Health inspection·July 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with MDS F on 07/13/23 at 12:52 PM revealed MDS was responsible for completing all care plans with the help of the DON. She stated the DON opened the care plans on admission, and she completed them within 7 days of completing the MDS assessment. She stated she was responsible for both short term and long-term care plans. She stated the short-term care plans were updated during morning meetings and long-term care plans were updated with MDS assessments. She cannot recall any breakdown or issues with care plans being missed. Interview and record review with MDS F on 07/13/23 at 2:09 PM revealed Resident #27 did not have comprehensive care plans and there were only three medication care plans available. She stated there should be more care plans to include other areas for the residents such as medical care, behavioral care, activities, dietary, fall prevention, and they should be person centered, she was not sure how they were missed. She stated the risk of not having up to date care plans could lead to complications and further decline of the resident. To avoid missing care plans she stated she will bring her laptop to their morning meetings to assess any short-term and long-term changes of the residents and discuss with IDT. Record review of Resident #27's Care Plan dated 06/20/2023, revealed person-centered comprehensive care plans were initiated and created on 07/13/23. Comprehensive care plans were provided at the conclusion of the survey. Interview with ADON/Staffing Coordinator on 07/13/23 at 2:13 PM revealed MDS F and DON were responsible for care plans, which also included the comprehensive person-centered care plans. MDS F also was responsible to complete the short-term and long-term care plans. She stated the CNAs could see the interventions for the residents based on the [NAME]. She stated her expectation was that the care plans would be completed according to the facility policy. She also stated the risk for the care plans not being up to date would be the CNAs and nurses would not know how to properly care for the resident. Interview with CNA G on 07/13/23 at 2:18 PM revealed she would be able to see how to care for the residents by looking in the [NAME]. This is where she would be able to see if the resident had specific interventions like if they are a fall risk. Interview with DON on 07/13/23 at 2:22 PM revealed MDS nurse was responsible to complete short-term and long-term person-centered comprehensive care plans. She stated that she opened them on admission and MDS F completed them within 7 days of completing the MDS assessment. She stated her expectation was that the care plans should be documented within the patient chart that includes goals and interventions. Her expectation was that MDS F would update care plans quarterly and as needed. Missing care plans for Resident #27 would be reviewed along with all residents moving forward to ensure completion. Risks to residents of gaps in care plans would be they would not be cared for properly. Record review of policy titled Care Plans, Comprehensive Person-Centered with a revision date of [DATE] revealed comprehensive, person-centered care plans will be developed within 7 days of the completion of the required comprehensive assessment (MDS). It also revealed that comprehensive, person-centered care plans that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 2 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 - Some 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 interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 9 (RN coverage days) of 101 days reviewed for RN coverage. The ADON/Staffing Coordinator failed to have an effective documentation and tracking system and was unaware of which RN's worked when she reviewed the schedule sheets and based on the timesheets, there was not 8 hours of RN Coverage on: 05/13/23, 05/14/23, 05/29/23, 06/11/23, 06/22/23, 07/06/23, 07/07/23, 07/09/23 and 07/10/23. These failures could place all residents at risk of not having an adequate amount of higher level nursing services which could result in a decline in the residents mental, physical and psycho-social well-being. Findings included: Record review of the facility's staff roster, undated indicated the facility had two RN Nurse Supervisors and one DON. Record review of the facility's 672 CMS form (Resident Census and Conditions of Residents) dated 07/13/23 revealed a census of 29 residents. Record review of the Facility's May Staff Schedule Sheet from 05/01/23 to 05/31/23 revealed no RN Coverage for 24 days: 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/07/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, 05/12/23, 05/15/23, 05/16/23, 05/17/23, 05/18/23, 05/19/23, 05/22/23, 05/23/23, 05/24/23, 05/25/23, 05/26/23, 05/29/23, 05/30/23 and 05/31/23. Record review of the Facility's June Staff Schedule Sheet from 06/01/23 to 06/30/23 revealed no RN Coverage for 19 days: 06/01/23, 06/02/23, 06/05/23, 06/06/23, 06/07/23, 06/08/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/18/23, 06/20/23, 06/21/23, 06/22/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23. Record review of the Facility's July Staff Schedule Sheet from 07/01/23 to 07/13/23 revealed no RN Coverage for 9 days: 07/03/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23, 07/12/23 and 07/13/23. A) Record review of RN A's time sheets 05/01/23 to 07/04/23, provided by the ADON/Staffing/ Coordinator revealed she worked 8 hours or more per day on 05/06/23, 05/07/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23, 06/03/23, 06/04/23, 06/09/23, 06/10/23, 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. Record review of the Facility's Staff Schedule Sheets for May 2023, June 2023 and July 2023 revealed RN A worked 05/06/23, 05/13/23, 05/14/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23. 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/19/23, 07/01/23 and 07/02/23. B) Record review of RN B's time sheet dated 06/01/23 to 06/30/23, provided by ADON/Staffing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 3 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 Coordinator revealed she worked 8 hours or more on 06/17/23, 06/24/23 and 06/25/23. Level of Harm - Minimal harm or potential for actual harm Record review of the Facility's Staff Schedule sheets for May 2023, June 2023 and July 2023 undated revealed RN B worked 05/06/23, 06/24/23 and 06/25/23. Residents Affected - Some C) Record review of the DON's time sheets dated from 06/20/23 to 07/13/23, provided by the ADON/Staffing Coordinator revealed she worked 8 hours or more on 06/20/23, 06/21/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23, 06/30/23, 07/03/23, 07/05/23, 07/11/23. Review of the Facility's Staff Schedule sheets for June 2023 and July 2023 undated revealed the DON did not work any days in June 2023 or July 2023. Record review of the facility's Direct Care Staff Daily Assignment Sheet/Sign in Sheets from 06/22/23 to 07/11/23, provided by ADON/Staffing Coordinator revealed the DON worked 06/22/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23. D)Record review of the facility's May 2023, June 2023 and July 2023 Schedule Sheets revealed the Clinical RN Clinical Specialist worked on 06/09/23, 06/16/23, and 06/23/23. E) Record review of the Staffing Agency time sheets dated 05/03/23, 05/04/23, 05/05/23, 06/18/23 and 07/08/23 revealed Shift details .RN nurse's name . shift resolution: Resolved .Provider Worked Shift. In the top right hand corner. F) Record review of the Staffing Agency time sheet dated 07/09/23 revealed, Shift opening, Shift details .Specialty: Registered Nurse did not have a RN nurse's name on it and no shift resolution and it did not indicate a provider worked shift, in the top right hand corner. Record review of the CMS PBJ Staffing Data Report ([DATE] - March 31 2023) run date 07/06/2023 revealed this facility triggered for A One star rating, No RN hours and failed to have licensing nursing coverage 24 hours/day revealed Infraction Dates: No RN hours 01/01 (SU); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 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); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/30 (MO); 02/01 (WE); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 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); 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11; (SA); 03/12 (SU); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) .Failed to have Licensed Nursing Coverage 24 Hours/Day 01/01 (SU); 01/03 (TU); 01/06 (FR); 01/07 (SA); 01/11 (WE); 01/14 (SA); 01/15 (SU); 01/20 (FR); 01/21; (SA); 01/25 (WE); 01/30 (MO); 02/09 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/22 (WE);03/18 (SA) . Record review of the PBJ Staffing Summary Report for 2023 2nd Quarter (01/01/23 - 03/31/23) run date 07/11/23 provided by the Administrator revealed staffing hours: One Registered Nurse Director of nursing 45.00 hours, two Registered Nurses - 153.11 hours . Interview on 07/11/23 at 4:00 pm, the ADON/Staffing Coordinator stated they used Agency staffing for RN coverage at times and said since being at this facility for the past three months, they always had RN coverage. She stated they had a DON and two RN weekend supervisors. She stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 4 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 - Some responsible for ensuring they had enough RN's for the weekends and the DON worked Monday - Friday. She stated RN A worked every weekend and if she could not work she asked RN B about working and if she could not, she contacted the Staffing Agency for RN coverage. She stated the staff had to contact her four hours before their shift to call off. She stated they did not have enough staff and needed three LVN's and one PRN RN Supervisor to work the weekends. She stated she could only go back to 04/01/23 for the timesheets because they had a CHOW on 04/01/23. She stated RN coverage was needed because the LVN's practice only went so far like they could not pronounce a death, sign off on care plans, do picc line dressings and if staff ever had a question they had an RN to go to. She stated for 05/13/23 and 5/14/23 she was not sure if RN A worked those days and thought maybe a Corporate RN came in and RN A was sent home. She stated she was not told by the Administrator or anyone else if an RN agency nurse worked those days. Interview on 07/13/23 at 10:75 am, RN A stated she had retired and was an RN nurse who worked at this facility PRN and usually worked two weekends/four days out of the month and the other RN B covered working the other two weekends. She stated she did not work too often. She stated on 05/13/23 she worked for 4 hours and did not work 05/14/23 and thought RN filled in for her. She stated she was not sure if she worked 6/11/23 - 06/18/23 but she worked on 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. She stated RN's were needed to make critical decisions and supervise the staff to ensure the residents had quality of care and was within the state regulations. Interview on 07/13/23 at 3:55 pm, RN B worked here at times as a PRN RN nurse and last worked here a few weekends back and passed out meds in June 2023 and was not sure if she worked 6/11/23 but did not work May 2023. She stated she had not worked July 2023 and added she was a PRN RN and RN A worked more than she did at this facility. Interview on 07/13/23 at 12:33 pm, the ADON/Staffing Coordinator stated RN A worked 06/11/23 and 06/12/23 and said she was not sure why RN A missed punch sheet was not filled out all the way showing she worked 06/11/23. She stated on 5/13/23 RN A worked four hours and was not sure why and would have to get on the phone and talked to her. She stated the Corporate RN's sat in her office but did keep up with when they worked and had no documentation to prove they worked. She stated on 07/09/23 she was not able to confirm an agency nurse worked because there was no RN listed on the time sheet form. She stated RN A covered pretty much every weekend. Interview on 07/13/23 at 2:29 pm, the DON stated she started work at this facility on 06/20/23 and had to call off work on 6/22/23 and 6/23/23 because she got sick and week after that on 07/06/23 and 07/07/23 she took off from work because she had a family emergency. She stated she was pretty sure the facility had RN coverage as far as she knew. She stated they had two RN Supervisors and herself working at this facility and the designated RN supervisor for the weekends was RN A and RN B was the other RN who worked the other weekends. She stated they also used agency nurses for RN coverage at times and stated she was not aware of any inconsistencies with the RN timesheets and schedule sheets. She stated the ADON/staffing coordinator was responsible for ensuring they had sufficient RN coverage. She stated the facility needed 8 hours of RN coverage for supervision of the clinical staff, the LVN's and CNA's and was a state regulation. She stated they did not have a nurse waiver in place and stated if there was no RN at the facility no one would be able to pronounce a death, pull picc line, have a delegation of duties and supervision of the staff. She stated her expectations for RN coverage was to meet the standard for RN coverage. Interview on 07/13/23 at 2:50 pm, the Clinical RN Specialist stated they did not have any nursing waivers and this facility had a CHOW on April 1, 2023, and added they had proof of RN coverage at all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 5 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 - Some times and if the facility did not have RN coverage in the building she or other Corporate RN's worked. She stated her and the other corporate RN hours did not sign the sign in sheets. She stated she was not sure why the Agency RN's name was not on the timesheet for 07/09/23 and thought the RN who worked had not logged in her time yet. She stated the ADON/Staffing Coordinator was good about letting her know when they needed to get an Agency RN and believed RN A worked the weekends but was not sure if she worked every weekend. She stated RN B worked but was not sure how often she worked here and the last time she worked here was last month. She stated they were trying to hire more RN's by posting on the job board Indeed. She stated the facility needed 8 hours RN coverage daily for overseeing the LVN's and making sure they were not doing anything out of their scope, communication with the Doctors and family members and took the DON duties on the weekends and to ensure everyone was being taken care of. She stated the RN's assisted with the resident's plan of care, removing picc lines, pronouncing death, changing out central lines and hub needles. She stated ADON/Staffing Coordinator tried to get the nursing schedule created a week in advance and if someone called off and she could not find a replacement she would let her know. She stated they had a policy that the staff must call the ADON/Staffing coordinator no later than two hours prior to starting their shift. She stated she was not aware of any inconsistencies between the time sheets and assignment sheets and added they had a good system with tracking the RN coverage hours. She stated the training was pending with new DON who just started working here 06/20/23 to assist with tracking the RN hours. She stated the DON called off one day Friday 6/23/23 she worked in the DON's place and thought that RN A worked 6/22/23 but was not sure, then the DON was off for a family emergency in July 2023 and think agency RN's worked in her place but was not sure. She stated the DON was responsible for ensuring they had RN coverage in the building and the administrator should follow-up to ensure it. She stated on 5/13/23 and 5/14/23 she was on vacation she did not work. She stated she had not done the orientation with the new DON so that they would have a better way of tracking and documenting to ensure they had RN coverages and was not sure why RN A timesheet on 06/11/23 was different from what was on the schedule sheet, then stated RN A had a mis-punch on 06/11/23 but was not able to provide a completed form with signatures from RN A and supervisor to confirm it. She stated when the RN's worked they needed to sign the schedule sheets also which was making it hard for them to determine who worked when. She stated RN A and DON had some issues with missed punches and could not provide proof they worked on certain days. She stated everyone had staffing challenges, but they figured it out and said she was getting ready to do an orientation training next week with the new DON who was going to do great here. Interview on 07/13/23 at 4:09 pm, the [NAME] President of Clinical Services stated she and the Corporate Representative reviewed the daily RN coverages to ensure there was 8 hours of RN coverage or more daily then submitted them with the other staffing data to CMS quarterly and said she was not aware of any RN coverage issues at this facility. Interview on 07/13/23 at 5:33 pm, the Administrator stated working at this facility since 12/01/22 and the facility did not have a nurse waiver. He stated he was not aware CMS had the facility listed with a one star rating because of not having enough RN hours since 10/01/22. He stated they had DON H in December 2022 until March 2023 and from March 2023 to April 2023 the facility had Acting DON D . He stated they did not have a fulltime DON from May 2023 to June 20, 2023, but the Clinical RN Specialist worked here at various times but was not sure of the actual days she worked and no documentation to confirm. He stated the facility was currently looking for a designated RN weekend supervisor to work the weekends because RN A and RN B work PRN weekends. He stated not being aware of any issues with the ADON/Staffing Coordinator not updating the schedule sheets if they changed and was not aware of any issues with her being able to keep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 6 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 - Some track of the RN hours. He stated after review of RN A's timesheet dated 06/11/23 and schedule sheet 06/11/23 and was not really sure why there was inconsistencies with RN A's timesheets and schedule sheets. He stated the DON was responsible for ensuring the facility had RN coverage, the Administrator said they needed to find a better way to document on the assignment sheets for RN coverage. He stated the facility was not using RN Agency in December 2022 because the facility had RN coverage daily since he worked here and with the help of the Corporate RN's and agency staffing. He stated he had no proof the Corporate RN's worked at the facility because they were salaried and would talk to Corporate about getting the Corporate RN to sign their names on the assignment sheets. He stated the facility needed to create a better schedule sheet for better record keeping. He stated the staff were supposed to notify the ADON/Staffing Coordinator if they called off 4 hours prior to starting their shift so the ADON/Staffing Coordinator had to find the nursing coverage by first contacting the PRN RN's and if they could not work then get an agency staff and if that failed to find coverage she was supposed to call him so he could help. Interview on 07/13/23 at 6:11 pm, the Business Office Manager stated she worked here 12 years and said they have had a few DON's within the past year. She stated she was not really sure, but DON D was the acting DON from April 2023, and she stopped working here May 2023. She stated they had two RN Supervisors RN A and RN B and was not aware of any RN coverage issues and RN A worked as far as she knew was the main RN supervisor on the weekends. She stated RN B did not work too much and that they were currently looking for more RN's using the job posting board Indeed and used agency nursing staff. She stated she was not aware of any RN coverages issues from October 2022 to current. Record review of the facility's RN Position Description updated 04_2017 revealed, Job Summary: Registered nurses oversee the activities of the nursing staff. The RN is responsible for overseeing each patient's overall health and medical histories .RN's are also responsible for advanced activities such as starting intravenous infusions, administering oxygen, monitoring blood sugar levels and consulting with the supervising physicians . Record review of the facility's Staffing, Sufficient and competent Nursing policy revised 03-2023 revealed, Policy statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with the resident care plan and the facility assessment .Sufficient Staff .A registered nurse provides services as least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 7 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the category of work for each person on direct care staff for 1 (facility) of 1 facility reviewed for PBJ Data submissions. The facility failed to ensure the PBJ staffing Data submitted to CMS was accurate on 05/15/23, which showed the facility had low levels of RN and DON staff hours for the 2nd quarter of the 2023 fiscal year. This failure could place residents at risk of not having adequate staffing coverage based on the facility's census which could result in inadequate care, decreased physical, mental and psycho-social well-being. The findings included: Record review of the facility's staff roster, undated indicated the facility had two RN Nurse Supervisors and one DON. Record review of the facility's 672 CMS form (Resident Census and Conditions of Residents) dated 07/13/23 revealed a census of 29 residents. Record review of the CMS PBJ Staffing Data Report ([DATE] - March 31 2023) run date 07/06/2023 revealed this facility triggered for A One star rating, No RN hours and failed to have licensing nursing coverage 24 hours/day revealed Infraction Dates: No RN hours 01/01 (SU); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 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); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/30 (MO); 02/01 (WE); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 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); 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11; (SA); 03/12 (SU); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) .Failed to have Licensed Nursing Coverage 24 Hours/Day 01/01 (SU); 01/03 (TU); 01/06 (FR); 01/07 (SA); 01/11 (WE); 01/14 (SA); 01/15 (SU); 01/20 (FR); 01/21; (SA); 01/25 (WE); 01/30 (MO); 02/09 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/22 (WE);03/18 (SA) . Record review of the PBJ Staffing Summary Report for 2023 2nd Quarter (01/01/23 - 03/31/23) run date 07/11/23 provided by the Administrator revealed staffing hours: One Registered Nurse Director of nursing 45.00 hours, two Registered Nurses - 153.11 hours . Interview on 07/11/23 at 3:15 pm, the Administrator stated he was not sure who sent the PBJ reports to CMS but would find out. Interview on 07/13/23 at 2:50 pm, the Clinical RN Specialist stated this facility had a CHOW on April 1, 2023, and was not sure who did the PBJ submission reports to CMS but would find out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 8 of 9 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Interview on 07/13/23 at 4:09 pm, the [NAME] President of Clinical Services stated she was not aware of any current RN shortages and the facility had RN coverage 8 hours or more that she knew of. She stated she and the Corporate Representative were responsible for ensuring the PBJ data was submitted and accurate. She stated her and the Corporate Representative reviewed and uploaded the PBJ employee data and reviewed the daily RN coverages to ensure the facility had 8 RN hours or more of coverage then submitted the data to CMS. She stated not being aware of any issues with the accuracy of the PBJ Data submitted to CMS for the previous quarters and this facility's PBJ data was not due again until August 2023. She stated the previous owner should have submitted the PBJ reports accurately for the previous months and would have to check to see if they did. She stated she thought their Corporate Representative checked to see if the previous owner submitted the PBJ data and accurately and could not confirm because the corporate representative was currently on leave and would reach out to the previous facility owner and follow-up with the HHSC Surveyor. Interview on 07/13/23 at 5:33 pm, the Administrator stated not being aware of any issues with inaccurate PBJ data submissions which were completed at their corporate level. He stated he was not aware and not sure why this facility had a one star rating and did not have enough RN hours based on the previous PBJ reports. He provided the HHSC Surveyor the contact information for the previous owner's corporate person who did the PBJ transmissions. After review of the PBJ summary report for the 2nd quarter 2023, the Administrator stated he was not sure why the number of RN and DON hours worked were so low. Interview on 07/13/23 at 6:17 pm, Previous owner's PBJ Representative I stated she had not submitted PBJ Data submissions to CMS for this facility. Interview on 07/17/23 at 8:43 am, The [NAME] President of Clinical Services stated she had not looked at the (01/01/23 - 03/31/23) PBJ quarter and was not aware the facility currently had one star, no RN coverage and low nurse staffing ratings with CMS and was not surprised. She stated she did not have to review or validate those previous PBJ reports because of the CHOW effective 04/01/23. She stated she had no access to the previous PBJ reports until just recently. She stated when the staff hours for a quarter was 150 hours or less it triggered for one star and low staff ratings. Record review of the PBJ policy revised 3/2023 revealed, Policy: Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act .9. Staffing information is collected daily and reported for each fiscal quarter . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 9 of 9