been instructed on the proper use of hair restraints, and that facial hair restraints were available at the entrance to the kitchen so they could be properly worn prior to entering the kitchen. Interview on 05/23/2023 at 11:32 a.m. with DA L revealed he was not wearing a facial hair restraint and he should have worn one. DA L stated he had been trained on the proper use of facial hair restraints but he forgot to put it on. DA L further stated hair restraints prevented food contamination by preventing hair from falling into the food and beverages. 2. Observation on 05/23/2023 at 11:35 a.m. in reach-in freezer #1 revealed: a. There was a 15.75 lb. case of cheese omelets. The omelets were stored in a bag inside a cardboard box. The box was wide open, and the bag inside was also open, exposing the contents to potential contaminants. b. There was a 32 lb. 8 oz. case containing 16 pizza crusts. The crusts were stored in a bag (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 40 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 inside a cardboard box. The box was wide open, and the bag inside was also open, exposing the contents to potential contaminants. Observation on 05/23/2023 at 11:50 a.m. in reach-in freezer #2 revealed: c. There was a bag containing pieces of garlic bread that was sealed with a knot at the top of the bag. There was no label or date indicating the date the garlic bread was stored. d. There was a bag containing four unbaked pie crusts that was sealed with a knot at the top of the bag. There was no label or date indicating the date the pie crusts were stored. Interview on 05/23/2023 at 11:38 a.m. with the DM revealed the dietary aides were responsible for storing food in the freezers, and they were trained to properly seal, label and date foods prior to storage. The DM further stated that the aides are in a rush in the morning, and if food isn't properly sealed, it could lead to ice buildup on the food and will not taste good. 3. Observation on 05/23/2023 at 11:55 a.m. in the reach-in cooler revealed there was a 46 oz. container of thickened orange juice and a 46 oz. container of thickened iced tea. Both containers had been opened. Neither container had a date indicating the date it had been opened or a use-by date. Interview 05/23/2023 at 11:56 a.m. with the DM revealed the DAs were responsible for storing opened items in the cooler, they knew they were supposed to label and date all items, and there was a sign on the outside of all coolers and freezers to remind them. The DA further stated that she'd been in the position 4 months and was in the process of establishing policies and training for the staff. 4. Observation on 05/23/2023 at 12:00 p.m. in the walk-in freezer revealed: a. There was a 15-lb. case of frozen fish fillets. The fish was stored in a bag inside a cardboard box. The box was wide open, and the bag inside was also open, exposing the contents to potential contaminants. b. There was a 30 lb. case of frozen carrots that was on the floor of the freezer. Interview on 05/23/2023 at 12:05 p.m. with the DM revealed the fish was not properly stored and exposed to potential contaminants and the case of carrots should not have been on the floor. The DM stated the fish was being served for lunch that day and the staff was likely rushing, but that was no excuse for the food to be left in that manner. The staff had been trained on the proper storage of food in the freezer. 5.Observation on 5/23/23 at 12:20 PM, in the dining room, revealed CNA S setting up Resident #36's lunch plate in front of him. Further observation revealed she placed the condiments and beverages around the plate and let Resident #36 know where they were located. CNA S then proceeded to cut his 2 sandwiches into quarters. She used her bare hands to hold the sandwiches while cutting them. Interview on 5/23/23 at 12:30 PM with CNA S revealed Resident #36 was blind and she set up his lunch plate. CNA S stated she held the sandwiches with her bare hands, on Resident #36's plate, to cut them. She stated she was nervous and not thinking about what she was doing until afterwards. CNA S stated she did not sanitize her hands before or after cutting Resident #36's sandwiches. She stated her hands were dirty and she could transfer bacteria to Resident #36's sandwiches, and he could get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 41 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 sick. CNA S stated she should at least sanitize or wash her hands in between assisting residents and should put gloves on before handling the resident's food. Interview on 5/23/23 at 12:45 PM with LVN B revealed staff should not touch resident's food with their bare hands and if they had to for whatever reason then they should put gloves hands on beforehand. LVN B stated she did not note CNA S cutting Resident #36's sandwiches but stated he required assistance with setting up his lunch trays. LVN B stated he was blind, and it was not unusual for staff to cut his sandwiches so he could easy grab the pieces. LVB further stated staff could transfer bacteria to the resident's food when they used their bare hands and could contaminate their food. LVN B stated most residents had a compromised immune system and would easily become sick. Review of facility policy, Preventing Forborne Illness - Employee Hygiene and Sanitary Practices, revised November 2022, revealed: Food and nutrition service employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of facility policy, Food Receiving and Storage, revised November 2022, revealed, Refrigerated/Frozen Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 4. Refrigerators/walk-ins are not overcrowded. Foods in the walk-in are stored off the floor. 8. Wrappers of frozen foods must stay intact until thawing. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 42 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that: Residents Affected - Some The facility, licensed for 150 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met. The findings were: Record review of Facility Summary Report, undated, revealed the facility had a total licensed capacity for 150 beds. Record review of the staff roster, provided by the facility, undated, revealed SW M's position was listed as Qualified Social Worker and SW N's position was listed as Social Services. In an interview with the Administrator on 05/26/2023 at 9:48 a.m., the Administrator revealed the facility does not have a full-time SW. The Administrator confirmed she was aware of the need for a full-time SW and stated she had been trying to hire one for several months, by placing ads and contacting universities to approach new graduates but still had no applications. The Administrator added that the VA had placed their contract on hold to be able to accept any new residents due to the facility not having a SW. The Administrator revealed SW M had taken another job but remained on the staff list because she planned to continue PRN. She stated SW M however has not been able to work enough shifts to assist with any SW needs. SW N worked only one day a week, however, was on leave the week of survey. The Administrator revealed that on the days SW N worked she reviewed the social service duties that have been performed by other staff and performed assessments that needed to be completed. The Administrator further revealed social service duties have been delegated out to several nursing staff members. The Administrator stated she was a SW as well and she made herself available to speak with residents and families as needed. Record review of a job description provided by the facility, Social Services Director, undated, revealed The primary purpose of the position is to ensure the highest quality of resident care available, support staff and . The Social Services Director will plan, organize, implement, evaluate, and direct the overall operation of the Social Service Department in accordance with current federal, state, and local standards, guidelines, and regulations, facility policies and procedures or as may be directed by the Administrator to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 43 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 to help prevent the development and transmission of infections for 2 of 5 staff (LVN O and CAN P) reviewed for infection control, in that: Residents Affected - Some 1. LVN O did not sanitize her hands prior to setting up wound care supplies for Resident #43. LVN O did not sanitizer the scissors prior to cutting gauze while setting up wound care supplies for Resident #43. 2. CNA P did not sanitize her hands in between glove changes while providing catheter care for Resident #1. These deficient practices could place residents who receive wound care or catheter care at-risk for infections. The findings included: During an observation on 05/24/23 at 10:28 a.m. LVN O prepared wound care supplies for Resident #43's pressure ulcers. LVN O washed her hands in the resident's bathroom. LVN O touched the resident's door upon returning to her nurse cart to set up supplies. LVN touched her computer to look at wound care orders. LVN O then grabbed gauze from the cart with her bare hands and put the gauze into cups. LVN O opened several packages of gauze and placed them on wax paper on top of her nurse cart. LVN O set up more wound care supplies on her nursing cart. LVN O then took a pair of scissors out of her nursing cart, did not clean them, and cut a bandage. LVN O then touched her computer again. LVN O then opened a package of collagen powder, stuck her fingers inside the collagen powder package to open it up more, and poured the powder into a cup. LVN O set up more supplies on the cart. LVN O took out a marker from her cart and dated the bandages. LVN O then used a bottle of hand sanitizer located on the top of her nursing cart to sanitize her hands. LVN O returned the pair of scissors and marker to a drawer inside her cart. LVN O did not use any wipes to sanitize her equipment or cart. LVN O performed wound care on Resident #43 with the wound care supplies. During an interview on 05/24/23 at 11:05 a.m. LVN O stated she sanitizes her nursing cart daily and she has cleaned it earlier down the hall by her office. LVN O stated in January she went through the whole cart and when she gets supplies, she also goes through the cart. LVN O stated she sanitizes her computer a couple times a day but did not sanitize it prior to setting up the wound care supplies for Resident #43. LVN O stated she sanitized the scissors after using them with a resident prior and placed them back in the drawer. LVN O stated she did not sanitize them after using them for Resident #43 because she forgot, and they would not be clean for the next use. LVN O stated she was not sure if she touched the door after washing her hands, but she did touch her keys in her pocket to open the nursing cart. LVN O stated she did not know why she did not use the hand sanitizer on top of her cart prior to and while setting up wound care supplies. LVN O stated she had not though about if she cleaned the pen she used. LVN O stated she could have contaminated the gauze and other wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 44 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 care supplies because she did not sanitize her hands after touching her keys, cart, computer, and pen. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 05/26/23 at 8:56 a.m. CNA P performed catheter care on Resident #1. During catheter care CAN P changed her gloves 4 times and did not sanitize between glove changes. Residents Affected - Some During an interview on 05/26/23 at 9:12 a.m. CNA P stated she should sanitize before she goes into the residents' rooms, before she starts working, when she comes out of the residents' room, and when she does peri care in between glove changes if the resident had a bowel movement. CNA P stated she had never been trained to sanitize in between any glove changes. During an interview on 05/27/23 at 1:58 p.m. the DON stated staff is expected to sanitize their hands before and after care of any kind, before entering rooms, before, during, and after peri care. The DON stated if they touch body fluids, they need to wash their hands. The DON stated staff did not need to sanitize in between each glove change unless they touch something or are wiping the resident during peri care. The DON stated she did not know what the policy stated for hand hygiene in between glove changes. The DON stated staff should sanitize equipment such as scissors before and after care. The DON stated LVN O should have sanitized her hands prior to touching the gauze used to clean Resident #43's pressure ulcers to prevent cross contamination. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 08/2015, stated Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall be trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of health care associated infections .7. Use of alcohol based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations: a. Before and after coming on duty; b. before and after direct contact with residents; c. before preparing or handling medications; d. before performing any non surgical invasive procedures; e. before and after handling an invasive device (e.g., urinary catheters, IV access site); f. before donning sterile gloves; g. before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. after contact with the residence intact skin; j. After contact with blood or bodily fluids; k. after handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g.; medical equipment) in the immediate vicinity of the resident; m. after removing gloves .[NAME] and Removing Gloves: 1. Perform hand hygiene before applying non sterile gloves . Record review of the facility's policy titled Cleaning and Disinfection of Resident- Care Items and Equipment, dated 08/2022, stated resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. Policy Interpretation and Implementation: 5. Reusable items are cleaned and disinfected or sterilized between residents(e.g., stethoscopes, durable medical equipment) .6. Reusable resident care equipment is decontaminated and or sterilized between residents according to the manufacturer's instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 45 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have bedrooms that measured 80 square feet per resident in multiple bedrooms for 16 of 99 rooms (Rooms #1-9, 12-14, 21, 27-28, and 46) resident rooms reviewed for square footage. Based on measured rooms, Rooms #1-9, 12-14, 21, 27-28 and 46 were between 72.2 and 77.25 per resident. This failure could negatively affect the quality of life for the residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limiting the resident's ability to move about the room, and decreasing resident's quality of life. The findings were: Interview on 05/23/2023 at 10:30 a.m. with the Administrator during the entrance conference revealed she wanted to continue with the room waivers. A review of Form 3740 (Bed Classifications) signed by the Administrator on 05/23/2023 revealed resident rooms 1-9, 12-14, 21, 27-28, and 46 were all certified rooms for two beds each. Review of the undated List of Rooms meeting any one of the following: Less than the required square footage revealed rooms 1-9, 12-14, 21, 27, 28 and 46 were listed. The measurements were as follows: room [ROOM NUMBER]: 10 feet x 15 feet = 150 (approximately 75 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 46 of 47 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 455628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Village Nursing and Rehabilitation 1400 Hilltop Rd Kerrville, TX 78028 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 0912 Level of Harm - Potential for minimal harm room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); room [ROOM NUMBER]: 10 feet 2 inches x 15 feet = 152 (approximately 76.2 square feet for each resident); Residents Affected - Many room [ROOM NUMBER]: 10 feet 3 inches x 15 feet = 153.75 (approximately 76.8 square feet for each resident); room [ROOM NUMBER]: 10 feet 1.5 inches x 15 feet = 151.87 (approximately 75.9 square feet for each resident); room [ROOM NUMBER]: 12 feet .5 inches x 12 feet = 144.48 (approximately 72.2 square feet for each resident); room [ROOM NUMBER]: 12 feet 7 inches x 11 feet 11 inches = 149.94 (approximately 74.9 square feet for each resident); room [ROOM NUMBER]: 12 feet .5 inches x 12 feet 1 inches = 154.5 (approximately 77.25 square feet for each resident); and room [ROOM NUMBER]: 10 feet 2 inches x 14 feet 10 inches = 150.8 (approximately 75.4 square feet for each resident). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455628 If continuation sheet Page 47 of 47