Health inspection·July 27, 2023

F 0570 trust by the center for the resident in an interest-bearing account . The center is required to hold a Surety Bond to guarantee the protection of all the residents trust funds managed by the center. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 2 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 0579 Provide information about how to apply for and use Medicare and Medicaid benefits. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to post, in an area of the facility that is readily available to residents, employees, and visitors five of 33 postings. Residents Affected - Many The facility failed to display the Facility admission Policy, a description of the protection of personal funds, how to apply for and use Medicare and Medicaid benefits, and how to receive funds for previous payments covered by such benefits. This failure could affect all residents who reside in the facility by placing them at risk of incomplete or inaccurate information. Findings included: During observations on 07/24/2023 from 10:35 AM to 01:00 PM during initial tour of the facility revealed there were no postings explaining the facility admission policy, how to apply for and use Medicare and Medicaid benefits, and how to receive funds for previous payments covered by such benefits or a description of the protection of personal funds, and the facility's policies on restraints and involuntary seclusion. During an interview on 07/27/2023 at 10:10 AM, the ADM stated he was unable to locate the facility's admission Policy, Restraint Policy, Personal Funds Protection Policy, information on applying for Medicaid/Medicare benefits, and information on how to receive a refund of prior payments. During an interview on 07/27/2023 at 01:49 PM, the ADM stated the importance of posting the required information was to inform residents, family members and visitors of regulations and policies. The ADM stated the reason some postings were missing was because he cleared the board when he started working at the facility in March 2023. He explained the board had outdated policies and information. The ADM stated he messed up when putting current information back on the board. During an interview on 07/27/2023 at 02:15 PM, the Senior ADM stated the facility did not have a policy on required postings, the facility follows government guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 3 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 - Some 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 residents care plans were reviewed and revised by the interdisciplinary team after each assessment for 6 of 13 Residents (Residents #1, # 12, #19, #22, #24, #25) reviewed for comprehensive care plans, in that; The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #1's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #12's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #19's comprehensive assessment on 07/01/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #22's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #24's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #25's comprehensive assessment on 06/30/2023. This failure could place residents at risk of not having his or her needs met to achieve the highest quality of life. Findings include: Resident #1 Record review of Resident #1's face sheet dated 02/09/2022, revealed a [AGE] year-old female was admitted on [DATE] with medical diagnoses of dementia, anxiety, depression, high blood pressure, a history of falls, difficulty walking, and heart disease. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #1's comprehensive assessments and care plans revealed the most recent quarterly comprehensive assessment was completed on 07/11/2023. Record review of Resident #1's record revealed most recent care conference was dated 04/12/2023. During an interview on 07/25/23 at 09:09 AM, Resident #1 stated she was not sure if she had attended care plan meetings. Resident #12 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 4 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 - Some Record review of Resident #12's face sheet revealed a [AGE] year-old female was admitted on [DATE] with medical diagnoses of Parkinson's disease, difficulty speaking, mood disorder, problems with blood circulation in her arms and legs. Record review of Resident #12's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #12's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Record review of Resident #12's record revealed most recent care conference was dated 04/12/2023. During an interview on 07/27/2023 at 11:14 AM, Resident #12 stated she did not attend care plan conferences because her family member takes care of all her business. Resident #19 Record review of Resident #19's face sheet revealed a [AGE] year-old male was admitted on [DATE] with medical diagnoses of enlarged prostate, difficulty communicating, lung cancer, heart attack, irregular heartbeat, and needed assistance with personal care. Record review of Resident #19's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #19's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 07/01/2023. The most recent care conference was dated 03/30/2023. Resident #22 Record review of Resident #22's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of mood disorder, difficulty walking, arthritis, digestions problems, and weakness. Record review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #22's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 07/11/2023. Record review of Resident #22's record revealed most recent care conference was dated 04/18/2023. Resident #24 Record review of Resident #24's face sheet revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of Alzheimer's disease, low back pain, fainting, heart burn, and depression. Record review of Resident #24's Quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 5 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 Record review of Resident #24's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #24's record revealed most recent care conference was dated 04/12/2023. Residents Affected - Some Resident #25 Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted on [DATE] with medical diagnoses of dementia, high blood pressure, heart failure, anxiety, and diabetes. Record review of Resident #25's Annual MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #25's comprehensive assessments and care plans revealed the most recent comprehensive assessment was completed on 06/30/2023. Record review of Resident #25's record revealed most recent care conference was dated 04/18/2023. During an interview on 07/27/2023 at 10:00 AM, the CRN stated her expectations were for care plan conferences to be done timely as per policy and residents participate when they were able. The CRN explained the facility policy reflected a care conference was to be scheduled within 7 days of the completion of the comprehensive assessment. She stated the failure to hold the care plan conferences was due to the previous DON resigning several months ago and difficulties finding a replacement. She stated the Interim DON's first day was 07/24/2023. The CRN stated consequences to residents of failing to conduct the care conference would be residents would not be included in care decisions and needed care may be missed During an interview on 07/27/23 at 01:01 PM, LVN A stated the RN was responsible for creating the care plans. LVN A stated she felt it was important for the residents to participate in order for the resident to know what was going on and what was being discussed. She stated the meeting gave residents a chance to make their wants and needs known, a chance to voice their opinion. During an interview on 07/27/2023 at 01:26 PM, CNA A stated she looked at care plans to learn about residents. Her position was as needed or PRN. She explained if there were a new resident, the care plan helped her to know what the resident needed. CNA A stated she will not take care of a resident by herself without knowing what to do and how the resident liked things done. She stated the care plan usually gave the information to properly take care of the residents. CNA A stated residents should be in care plan meetings and meetings should be every few months if not more often due to how quickly a resident can change. During an interview on 07/27/2023 at 01:42 PM, CNA B stated he reviewed care plans regularly to keep up on how residents were doing and if anything changed. He stated it would be important for residents to participate in care planning and meetings should be quarterly. CNA B stated residents should have a say in their care. Review of facility policy titled Resident Participation - Assessment/Care Plans dated February 2021 revealed, 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 15. The Interdisciplinary Team must review and update the care plan: . d. At least quarterly, in conjunction with the required quarterly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 6 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 MDS assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 7 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week or designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day. The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. These failures placed all residents at risk of their clinical needs not being met. Findings included: Record review of PBJ report ran 07/11/23 for Fiscal Year Quarter 2 (January 1,2023 to March 31, 2023) revealed no RN coverage for 01/01 (SU); 01/02 (MO); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12 (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/22 (SU); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/28 (SA); 01/29 (SU); 01/30 (MO); 01/31 (TU) 02/01 (WE); 02/02 (TH); 02/03 (FR); 02/04 (SA); 02/05 (SU); 02/06 (MO); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11 (SA); 02/12 (SU); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/20 (MO); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 02/27 (MO); 02/28 (TU) 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/04 (SA); 03/05 (SU); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11 (SA); 03/12 (SU); 03/13 (MO); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 8 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 03/18 (SA); 03/19 (SU); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 Level of Harm - Minimal harm or potential for actual harm (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR). Record review of daily staffing sheets revealed no RN coverage on: Residents Affected - Many January 2023:1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 28, 29. February 2023:4, 5, 11, 12, 18,19, 25, 26. March 2023: 4, 5,11, 12, 18, 19,25, 26. June 2023: 10, 24th 25, 26 27, 28, 29, 30. July 2023: 8. 9, 10, 14, 15, 16, 21, 22, 23. Record review of former RN staff revealed: RN/DON first date worked was 01/23/23 and last date worked was 06/19/23. RNB first date worked was 04/17/23 and last date worked was /06/30/23 as a weekend RN. During an interview on 07/26/23 at 02:48 PM with RRN, she said the former RN/DON started 01/16/23 and worked Monday through Friday. She never worked any weekend. She said they did not have a weekend RN during the months of [DATE] through March of 2023. She said RNB was hired and worked April 2023 on weekends and some weekdays, but he quit at the end of June 2023. RRN said they had another RN that had worked some in June and now July, however they still didn't have one for weekends. RRN said she had been working periodically in July and has worked 7/11/23-7/13/23, 7/17/23-7/20/23, and had been in facility daily from 7/24/23 to present (07/26/23). She said they had an interim DON that was from Corporate that started Monday 7/24/23. She said the facility had advertisements in papers and online, however, RNs were wanting a wage that was above what could be offered at that time. Record review of RN Job Description revised 05/20/21 revealed: supervise other professional and nonprofessional staff in the day-to-day delivery of resident care; schedule job assignments and develop nursing unit priorities; Orient new staff and participate in the recruitment and selection of nursing personnel; communicate policies, assistant coaches needed; monitor work assignments, provide feedback, evaluate performance, and rate of rec and discipline employees as needed . monitor environment and care practices of nursing personnel to ensure compliance with established safety, fire, disaster, infection control and all other departmental policies and procedures; insert cleanliness and safety of work and treatment areas. Record review of DON Job Description revised 12/16/21 revealed: under the supervision of the administrator, the director of nursing, manages the overall operation of the nursing department in accordance with company policies, standards and nursing practices and government regulations to ensure the quality resident care is delivered in an efficient manner. Works with the administrator, consultants, and facility staff and planning all aspects of nursing services to include interface with other disciplines and departments; established priorities and job assignments; monitor department activities, communicate policies, evaluate performance, provide feedback and assist, coach, redirect and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 9 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete discipline as needed: maintain records, manage budget and supplies, and function as a senior department head. Ensure equipment and work areas are clean, safe, and orderly, and any hazardous conditions are addressed; ensure universal precautions and infection control, isolation, fire safety and sanitation practices and procedures are followed. conduct regular rounds and monitor resident activity, assess residents physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to the physicians orders, care plans, and established standards and facility policies; manage admissions, transfers, and discharge of residents; family members and management regarding resident status; personally participate in the assessment and delivery of care when needed . ensure appropriate staffing levels are maintained through the development of recruitment resources, and through appropriate selection, orientation, training, and staff education. Event ID: Facility ID: 675058 If continuation sheet Page 10 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 in the facility's only kitchen. Residents Affected - Many The facility failed to appropriately label, date, seal/close items stored in pantry, refrigerator, and freezer. The failure could place residents at risk for food-borne illness from food contamination. Findings include: During an observation in the facility's only kitchen on 07/24/2023 from 09:40 AM to 10:15 AM revealed the following: Four containers of spices on a shelf had lids open to air: Lemon pepper, sea salt, garlic powder, ground cumin. One 32-oz open bag of cheese sauce mix half full, folded over once and with no date of when opened One 32-oz open bag of potato flakes with no date of when opened One 1 lb. 8 oz bag of fried onions with no date of when opened One 5 lb. white cake mix was open to air with no date of when opened One 5 lb. bag of devil's food cake mix, half full, wrapped in clear plastic with no date of when opened One 5 lb. bag of blueberry muffin mix, wrapped in clear plastic with no date of when opened During an observation in the facility's only kitchen of the free-standing freezer revealed to the following: One clear plastic bag of tater tot was open to air with no date of when opened Top left shelf of the freezer, an item was wrapped in clear plastic was not labeled with no date of when opened Left 3rd shelf in the freezer, an item was wrapped in clear plastic was not labeled with no date of when opened One opened box labeled frozen enchiladas with no date of when opened. One opened box labeled cut green beans with no date of when opened One 10 lb. open box labeled chicken strips in a clear plastic bag that was open to air with no date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 11 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 of when opened Level of Harm - Minimal harm or potential for actual harm One box labeled Salisbury steaks in an opened clear plastic bag that contained 8 patties and was open to air with no date of when opened Residents Affected - Many Three meat patties in an opened clear plastic bag labeled pork chop steak with no date of when opened During an observation in the facility's only kitchen of the walk-in refrigerator revealed the following: One 16-oz. tub of whipped topping was opened with no date of when opened One clear plastic bag of shredded lettuce with no date of when opened One 1-gallon jar labeled ranch dressing with no date of when opened One 1-gallon jar labeled dill pickle relish with no date of when opened One 8 lb. 7 oz. jug labeled picante sauce with the lid not properly secured, exposing the contents to air with no date of when opened One clear plastic bag labeled shredded cheese was open to air with no date of when opened One clear plastic bag labeled shredded cheese wrapped in clear plastic with no date of when opened One clear plastic bag of shredded lettuce, that was brown, wrapped in clear plastic with no date of when opened One package cheese slices was not labeled with no date of when opened One clear plastic bag of shredded lettuce was open to air with no date of when opened One metal bowl containing cubes of cantaloupe and watermelon was open to air with no date of when opened One gallon of 2% milk half full that had an expiration date of 07/25/23. One 6 lb. 2 oz. can labeled applesauce was open, covered with foil with no date of when opened One 1-pint jar of an unknown dark brown substance that was not labeled with no date of when opened One 46-oz. container labeled thickened sweetened tea that was open and with no date of when opened Two 12-count packages of hot dog buns dated 05/30/23. One 46-oz. container labeled thickened sweetened tea that was open with no date of when opened One grey grocery bag tied closed that was not labeled with no date of when opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 12 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 One clear plastic bag containing square breaded patties that was open to air with no date of when opened Level of Harm - Minimal harm or potential for actual harm One box labeled bread sticks that contained a clear plastic bag that was open to air with no date of when opened Residents Affected - Many One box labeled cheese & garlic biscuit dough that contained a clear plastic bag that was open to air with no date of when opened During an interview on 07/25/2023 at 10:55 AM, the DM stated he was responsible for labeling and dating inventory. He explained all dietary staff were responsible for rotating stock, removing and disposing of expired or past use by date items. The DM stated when he was hired, he had one day of training. The DM stated consequences to residents could be they get sick if the food was not labeled, dated, or expired. During an interview on 07/27/2023 at 10:10 AM, the ADM stated his expectations of labeling and storing food items was for the tasks to be completed when food items were delivered to the facility. The ADM stated it was unacceptable for food items to be left open to air and an opened date and use by date not visible. He stated all dietary staff were responsible for proper labeling and storage of food inventory. The ADM stated the failure occurred because the dietary staff were new to the facility and training was ongoing. Review of the facility's policy titled Food Storage dated 2018 revealed under Section 2. Refrigerators item D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for storage. Section 3. Freezers item e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Review of FDA Food Code 2022 revealed the following: 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. On-premises preparation Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Commercially processed food Open and hold cold (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 FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 13 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 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. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. (E) Paragraphs (A) and (B) of this section do not apply to individual meal portions served or rePACKAGED for sale from a bulk container upon a consumer's request. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 14 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Potential for minimal harm Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility's reviewed for QAPI. Residents Affected - Many The facility failed to maintain documentation of QAPI meetings prior to February of 2023. This failure placed residents at risk of maintaining and improving safety and quality of life. Findings included: Record review of QAPI meetings revealed: Facility had maintained QAPI meeting minutes from 02/2023 to 07/2023. No previous meeting documentation was available. During an interview on 07/25/23 at 10:30AM with ADM and RRN, ADM said he had been scouring the ADM office for evidence of previous QAPI meetings with no success. He said he became the ADM in March of 2023. RRN said the former ADM had been an AIT during the Covid-19 pandemic and it had been revealed that she had not been trained sufficiently and did not maintain records as she should have. During an interview on 07/25/23 at 1:30PM with ADM, he said that he was unable to locate any other QAPI documented meetings prior to Feb of 23. He said he had maintained records since taking over as the ADM in March of 23. He said the staff was not aware of PIP's and/or how to complete them with identified problems and solutions prior to him becoming the ADM. He said that the maintenance of the QAPI records was a group effort of the IDT, and that documentation would alert the facility to identified problems and resolutions that did or did not work and assisted the facility to assess problems and the effectiveness of solutions. Record review of QAPI policy revised 02/08/23 revealed: This facility shall develop, implement, and maintain and ongoing, facility wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, to pursue methods to improve care quality, and resolve identified problems . Establish systems and processes to maintain documentation relative to the QAPI program, as a basis for demonstrating that there is an effective ongoing program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 15 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record reviews the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 6 of 7 months reviewed for antibiotic stewardship. Residents Affected - Some The facility failed to maintain a system to monitor antibiotic use during the months of January 2023 through June 2023. These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics. Findings included: Record review of Facility Infection Control Log for January 2023 through July 2023 revealed facility maps with color coded rooms and the legend revealed the color to coordinate with the type of infection. There was also a page for each month that included each resident order for that corresponding month of a resident with an abx. There was no tracking form for the months of January 2023 through June 2023 that included if a resident had a lab completed before starting an abx, if they met/didn't meet the McGreers criteria for abx therapy, or if the infections were facility or community acquired. During an interview on 07/27/23 at 09:53 AM with ADON, she said that she was not responsible for the tacking/trending IC book. She said the nurse was supposed to use the McGreers form inside their Event tab of their EHR. She said that would include what abx was utilized, if a lab had been ordered and what those results were, as well as the reason for the abx with a start and stop date. ADON said after that, the nurse's should have been documenting per shift on an infection care note within the progress notes of the resident's EHR. ADON said she was not sure if it had been completed and/or tracked for every resident on every abx since January of 2023. During an interview on 07/27/23 at 10:51 AM with RRN, she said one of the reasons of termination for the former DON was due to job performance. RRN said the former DON was not tracking the infections that included tracking of and or performing lab cultures, the McGreers form for antibiotic stewardship or the mapping of the infections throughout the building. She said January to June of 2023 was not completed. RRN said she been working with ADON to get all the information for July of 2023. During an interview on 07/27/23 at 01:05 PM with RRN she said that the only way a resident with an infection and abx would go on the tracker was if an infection event was started in a resident's EHR. She said the form was an ongoing form until abx was completed. RRN said the tracker would not pick up a resident with an infection and/or their use of an abx unless the event was triggered. She said the form included if a lab was completed, what abx was used, the McGreers was met or not and it would assist in knowing if the infection was in house or community acquired. RRN said it was from pulling the abx list from the EHR system that through investigation it was revealed that the former DON was not utilizing the tracker. Record review of facility policy labeled Infection Prevention And Control Committee revised February of 2022 revealed: develop policies and procedures for surveillance and monitoring of infection control practices . Establish and monitor the facility antibiotic stewardship program . Maintain written accounts of meetings conducted and action taken by the committee . The infection prevention and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 16 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some control committee will advise administration and management about ensuring that records are maintained to document the following . Findings made during surveillance of antibiotic usage patterns. Record review of facility policy labeled Infection Control Documentation Workflow last revised 06/30/22 revealed: infection tracker infection control log the infection tracker in EHR is your infection control log. the log is auto generated from the completion of infection events in EHR. When a surveyor asks you for your infection log, the infection tracker is what you will produce. Note if infection tracker with McGreers criteria events are not initiated and completed timely, your infection tracker will not be accurate. Record review of facility policy labeled Antibiotic Stewardship revised Dec of 2021 revealed: this intern infection prevention and control program overseas the antibiotic stewardship program. The antibiotic stewardship program promotes the appropriate use of antibiotics including antibiotic use protocols and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The center develops and implements protocols to optimize the treatment of infection by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic reduces the risk of adverse events, including the development of antibiotic resistant organisms, from unnecessary or inappropriate antibiotic use and develops, promotes, and implements a center wide system to monitor the use of antibiotics . center leadership, including the administrator, is committed to safe and appropriate antibiotic use. This includes the development of antibiotic use protocols and a system to monitor antibiotic use. Leadership communicates with nursing staff and prescribing practitioners the centers expectations about use of antibiotics in the monitoring and enforcement of stewardship policies . The infection preventionist and director of nurses is responsible for the infection control program and oversight of the antibiotic stewardship program. The infection preventionist and director of nursing set the practice standards for assessing, monitoring and communicating changes in a resident's condition by frontline staff. Antibiotic orders and orders for lab cultures are reviewed by nursing leadership in the daily clinical meeting. They are reviewed for appropriateness and adherence to the center's antibiotic use protocols. The medical director set standards for antibiotic prescribing practices for all clinical providers credentialed to deliver care in the center and is accountable for overseeing adherence. To be effective in this role, the medical director should review antibiotic use data and ensure best practices are followed in the medical care of the resident . the center monitors measures of antibiotic use sample measures of antibiotic use: track the right of new starts of antibiotics/1000 resident days. Track center acquired infections. Track how and why antibiotics are prescribed. Track how often and how many antibiotics are prescribed. Track the adverse outcomes and costs from antibiotics. Track antibiotic days of therapy/1000 resident days. Adhere to clinical assessment documentation (sign symptoms, vital signs, physical exam findings.) Adherence to prescribing documentation. Identify and record community acquired infections. Identify and record types of infections and number of cases example UTI, Uri, L R I, wound infection. Review antibiotic resistance patterns in center to understand which infections are caused by resistant organisms. Monitor adherence to McGreers criteria to identify resident's signs and symptoms of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 17 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview, and record review, the facility failed to provide the required 80 square foot of usable living space per resident in 8 multiple occupancy resident rooms (16, 17, 18, 19, 20, 21, 22, and 23) of 31 rooms reviewed for room classification. The rooms measured less than the 80 square feet of usable living space per resident in multiple occupancy resident rooms. This failure could impede the ability of residents to live in these rooms. Findings included: Record review of state form 3740 labeled Bed Classification dated 07/27/23 revealed Rooms 16-23 (8 rooms) as double occupancy Medicare certified resident rooms. During an interview on 07/27/23 at 12:26PM, with ADM, he said they could not successfully make the rooms 16-23 available as resident rooms within 24 hours. In their current state, they were not able to be 80 sq feet per person for the 8 rooms that were double occupancy. He said he could make the ADM office as a temporary office to put all offices together but would probably have to establish a couple of the rooms down another hall as offices as well. ADM said they could make rms 16-23 available as resident rooms for a crisis situation but could not be a permanent situation. He said they could make a 10-bed situation that they already had from other rooms in the facility if they needed. He said with the supplies they had, the facility could fill 3 rooms at that moment all the way for double occupancy giving 80 sq ft of resident space. He said he has decertified beds in the past in other facilities and would talk with corporate about the situation. ADM said he understood that a crisis could have been any natural disaster or in the most recent years with Covid-19 and some facilities needed to place a resident in another facility for a short period of time. He said he understood that the facility had a license for a certain number of beds and that due to the offices being in the rooms 16 through 23 for a long time, that would present difficulty with finding placement for residents. During an interview on 07/27/23 at 1:33PM, ADM said the facility did not have a room waiver for their rooms of the facility. He also said he did not have a policy regarding room size or room availability/readiness. Record review of Facility layout dated 11/20/20 revealed Rm 16 -Bed A and Bed B- Semi-private Medicare Certified. Rm 17- Bed A and Bed B- Semi-private Medicare Certified. Rm 18- Bed A and Bed B- Semi-private Medicare Certified. Rm 19- Bed A and Bed B- Semi-private Medicare Certified. Rm 20- Bed A and Bed B- Semi-private Medicare Certified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 18 of 19 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 Rm 21- Bed A and Bed B- Semi-private Medicare Certified. Level of Harm - Potential for minimal harm Rm 22- Bed A and Bed B- Semi-private Medicare Certified. Rm 23- Bed A and Bed B Semi-private Medicare Certified. Residents Affected - Some Record review of Facility Map with date of 1/3/22 revealed Rm 16-Considered as the BOM office Rm 17-Considered as the ADON office. Rm 18 and 19-Considered as Maintenance office and storage rooms. Rm 20 -Considered as the facility staff breakroom. Rm 21-Considered as Central Supply storage room. Rm 22-Considered as the Conference Room. Rm 23-Considered as the DON office. Record review of TULIP accessed 08/02/23 at revealed the last time the facility had a change in capacity was 08/01/2014 and that had been to deallocate Medicaid certified beds for the facility. It specified that there were 17 Medicare only certified beds in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 19 of 19