Health inspection·October 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have access to receive assistance for Resident #1 from another nurse. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1's room. She lifted Resident #1's left leg up and Resident #1 began to scream. CNA H let Resident #1's the left leg fall onto the bed and began to exit Resident #1's room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time CNA H lifted her leg and when Resident #1 lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. As she was walking out Resident #1's room she stated you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you are not hurt. You had complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on [DATE]. He also stated a staff came into Resident #1's room on 09/18/2023 ( the staff was identified by the DON as CNA H) and staff picked up Resident #1's leg dropped it back on the bed and stated to Resident #1, she was not hurt. He stated in the video after staff (CNA H) began walking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm toward the door they stated to Resident #1 you are crazy . He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after these statements to hear what staff was saying. He also stated Resident #1 was in surgical unit at Hospital B and awaiting surgery. He stated Resident #1 was not available for interview. He did not want to show the video to administration except to identify the staff in the video. Residents Affected - Few In an interview/observation on 09/21/2023 at 10:30 AM the Director of Nurses stated if Resident #1 were having severe pain in her left leg and CNA H picked up Resident #1's left leg and did not place the leg gently on the bed with Resident #1 yelling the entire time I would consider this physical abuse. She also stated if CNA H allegedly stated to Resident #1 you are crazy as CNA H was exiting the room this is verbal abuse. She stated staff had been in serviced on abuse and neglect numerous times. She stated this was abuse. The Director of Nurses was required to identify the staff in the video. Director of Nurses viewed the electronic monitoring video provided by the family on 09/21/2023 and observed CNA H pick up Resident #1's leg and lower it and heard CNA H state you are crazy as CNA H was exiting the room. The Director of Nurses stated this was verbal and physical abuse by CNA H. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was working the night of 09/18/2023. In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency, and phone number . CNA I was in Resident #1's room when Resident #1 was complaining of pain. CNA I may have heard in the hall what CNA H stated to Resident #1. In an interview on 09/21/2023 at 2:45 PM the Administrator stated if Resident #1 was having severe pain in her left knee and left leg, and if CNA H was aware Resident #1 had pain and was not given care to Resident #1 and lifted her left leg up and resident yelling from pain and did not lay the left leg softly on the bed, she stated that would be considered abuse. She also stated if CNA H was exiting Resident #1's room and allegedly stated you are crazy, that was considered verbal abuse. The Administrator stated it was her, the DON, ADON and all staff's responsibility to monitor for any type of abuse and report it immediately to her, the DON, ADON or the staff's supervisor . In an interview on 09/20/2023 at 8:40 AM Med Aide E stated she had been in-serviced on abuse and neglect. She stated she did not recall the last time she was in-serviced. She also stated if a CNA picked up a resident's leg and was aware the resident had pain and swelling in the knee and pain in that leg and was not providing care, she stated if the resident were screaming when the CNA did that, she would consider that physical abuse. She stated if a CNA stated you are crazy as she was exiting a resident's room that would be verbal abuse. She stated the Administrator was abuse coordinator. In an interview on 09/22/2023 at 10:30 AM, the ADON stated if a CNA picked up Resident #1's leg and if they knew Resident #1 was in severe pain and her knee was swollen, that would be considered physical abuse. She also stated if a CNA was exiting Resident #1's room and allegedly made the statement you are crazy , that was verbal abuse. The ADON stated an abuse and neglect in-service was given recently, however, she did not recall the date. She stated the Administrator was the abuse coordinator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility on the night of 09/18/2023 and needed to interview LVN A to determine if she heard what CNA H stated to Resident #1 or if she knew about CNA H picking up Resident #1's leg. In an interview on 09/22/2023 at 1:40 PM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/22/2023 at 1:47 PM, attempted to contact CNA I and left voice message of name, agency, and phone number. CNA I was in the facility on 09/18/2023 and may have witnessed what CNA H stated from the hallway. Record review of the facility's policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of , oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse/neglect of residents for one Resident #1) of three residents reviewed for abuse and neglect. Residents Affected - Few The facility failed to implement their abuse/neglect policy when LVN A was notified of Resident #1's pain and the administrator was notified of the incident by the COTAand the administrator failed to investigate the injury per policy. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Record review of Facility Policy on Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The facility will investigate of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 1. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Verbal abuse is defined as the use of , oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff responsibility to immediately report any violations or alleged violations. 3. Neglect: was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect. All incidences of unknown origin will be investigated. Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain. Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur Level of Harm - Minimal harm or potential for actual harm (where the bone flares out like an upside-down funnel). Residents Affected - Few Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few camera in Resident #1's room on 09/18/23 at 5:51 PM staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. You've complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 9/19/2023 at 10:44 AM and an ambulance was called to take Resident #1 to the hospital on 9/19/2023 at 10:44 AM. He stated there was also video of a CNA checking Resident #1's leg, picking the broken leg up and dropping it back on the bed and telling Resident #1 she was not hurt. Resident #1's family member also stated in the video after CNA dropped Resident #1 leg and began toward the door the CNA stated to Resident #1 you are crazy. He also stated the facility did not do anything for Resident #1 except give her pain medication she was already receiving. He stated he did not believe this medication helped Resident #1 due to Resident #1 continued to be in pain. He also stated Resident #1 was neglected and she needed to be in the hospital for x-rays immediately when Resident #1 began to yell she was in pain and her leg was broken. He stated she would rub on her left leg and by her expression from the video footage he noticed she was in pain. He stated he did not view the videos until 09/19/2023 after family received a phone call Resident #1 was going to be transferred to the hospital. He stated if he had seen the videos from Resident #1's room on 09/18/2023 he would have drove two hours to ensure she was getting the treatment she needed and was sent to the hospital immediately. He stated that was a new pain for Resident #1 and she had not been complaining about her knee. He also stated it was a new symptom for her knee to swell. In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/ Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (narco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/ leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yelled out frequently. She stated when she was yelling, she was in pain. LVN D stated resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete pain assessment and document in nurses notes about Resident #1's pain. She also stated the nurses was expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero - no pain and ten- extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident reports or pain assessments due to this was how Resident #1 she was always complained about pain. She stated this was her normal behavior. LVN D stated resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1 physical condition, moods, and behaviors. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone in the facility was aware if Resident #1 was in pain she will yell, and we don't assess the pain very closely when giving pain medication. She stated we give her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. She also stated if a nurse was informed by staff over an hour that Resident #1's knee had increased in size due to swelling, Resident #1 was yelling in pain and Resident #1 stated she thought she broke her leg/knee, a nurse was expected to go to that room immediately due to that was a new pain for Resident #1; and anytime a resident stated they thought their leg/knee was broken that was serious. She stated if a nurse did not visit Resident #1 immediately after allegedly being informed every 10 minutes of her change in physical condition, that would be considered neglect. She stated unless there was an emergency with another resident. She stated a nurse could not ignore when staff was concerned about a resident's physical condition, and they felt there was a major concern for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's physical health. She stated if a nurse continued to refuse to go to Resident #1's room for almost 2 hours, they did neglect Resident #1. She stated if the staff did not know why Resident # 1's knee was swelling, very painful to touch and Resident #1 allegedly stating her leg was broken, that would be considered an injury of unknown origin and would need to be investigated. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident was in pain and complaining of her left knee hurting In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room to complete an assessment. She stated if an assessment had been completed and LVN A would have went to Resident #1's room at approximately 6:10 PM she believed Resident #1 would have been sent to the hospital for evaluation that night. She stated she did believe LVN A was neglecting Resident #1. She stated the statements from LVN A was that Resident #1 was always like that and she was always complaining about something, and there was not anything wrong with her. She stated that was deliberate neglect from LVN A . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed of Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the Emergency Room. She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents was receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. She stated it was discussed in the morning meeting on 09/19/2023 about Resident #1's knee and leg. She stated it was discussed Resident #1 needed an X-Ray. She stated the staff was not interviewed and there was not any questioning of what happened to Resident #1's left knee or left leg. The Administrator stated after today ( 09/21/2023) she realized either she or the DON needed to complete an investigation of what happened with Resident #1. She stated if a nurse continued to refuse to assess a resident after being asked several times by the staff, she would consider that neglect. She also stated if a staff knew Resident #1 was in extreme pain in her left leg and they lifted the left leg in the air and did not gently place the left leg on the bed she would consider that abuse. She also stated if staff made a statement to Resident #1 as she was leaving the room that Resident #1 was crazy, she stated that was verbal abuse. She stated in the abuse and neglect policy and protocol it was clear what to do if anything was suspected and she stated they did not follow protocol to investigate what occurred with Resident #1 on 09/18/2023. The Administrator also stated if Resident #1 complained that her leg was broken, her knee continued to swell and she was in extreme pain within a few seconds after she was transferred from a wheelchair to the bed, there was a potential of an injury of unknown origin. She stated no one reported that to her. The Administrator did not see the electronic video given from family; however, she heard the video and the Administrator stated Resident #1 stated her leg was broken. In an interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse of Resident #1 having pain and swelling in her left knee and Resident #1 believed her left knee or left leg was broken, LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on [DATE]. LVN B stated if staff continued to report to LVN A over an hour that Resident #1 was in pain, the swelling in left knee had increased in size and Resident #1 stated her leg/knee was broken, LVN A was expected to go to Resident #1's room immediately. She stated if LVN A continued to refuse to assess Resident #1 that would be considered neglect, unless there was an emergency with another resident. She stated if it was verified there was not an emergency every time staff was reporting the new physical condition Resident #1 was in , LVN A did neglect Resident #1. She also stated on Tuesday 09/19/2023 at approximately 9:00 AM in the staff meeting she reported Resident #1's knee was swollen, and she had been in pain. She stated she also informed the administrative staff in the morning meeting that the x-ray department may not be available to come to the facility until the afternoon. She stated the Administrator stated to call the physician and send Resident #1 to hospital[TRUNCATED] Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of five residents reviewed for quality of care. Residents Affected - Few The facility failed to assess and obtain x-ray when Resident #1 began complaining acute pain and her knee/leg was broken in her left leg. The facility failed to order x-ray on 09/18/2023. An Immediate Jeopardy (IJ) situation was identified and on 09/21/2023 and Immediate Jeopardy template was presented to the facility on [DATE] at 3:37 PM. While the IJ was removed on 09/23/2023 the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed residents at risk for potential delay in medical intervention, uncontrolled pain, decline in health and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident complain of pain to the left knee and left knee slightly swollen, awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and received an order for an x-ray to left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to knee. ( Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected the pain medication was given to the resident. Resident #1 complaining of pain in left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report received from LVN A concerning Resident #1 had an order for left knee x-ray. LVN B notified the X-ray company and was informed x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild, 4-6- moderate, 7-10- severe. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the X-Ray company was unable to do the x-ray at the facility for resident #1 left knee. Resident #1 will be transferred via EMS to a hospital for x-ray to left knee. Resident #1 aware and notified family. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS at the facility to transport resident to hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five. Resident #1 transferred to emergency room for evaluation and treatment. Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by MDS Coordinator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain and knee swelling. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1 room approximately 6:05 PM Resident #1 was needing assistance to be transferred to bed from her recliner. She stated she explained to resident she needed to find a gait belt and get someone to help her with the transfer. The COTA/ Marketing Coordinator stated she asked the PTA C to assist her transferring Resident #1. She stated PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. COTA/Marketing Coordinator also stated Resident #1 wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on resident and assisted her from the wheelchair and pivoted resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within a few seconds of resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurts. COTA/ Marketing Coordinator stated she and the PTA C assisted resident to lie in bed in supine position and this is when she noticed Resident #1's knee begins to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of 0 being in no pain to 10 being in extreme pain. She stated the PTA stayed in the room and she left the room to report this to the LVN A approximately 6:30 PM She stated LVN A did not go to Resident #1's room to assess resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after reported to LVN A of Resident being in pain. She stated she did become frustrated with LVN A ignoring Resident #1 pain and knee swelling that she told her just give me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing coordinator stated she got the pain medication from the nurse and took it to Resident and gave the pain medication to Resident #1. She stated she reported to LVN A Resident #1 was complaining her leg/knee was broken and LVN A stated resident is always complaining about something hurting this was not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and come to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not coming to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN D gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. She also stated LVN A stated Resident #1's left knee doesn't look any different than it has in the past. LVN A told COTA/Marketing Coordinator and PTA C to go home she had this and promised to take care of Resident # 1. The PT/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital for x-rays. She stated she saw Resident #1 being transferred to the ambulance. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. She stated after she got home, she was afraid Resident #1 might have known she had a broken bone, and she may lie in the bed all night without any treatment. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he reviewed the video in Resident #1's room from his house. He stated on 09/18/2023 when the COTA and PTA transferred Resident #1 from the wheelchair to the bed Resident #1 began yelling as soon as she sat on the bed that her knee was hurting, and her leg was broken . He stated she was rubbing her left leg. He stated the COTA and PTA C assisted the resident in her bed and she continued to yell. He stated his concern was the staff allowed Resident #1 to lay in the bed until the next day in pain and complaining her leg was broken and they did not do anything but put an ice pack on her knee and put a small pillow under her left knee. He also stated everything was on the video of what occurred, and the facility failed to provide Resident #1 care when she was in extreme pain and complaining her leg was broken. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was in pain. In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. CNA H was in Resident #1 room for a short time when Resident #1 was in pain on 09/18/2023 In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency and phone number . CNA I was in the facility and was in Resident #1's room when she was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 pain. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room. She also stated LVN A stated Resident #1's left knee does not look any different than it has in the past. LVN A told the COTA/Marketing Coordinator and the PTA C to go home she had this and promised to take care of Resident # 1. Residents Affected - Few In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated was informed Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the Emergency Room. She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 was required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents were receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse that Resident #1 was in pain, she would have immediately assessed Resident #1. She stated LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on [DATE] . LVN B stated she was the oncoming nurse after LVN A. In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she stated she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with it swelling and the resident yelling her leg was broken that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurses was to complete pain assessment. She stated the nurse was required to ask resident where the pain is located and the pain level using the pain scale of zero - not having any pain and ten- having extreme pain. She stated a nurse was expected to document this in nurses notes when they administer pain medication and if a resident is in pain an assessment was required to be completed. She stated LVN A was expected to go immediately to Resident #1's room to complete an assessment and if Resident #1 was complaining about extreme pain and stated her leg/ knee was broken, Resident #1 needed to be sent to the emergency room immediately. In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few an interview on 09/22/2023 at 10:30 AM, the ADON stated anytime a Resident had pain whether a new pain or an ongoing pain the nurse was expected to assess the resident and complete a pain scale with the resident. ADON stated pain scale was when zero - no pain and ten- extreme pain. She stated any time a resident reported pain the nurse was to complete a pain assessment and document in the nurses notes where the pain is located and the pain scale. She stated Resident #1 only had one pain assessment completed and it was completed at the time of the MDS Assessment. She stated Resident #1 did complain about pain frequently, however, she expected the nurses to complete pain assessments each time the resident had a pain higher than a zero. She stated the nurses will document pain once a shift on the MAR, however, that does not indicate the resident did not have any pain that shift. The ADON stated there was a pain assessment in the electronic medical record and it was expected for the nurses to complete pain assessment each time a resident complained of being in pain. She stated there was a possibility something else may be occurring with the residents' physical condition and completing an assessment it will ensure the nurse will not be missing any other acute physical issues with the resident. She stated if LVN A had completed a pain assessment on Resident #1 she would have known the extent of the pain and Resident #1 needed to be transferred to the hospital immediately. She also stated if it was reported to LVN A Resident #1 was complaining of her leg being broken the nurse was expected to call 911 immediately, contact the physician and the family. She stated there was a failure in the facility's protocol regarding Resident #1's care on 09/18/2023. In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was complaining of pain and her left knee hurting Review of Resident #1's Facility Policy on Pain Management Program dated 01/2023 reflected the facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility will assess everyone for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The facility will identify the characteristics of pain such as location, intensity, frequency, pattern , and severity. The facility will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The facility will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. The interdisciplinary team will make attempts to determine root cause of the pain and collaborate with physician to conduct necessary diagnostics and evaluation to identify potential source of pain and determine plan of care. The Administrator and Director of Nurses was notified on 09/21/2023 at 3:37 PM than an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided and POR was requested at this time. The following POR was accepted on 09/23/2023 at 7:38 AM: On 09/21/2023 an abbreviated survey was initiated at (facility). On 09/21/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: On 09/21/2023 an abbreviated survey was initiated at facility. On 09/21/2023 the surveyor provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows:

F684: Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. DON/Designee conducted pain assessment for all residents on September 21, 2023, to ensure that no other resident effected. Documents are in POR binder and uploaded to resident's chart. The facility will follow policy and procedure regarding assessment injuries and pain to protect individuals in similar circumstances. No other residents noted to have injuries. Action Taken: Immediately, on September 21, 2023, Corporate clinical specialist in serviced DON and ADM to include Quality of ca[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of five residents (Resident #1) reviewed for injuries and supervision. Residents Affected - Few The facility failed to ensure staff properly transferred Resident #1 from her wheelchair to her bed resulting in a fractured left leg causing severe pain. An Immediate Jeopardy (IJ) situation was identified 4:37 PM and on 10/18/2023 at and Immediate Jeopardy template was presented to the facility on [DATE] at 4:39 PM. While the IJ was removed on 10/19/2023 at the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain (pain between the lower edge of the ribs), signs symptoms of musculoskeletal system (mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness (a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), left foot drop (caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the resident's cognition was intact. Resident #1 did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed to require staff to stabilize her when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions included that the resident required extensive assistance by two staff members with transfers. Resident #1 required extensive assistance by one staff member with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia(treatment that prevents you from feeling pain while you are awake) including pain relief, side effects and impact on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety function; monitor/document for probable cause of each pian episode; and remove/limit causes where possible. Resident #1's further interventions were: monitor/document for side effects of pain medication; administer analgesia as per orders; give ½ hour before treatments or care; notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; provide the resident and family with information about pain and options available for pain management; and discuss and residents' preferences. Residents Affected - Few Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room Hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors note from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur (where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by the family revealed on 09/18/2023 revealed the following: - At 05:44 PM, the COTA/Marketing Coordinator stated to Resident #1 she had not transferred Resident #1 before and asked Resident #1 if she was able to help during transfers or did, she need a gait belt. The PT/Marketing Coordinator stated she was going to find a gait belt. -At 05:49 PM, the COTA/ Marketing Coordinator and PTA began transferring Resident #1 from the recliner to the wheelchair ( on 09/18/2023 PM). Resident #1 complained about her back hurting but was not yelling. -At 05:52 PM, the COTA/Marketing Coordinator and PTA began to transfer Resident #1 ( by 2 person assist with gait belt) from her wheelchair to her bed in PM. Resident #1 was not yelling or complaining about pain. PTA C was standing behind the wheelchair to the left when COTA/ Marketing Coordinator was standing in front of Resident #1. Resident #1 had her right hand on COTA / Marketing Coordinator upper left arm and her left hand on COTA/ Marketing Coordinator upper right arm. Resident was in wheelchair and the left side of resident was next to the bed. PTA C was standing behind the wheelchair. PTA C had her hand on Resident #1 upper back and continued to stand behind the wheelchair when COTA/Marketing Coordinator transferred Resident #1 from wheelchair to the bed. During the transfer PTA C did grab Resident #1's pants. PTA C was not to the side of resident or in front of resident where she could view Resident #1's left foot or assist with the left foot due to Resident #1 having left foot drop. - Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. At 6:00 PM. Resident #1 stated to PTA that they turned her around and Resident #1 was looking at PTA as she made the statement. The PTA stated to Resident #1 they did not mean to hurt her. In an interview on 10/15/2023 at 10:40 AM, LVN D stated Resident #1 required 2 staff assist with a gait belt when Resident #1 was transferred. LVN D stated she had assisted Resident #1 with transfers from her wheelchair to her bed. She stated for a successful transfer with Resident #1 it was easier to place the wheelchair near the bed where there was enough room for one staff be between the bed and the wheelchair. She stated one staff would be on Resident #1's left side and one staff would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on Resident #1's right side. LVN D also stated the staff on the left side of Resident #1 would be observing her left foot to ensure it didn't drag on the floor or would hang on the wheelchair. LVN D stated it was best practice if the left foot (one had the foot drop) was not next to the bed when transferring Resident #1 and her right foot was positioned next to the bed during transfers. She stated if staff transferred Resident #1 this way the left foot would not get caught between the wheelchair and the bed. There were less of a chance the left foot would be injured during transfer She stated Resident #1's had a left foot drop and sometimes she would place the left foot on the floor, however, most of the time she would keep the left foot raised a few inches off the floor during transfer. She stated if no one was on the left side of Resident #1 it would be very difficult to monitor the left foot to ensure it didn't drag on floor or get caught on wheelchair. LVN D also stated this type of transfer was more efficient with Resident #1. She also stated the two staff would have one hand on the gait belt, and the two staff would transfer Resident #1 together with one staff on her left side ensured her left foot was not dragging and not touching the floor. She stated the left foot would be smooth turn with her right foot and it would be in sync at the same time. She stated Resident #1's hips and feet would go at the same time, and it would be a smooth transfer. She stated the most important information with Resident #1's transfer was to watch the left foot. LVN D stated Resident #1 always wore non-skid socks and did not have regular socks in her room. She stated she would have shoes on or her non-skid socks when out of bed and when she was in bed, she preferred to wear her non-skid socks. LVN D stated Resident #1 did have weight bearing on her right foot, however, did not have very much if any weight bearing on her left foot. LVN D stated if someone was behind Resident #1's wheelchair and someone was in front of Resident #1 it would be difficult for anyone to observe her left foot. She stated someone needed to be by the left foot to prevent it from dragging or hitting anything. She stated it was best if the left foot (one had the foot drop) was not next to the bed when transferring Resident #1 and her right foot was positioned next to the bed during transfers. She stated if staff transferred Resident #1 this way the left foot would not get caught between the wheelchair and the bed. There were less of a chance the left foot would be injured during transfer. In an interview on 10/15/2023 at 11:00 AM, CNA M stated she had transferred Resident #1 in the past. She stated she began working at the facility 07/12/2023. She stated she had been assigned to Resident #1 or have assisted other staff in transferring Resident #1 at least 4-5 times per week. CNA M stated Resident #1 had problems with her left foot. She stated she was not capable of placing her left foot on the floor but for a few seconds. She stated Resident #1 did not have but very little weight bearing on her right foot and none on her left foot when she assisted Resident #1 with transfers. CNA M stated Resident #1 was a two person gait belt transfer. She stated there was no issues in transferring Resident #1 when one staff stood on one side of Resident #1 and another staff stood on the other side of Resident #1. She stated the staff on the left side was the one observing the left foot to ensure the left foot did not hit anything or drag on the floor during the transfer. CNA M stated Resident #1 would sometimes put her left foot on the floor during transfer and this is when the staff would reposition her foot. She stated if staff left room between the wheelchair and the bed it was very easily for one staff to be on each side of Resident #1. CNA M also stated Resident #1 would put some weight on her right foot but not all the time when she was assisted to the standing position. She stated Resident #1 left foot required to be watched the entire time of transfers due to having left foot drop and she could put her foot down and not have any control of the left foot. She stated this is why having one person on each side of Resident #1 was very important with her transfer. CNA M stated the staff did most of the transfers with Resident #1. She also stated it would be very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety difficult to transfer Resident #1 with one staff standing in front of her and one staff behind the wheelchair and hold onto her shirt or pants. She stated who would be observing the left foot and reposition it if needed. She stated Resident #1 left foot needed to be watched during the entire transfer process and someone may need to reposition the foot if it was dragging on the floor or if it hit the wheelchair. She stated unless someone was on each side of Resident #1 no one would be able to reposition the left foot if it was dragging. Residents Affected - Few In an interview on 10/15/2023 at 11:16 AM, TNA N stated she had been a TNA approximately 4 months. She stated she had assisted in transferring Resident #1. She stated Resident #1 left foot would drop and she could not use very much weight on the left foot. She stated she would place her right foot on the floor, however, was not able to use right foot very much. She stated Resident #1 was a two staff person assist using a gait belt. TNA N stated the staff was required to do most of the work when transferring Resident #1. She stated Resident #1 had a left foot drop and the staff needed to watch the left foot when transferring Resident #1. She stated Resident #1 would hold her foot up a few inches off the floor but sometimes would put her left foot down during transfer and this is when the staff on the left side could reposition the left foot. She stated during transfers of Resident #1 one staff always watched her left foot to prevent it from dropping and getting caught in the wheelchair or anything during the transfer. She stated resident was very fragile and everyone needed to be extremely careful when transferring Resident #1. She stated if staff was standing behind Resident #1 and staff in front of Resident #1 that would be very difficult to transfer her due to someone needed to be on her left side to watch the left foot. In an interview on 10/15/2023 at 11:31 AM, the MDS Coordinator/LVN stated Resident #1 required extensive assistance with two staff using a gait belt to transfer Resident #1. She stated Resident #1was minimal weight bearing on right foot when standing. She stated Resident #1 had a left foot drop and was not capable of placing full weight on her left foot. The MDS Coordinator stated when transferring Resident #1 the right foot was expected to be next to the bed. She also stated if the right foot was next to the bed and when staff transferred Resident #1 there was less chance of the left foot getting caught on the wheelchair or dropping her foot on the floor during transfer. She stated one staff needed to be on each side of Resident #1 to observe the left foot and reposition it during transfer if needed. MDS Coordinator stated she had not transferred Resident #1 or observed anyone transfer Resident #1. She stated based on Resident #1's physical condition she needed someone to observe the left foot during transfers. She also stated if a staff was behind Resident #1 and a staff was in front of Resident #1 it would be very difficult for staff to observe the left foot during transfer. She stated with Resident #1 she believed transferring her with one staff on each side of resident was the most efficient transfer. She also stated if a staff made a statement of never transferring Resident #1 and asked Resident #1 what type of transfer did she require, she stated she would assume the staff did not know how to transfer Resident #1. In an interview on 10/15/2023 at 11:45 AM,RN O stated she began working at the facility on 09/16/2023 and 09/17/2023. She stated Resident #1 did not complain of any type of pain in her left leg or left knee the entire weekend. She stated she had never transferred or observed Resident #1 being transferred. She stated she administered medication to Resident #1. She stated all staff should be familiar with what type of transfers each resident required before attempting to transfer a resident. RN O stated the staff was expected to view the electronic medical record to gather information on transfers. She stated it was not appropriate to ask a resident what type of transfer they required and ask if the resident needed a gait belt. She stated any resident may become confused at that time and may give the correct information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 10/15/2023 at 12:10 PM, the ADON stated she did not know about Resident #1 weight bearing on either foot. She stated she knew she was receiving PT. The ADON looked at the electronic medical records and reviewed the Physician Orders and stated Resident #1 was not on PT she was on OT. She stated she had not observed any staff transferring Resident #1. She also stated Resident #1 was a two person assist during transfers. ADON stated she expected there be one staff on each side of Resident #1. She stated one staff needed to watch Resident #1's left foot to prevent the left foot from dragging. ADON stated Resident #1's right foot should be next to the bed. She stated during transfer the left foot would not become tangled on the wheelchair or anything else. ADON also stated the therapy department did proper transfers. ADON stated if a staff is in front of Resident #1 and a staff is behind Resident #1 wheelchair during a transfer this would not be considered a proper transfer. In an interview on 10/15/2023 at 2:50 PM, the Administrator stated the facility could not be held responsible for the actions of any employee if the employees did not perform their job correctly. She stated if the staff had been in serviced and received training the facility did all they were required to do, and the facility did nothing wrong. She stated the employees are the ones that needs to be corrected and not the facility. She stated the facility was not responsible for the employees' actions. The Administrator stated she was not clinical and did not know anything about transfers and what was required of transfers. She stated she was the administrator and not clinical whenever asked about the facilities protocol of transfers, injuries, and investigations of injuries. She stated that was clinical responsibility. In an interview on 10/18/2023 at 10:00 AM the Director of Rehabilitation stated Resident #1 was on her caseload for OT. She stated Resident #1's right leg was full weight bearing. She also stated Resident #1 was able to put weight on her left foot as tolerated during therapy sessions. She stated transferred Resident #1 without any other staff assisting her. She stated it was different when residents were in therapy than when the resident was being transferred by CNAs or Nurses. Rehab Coordinator stated she did attend care plans and had attended care plan on Resident #1 and did make suggestions. She stated anytime a staff made suggestions it was discussed as a group. Rehab Coordinator stated she was not required to follow Resident #1's care plan or any residents care plan. The therapy department was not a part of the facility. She stated she did not know what was written on Resident #1's care plan. Rehab Coordinator stated she did attend Resident #1's care plan meetings. She stated she did not know how to answer the question when asked if therapy was expected to follow the facilities care plans. Rehab Coordinator also stated the therapy department was expected to follow Resident #1's care plans. She stated any transfer with Mrs. Hill needed to be very observant during the entire transfer. She stated if a staff asked a resident how they are transferred and if the resident required a gait belt, she believed the staff did not know what type of transfer the resident required. She also stated Resident #1 could be transferred from the front and from the back of the wheelchair. She stated if Resident #1 left leg was dragging or got caught on something the person behind the wheelchair would need to move the wheelchair out of the way to reposition Resident #1's left leg. She also stated there was a possibility of an injury during a transfer with Resident #1 related to her being so fragile. In an interview on 10/18/2023 at 11:35 AM, the Director of Nurses (DON) stated Resident #1 required two staff assistance using a gait belt She stated Resident #1 was very fragile and had left foot drop. She stated during a transfer with Resident #1 her left foot was expected not to be next to the bed. She stated there needed to be enough room between the bed and wheelchair where one person would be on each side of Resident #1. The Director of Nurses stated one staff needed to observe Resident #1's left foot during the transfer to ensure Resident #1 did not drag or hit anything. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with the one staff observing the left foot the staff could reposition the left foot as needed or stop the transfer and assist resident to the wheelchair until Resident #1 was ready for the transfer. She stated if staff was behind the resident and staff in front of the resident, she would consider this a one person transfer. She stated with Resident #1 she needed someone to watch the left foot and be able to get to the left foot if it was dragging on the floor or was caught in the wheelchair or anything could happen and someone would need to immediately reposition the left foot She stated if staff was behind the wheelchair during the transfer it would be very difficult for that person to move the wheelchair to reposition Resident #1's left foot. Director of Nurses also stated all staff including therapy was expected to follow residents care plans. She stated therapy care was on the facilities care plans in the electronic medical records and they were expected to follow care plans. In an interview on 10/18/2023 at 2:17 PM, the MDS Coordinator/LVN stated the Therapy Coordinator had attended Resident #1's care plan meetings. She stated all staff in the facility including therapy was expected to follow facilities care plans. She stated she had not been informed of the Therapy Department not attending care plan meetings or follow what is documented on the resident's care plans including transfers. She also stated therapy department has their own interventions on resident problems. MDS Coordinator/ LVN stated the Therapy Coordinator attends care plan meetings and makes suggestions and the suggestions is discussed during the meetings with the interdisciplinary team. In an interview on 10/19/2023 at 10:50 AM, CNA P stated she was not working at this facility when Resident #1 was residing at the facility. She stated she had been a CNA since 1996 and received a lot of training on transfers. She stated she was never taught in all the years of being a CNA for one staff stand behind the wheelchair and a staff stand in front of a resident during a transfer. She stated if a staff is behind the wheelchair and resident had issues with their foot/ leg it would be difficult for the person behind the wheelchair to observe the foot/leg to ensure the leg/foot was not caught on wheelchair or anything during the transfer. CNA P stated the weaker foot needed to be away from the bed and the foot without any issues needed to be next to the bed. She stated that is how she was taught to transfer a resident with weakness or unable to have full weight bearing on a particular foot/ leg. In an interview on 10/19/2023 at 1:15 PM, the Administrator stated I am not answering any questions about transfers. I am not clinical and not responsible for training on transfers. She stated she was in serviced on 10/18/2023 of how to transfer residents using Hoyer lift, two person assist with gait belt and one person assist. She stated she would not answer any questions about transfers related to Resident #1. The administrator left the conference room before finishing the interview. Record review of the facility's policy on Gait Belt Transfer Techniques dated July 2017 reflected two person stand pivot transfer to be utilized when transferring residents who can bear weight through at least one lower extremity and require the assistance of two persons due to weakness, confusion, or weight: 1. Place the gait belt around the resident's waist securely. 2. Bring resident to upright position and to the edge of the surface where they are seated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 3. Level of Harm - Immediate jeopardy to resident health or safety Place the transfer surfaces at a 45 degree angle to one another and secure breaks. Residents Affected - Few One person stands in the space between the wheelchair and the transfer surfaces ( to the side of the resident) 4. 5. The other person stands in front of the resident to block the knees. 6. Reach around the resident and grasp the belt in the mid back area (avoid grasping on the side due to risk of injury) 7. Assure that the residents' feet are placed firmly on the floor. 8. Bring the resident forward close to your trunk and shift your weight backward while pulling/ guiding the resident up. 9. The person on the side will grasp onto the gait belt and guide the pelvis to the transfer surface. 10. Cue the resident to shift his/her weight and move the feet in small steps towards the transfer surface. 11. Guide/gently lower the resident on to the transfer surface. 12. If needed, the person on the side can move back on the surface while the person in front guides the knees. 13. Once the resident is seated/ positioned safely, remove the gait belt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Administrator and Director of Nurses was notified on 10/18/2023 at 4:39 PM that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The POR was requested at this time. The following POR was accepted on 10/19/2023 at 10:40 AM and indicated the following: On 09/21/2023 an abbreviated survey was initiated at (facility). On 10/19/2023 at 4:39 PM the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: On 09/21/2023 an abbreviated survey was initiated at facility. On 10/19/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Investigate Accidents and Hazards applies treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Action Taken: Monitoring was completed from 10/19/2023 and was as follows: Immediately, the two employees who were reported to have improperly transfer on the video viewed by HHSC were suspended pending investigation. Immediately, on October 18, 2023, all residents plan of care were validated by assessing resident transfer status to ensure they are receiving proper transfer and assistance and Kardex reflects the appropriate level of care by Corporate Clinical Specialist Immediately, on October 18, 2023, Physical Therapist Area Director of Operations in serviced Director of Rehab, DON, and ADON on resident transfers to include policy and procedure for on one person , two person, and Hoyer transfers to follow resident plan of care for transfers and repositioning. In-service will include staff education regarding what to do in the event of an acute change of condition or injury during a transfer. Education to include escalation if the nurse does not respond including calling for alternate nurse, DON, Administrator, or 911 as needed. Training and competency validation by return demonstration for DOR/DON/ ADON was completed on 10/18/2023 by using the transfer, mobility, repositioning techniques checkoff. Training on resident transfers to include policy procedure on one person, two person, and Hoyer transfers staff education regarding what to do in the event of an acute change of condition or injury during a transfer. Education to include escalation if nurse does not respond including calling for alternate nurse, DON, ADM, or 911 as needed material will be incorporated into the new hire nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0689 orientation by DON/Designee effective October 18, 2023, and ongoing. Level of Harm - Immediate jeopardy to resident health or safety DON/Designee will monitor compliance of resident transfers by performing observations and competency validation on 2 staff per week for 12 weeks, then every other week for 12 weeks. Thereafter, DON/Designee will monitor residents for safe transfers once [NAME][TRUNCATED] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain in that: Residents Affected - Few The facility failed to properly assess or provide effective pain management to Resident #1 after a new onset of pain following the accidental fracture of her left tibia during a transfer from wheelchair to her bed. This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical dysfunctions in an effective and timely manner to prevent residents from further harm, injury, or death Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain (pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the resident's cognition was intact. Resident #1 did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed to require staff to stabilize her when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions included that the resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff member with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia (treatment that prevents you from feeling pain while you are awake) including pain relief, side effects and impact on function; monitor/document for probable cause of each pian episode; and remove/limit causes where possible. Resident #1's further interventions were: monitor/document for side effects of pain medication; administer analgesia as per orders; give ½ hour before treatments or care; notify the physician if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; provide the resident and family with information about pain and options available for pain management; and discuss and residents' preferences . Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Norco Oral Tablet 7.5-325 milligram give tablet by mouth every four hours as needed for pain. Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Acetaminophen Extra Strength oral Tablet 500 mg by mouth every six hours as needed for pain. Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the x-Ray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room Hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel) Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. There was not another nurse the staff could report Resident #1 was in pain. LVN A was the only nurse on duty. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by the family revealed on 09/18/2023 revealed the following: - At 05:44 PM, the COTA/Marketing Coordinator stated to Resident #1 she had not transferred Resident #1 before, and asked Resident #1 if she was able to help during transfers or did, she need a gait belt. The COTA/Marketing Coordinator stated she was going to find a gait belt. -At 05:49 PM, the COTA/ Marketing Coordinator and PTA began transferring Resident #1 from the recliner to the wheelchair ( on 09/18/2023 PM) Resident #1 complained about her back hurting but was not yelling. - At 05:52 PM, the COTA/Marketing Coordinator and PTA began to transfer Resident #1 ( by 2 person assist with gait belt) from her wheelchair to her bed in PM. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell that her knee was hurting, and her knee was broken. - At 05:53 PM, Resident #1 began to rub her left leg as she continued to yell. Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident #1 would scream she was hurting. - At 6:00 PM. Resident #1 stated to PTA that they turned her around and Resident #1 was looking at PTA as she made the statement. The PTA stated to Resident #1 they did not mean to hurt her. In an interview on 09/20/2023 at 12:58 PM the Director of Nurses stated anytime a resident was requesting a pain medication or makes a statement they are in pain; prior to giving the pain medication the nurse was expected to ask the resident where the pain was located and to ask the resident on a scale of 0-10 with zero meaning no pain and ten being the highest pain level what was the resident's pain level was. She stated the nurse was expected to document that information in the nurses notes of where the pain was located and the pain scale. The Director of Nurses stated a pain assessment was required to be completed when a resident reported they were in pain. She also stated the nurse administering the pain medication was the nurse expected to complete the pain assessment. She stated there was only one pain assessment in Resident #1's electronic medical record. The Director of Nurses stated pain assessment was required whenever a resident complained about being in pain. She stated Resident #1 did yell al lot when she was in pain and was in pain al lot. She stated if Resident #1 complained about her left knee and leg hurting that was a new pain for Resident #1. She stated if Resident #1's left knee was swollen the nurse was expected to do a complete pain assessment and possibly incident report to determine if anything happened during the resident's transfer from the wheelchair to the bed. The Director of Nurses stated it was reported to her by the PT/ Marketing Coordinator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 09/19/2023 Resident #1 was yelling her left knee and left leg were hurting after she was transferred from the wheelchair to the bed. She stated the nurse was expected to gather information from the COTA/Marketing Coordinator and PTA who transferred Resident #1 and possibly needed an incident report completed and the nurse was required to completed a pain assessment or do some type of assessment of the resident. The Director of Nurses stated Resident #1 only yelled out when she was in pain. She stated she was not aware of any behavior problems Resident #1 had with staff or with anyone. She stated Resident #1 should have been transferred to the emergency room on [DATE] after the nurse received orders for the x-ray. She stated the x-ray company does not come to the facility if there is an x-ray needed any time after 5:00 PM and before 8:00 AM. She also stated the nurse was expected to complete a pain assessment or document in the nurses notes of Resident #1 complaining about her knee and the knee swelling. She stated the nurse on duty that night was responsible for documenting on Resident #1 on 09/18/2023. In an interview on 09/20/2023 at 2:41 PM the COTA/Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1's room at approximately 6:05 PM Resident #1 was needing assistance to be transferred to her bed from her recliner. She stated she explained to the resident she needed to find a gait belt and get someone to help her with the transfer. The COTA / Marketing Coordinator stated she asked PTA C to assist her transferring Resident #1. She stated the PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. The COTA/Marketing Coordinator also stated Resident #1's wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on the resident and assisted her from the wheelchair. They pivoted the resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within few seconds of the resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurt. The COTA/ Marketing Coordinator stated she and PTA C assisted the resident to lie in bed in a supine position (resident is face up with their head resting on a pad positioner or pillow),and that was when she noticed Resident #1's knee began to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of zero being in no pain to ten being in extreme pain. She stated the PTA stayed in the room and she left the room to report that to the LVN A at approximately 6:30 PM. She stated LVN A did not go to Resident #1's room to assess the resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after she reported Resident #1's pain and swelling to LVN A. She stated she did become frustrated with LVN A ignoring Resident #1's pain and knee swelling that she told her just give Me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing Coordinator stated she got the pain medication from the nurse and took it to Resident #1 and gave the pain medication narco to Resident #1. She stated after numerous times of reporting to LVN A to go assess Resident #1, the LVN A stated the resident is always in pain that is not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN A gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yells out frequently. She stated when she is yelling, she is in pain. LVN D stated the resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete a pain assessment and document in the nurses notes about Resident #1's pain. She also stated the nurses were expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero was- no pain and ten was extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident report or pain assessment due to Resident #1always complained about pain. She stated that was her normal behavior. LVN D stated the resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1's physical condition, moods, and behaviors. LVN D stated Resident #1 will yell out when she is in pain. She stated she had severe back pain and had an MRI. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone knows if Resident #1 is in pain she will yell, and they do not assess the pain very closely when giving pain medication. She stated the nurses gives her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51 PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. He stated the staff said to Resident #1 she complained about her back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on [DATE]. He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after those statements to hear what staff was saying. On 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave a message. On 09/21/2023 at 11:05 AM, attempted to contact CNA H and left a voice message . CNA H was in Resident #1's room for few minutes on 09/18/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the PT/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed Resident #1 had pain and some swelling in her left knee. She stated she asked the COTA/Marketing Coordinator to inform the nurse to contact the physician and request an x-ray to be ordered. The Administrator stated anytime a resident complained of pain whether it was an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff who was in Resident #1's room questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1, completing a pain assessment, and asked staff questions of how Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the hospital. She stated anytime a resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all that information in the nurses notes and complete a pain assessment. She stated if Resident #1 had new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report (reviewed incident reports and did not observe any incident reports of this incident of Resident #1 on 09/18/2023) if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician, then call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated it was the DON's responsibility to monitor the nurses to ensure they are following protocol. In an interview on 09/22/2023 at 8:40 AM Med Aide E stated she had given medications to Resident #1 except pain medications and her anxiety medications. She stated whenever Resident #1 has reported to her she was in pain she would inform the nurse. She stated Resident #1 did not exhibit any behavior problems; however, she would yell only when in pain. She stated other than yelling she was not aware of any behavior problems with Resident #1. She also stated if a resident had new pain and was complaining for hours of being in pain and had stated her leg or knee was broken, the resident needed to be transferred to emergency room immediately. Med Aide E stated Resident #1 was alert and oriented and was able to verbalize her pain, and the nurse needed to listen to Resident #1 and should know it could be serious and needed immediate medical attention in the hospital. She stated she would continue to ask the nurse to send a resident to hospital if the resident was complaining of knee pain, if the knee was swollen, and if resident stated her leg was broken. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated the resident did not have any behavior problems except for yelling when she was in pain. She stated whenever a resident complained about pain, the nurse was expected to ask where the pain was located and complete a pain scale assessment with zero indicated no pain and ten indicated extreme pain. She stated that was to be documented in the nurses notes at the time of administer the pain medication. LVN B also stated the nurse was expected to speak to the resident within 2 hours and determine if the pain medication was effective. She stated a pain assessment was required whenever a resident was in pain. She stated she had given medications to Resident #1 when she had been in pain. She also stated there should be more than one pain assessment completed on Resident #1 due to her having pain a lot. She stated a nurse giving the resident pain medication since she had been admitted should have completed a pain assessment on Resident #1. She stated the nurse would document the pain level on the MAR when they interact with a resident. LVN B stated, however, the resident may have pain during the shift and there was not a place on the MAR to document that pain. She stated when a resident had pain during the shift where the pain is located, and the pain level was required to be documented in the nurses notes prior to administering pain medication. She also stated if the pain was not a zero, a pain assessment was required to be completed. She stated she was surprised that only MDS Nurse completed a pain assessment. In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated the nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with swelling and the resident yelling her leg was broken, that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken, if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurse was to complete pain assessment. She stated the nurse was required to ask the resident where the pain is located and the pain level using the pain scale of zero which indicated no pain and a ten which indicated extreme pain. She s[TRUNCATED] Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs as identified through resident assessments and described in the plan of care for one of one resident (Resident #1) one of one nurses and one of one COTA reviewed for competent nursing staff. The facility failed to ensure nursing staff were properly trained and nursing staff failed to report to management when the nurse gave the COTA a pain pill to administer to Resident #1. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. The findings include: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members with transfers. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . Record Review of the video provided by the family member on 9/18/2023 reflected COTA/ Marketing Coordinator and PTA was in Resident #1's room. The COTA/ Marketing Coordinator exited Resident #1 room at 6:09 PM. PTA stayed in Resident #1 room and was talking to Resident #1. Resident #1 stated several times I think it is broken as she was rubbing her left leg. COTA/ Marketing Coordinator entered Resident #1's room and at 6:12 PM she began to open the small clear plastic pouch with medication been crushed and poured it into a medication cup. COTA/ Marketing Coordinator opened a small container of apple sauce and put apple sauce in the medication cup with the medication. COTA / Marketing Coordinator began to stir the medication in the cup and at 6:13 PM the PTA poured some more crushed medication into the cup. COTA /Marketing Coordinator asked Resident #1 if she wanted her medicine. She also asked Resident #1 if she wanted to take one big bite and at 6:13 PM COTA/ Marketing Coordinator gave Resident #1 her medication. COTA/Marketing Coordinator asked Resident #1 how long it took for her medicine to help her. Record review of Resident #1's medication administration record for the month of 09/2023 reflected on 09/18/2023 there was not any medication signed out by anyone around the time of 6:09 PM. The PRN medication was signed out be LVN A at 6:50 PM and at 11:41 PM. In an interview on 09/20/2023 at 2:41 PM, the COTA /Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (Norco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 (did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated, oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. 1. In an interview on 10/18/2023 at 11:35 AM, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nurses stated only a licensed nurse or a medication aide was the only staff to administer any type of medication to a resident. She stated a non-nurse staff would not know if she was administering the correct medication. She stated it was not the facilities protocol for a non-nurse to administer any medication. She stated a resident could choke and there were protocols to follow when administering medications such as: ensuring it is the correct person by viewing the resident picture on the medication administration record, the nurse required to check to ensure it was the correct medication, ensure it was given at the right time and it was the right dose. She stated if a non-nurse was giving the medication how did that person know the nurse completed all of these precautions prior to placing medicine in the cup and give the medication to the non-nurse. She stated this is not the facility protocol. In an interview on 10/19/2023 at 10:40 AM, Med Aide E stated she had been a Med Aide approximately 10 or 15 years and she stated she was taught in med-aide class it was not protocol for a med-aide or a nurse to give medication to a non -nurse staff to administer to a resident. She stated if a nurse or med-aide signs the medication administration form that the nurse or med-aide gave the medication and then give the medication to a non-nurse, a nurse or med-aide could lose their license. She stated anything could go wrong with a non -nurse administering any type of medication. Med Aide E stated how does the nurse knows the non -nursing staff will give it to the resident. She also stated there were certain residents required their medication be administered a certain way such as in pudding or may need extra water to ensure the resident swallowed the pill. She stated this was against nursing protocol and she would never allow anyone give medication she had put her initial on the medication administration record. She stated whoever signs the record they are responsible for the medication. Med-Aide E also stated if a nurse gave medication to a non-nurse staff the nurse was 100 percent wrong. She stated a resident could choke on the medication, may pocket the medication, and not swallow the medicine. She stated there was a cluster of mistakes possibly could occur with the resident. She also stated when administering medications, the nurse or med-aide was expected to look at the picture on the MAR prior to administering the medication. She stated she had been in serviced on medications on 10/19/2023 from the ADON. She stated the ADON discussed all medications was only to be administered by nurses and med-aides and if you are not a licensed nurse or medication- aide do not take any medications from the nurse or medication aide and administer the medication to a resident. In an interview on 10/19/2023 at 10:50 AM CNA P stated she received an in-service on medications from the ADON on 10/19/2023. She stated anyone who was not a nurse or medication -aide was not to give medicines to a resident or take medications from the nurse or med-aide. In an interview on 10/19/2023 at 11:15 AM, LVN D stated the ADON gave an in-service on 10/19/2023 about not giving medications to a non-nurse staff for them to administer medication to a resident. She stated it could be dangerous for the resident if a non-nurse gave a resident medication. She stated a resident could choke and how did the nurse know the staff would not take the medication themselves and not give it to the resident. She stated when she gives medications, she views the medical medication record and compares it to the medicine located in the package. She stated when she determined it was the correct medication, she would place the pills in a medicine cup. She stated after she completed this process with all the medicines a resident takes, she would compare the resident to the picture on the mar and then administer the medication. She stated if a resident required medications to be crushed, she would crush the medicines. She stated a resident receiving medication from a non-nurse may choke or have difficulty with swallowing med or may prefer to take the medication a certain way such as place the pill in a certain area in the resident's mouth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/19/2023 at 1:00 PM the Administrator stated she as in serviced on medications by the Corporate Nurse she stated a non-nurse was not qualified to administer medications. She stated only nurses and med-aides were qualified to administer medications. When asked her the potential of what may happen to a resident or with the medication if a non-nurse administer medication to a resident, the Administrator stated she was no clinical and was not answering any questions about medications or the potential result of non-nurse giving medications. That would be a nursing question not an Administrator question. She stated again she was not clinical and don't know what a nurse was supposed to do when administering medications. I will have to refer to the facility policy and protocol I am not familiar with it at this time. When the Administrator was asked if she was not in serviced by the corporate nurse today, she stated I will not answer any questions. The administrator left the conference room and did not return for further interview. 2. In an interview on 10/19/2023 at 1:20 PM the ADON stated she stated gave in-service on 10/19/2023 to all staff about medications. She stated she in serviced all staff related to only licensed nurses and medication-aides were the only staff to administer any type of medication to a resident. She stated there was a possibility a resident could choke when given a medication and if a non-nurse was giving the medication there were several negative possibilities could happen to the resident. The ADON stated she could keep naming them, but she believed point was made of negative outcome with possible choking. She stated there were 5 rights on giving medications. She stated all nurses and med-aides was expected to follow the 5 rights: Right Person, Right Medication, Right Route, Right Time, Right Dosage The ADON stated when a nurse was administering medication it was expected for the nurse to view the resident picture in the medication administration record and to ensure when administering the medication, it was to the right person and had the right dose and medication. She stated as a nurse she would not expect a non-nurse to administer medications. She stated she did not have any idea how the non -nurse would know if she was giving the right medication. The ADON also stated she did not know why the nurse gave the medication to the non-nurse. She stated she was not aware of the knowledge the non-nurse had about medications. Record Review of the in-service on Medication Administration given by the ADON ( the in-service was not dated but was verified by the Administrator this was the in-service given to all the staff by the ADON. The in-service consists of the following: 1. All medications should only be administered by a licensed nurse or medication aide. 2. If you are not a licensed nurse or medication aide. Do not take medication from a licensed nurse or medication aide and administer the medication to a resident. Record Review of in-service on Medication Administration given by the Administrator and Corporate Clinical Specialist on 10/19/2023. A video was shown to all staff on medication administration training from the corporate you tube video. The video explained how to administer medication correctly. There were not any details about the video shared prior to exit. Record Review of in-service on medications not dated, however, it came from a binder dated January 2023 to June 2023. The in-service was on medications need to be given in a timely manner. Medication times are part of the five medication rights such as: 1. Right person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0726 2. Right medication Level of Harm - Minimal harm or potential for actual harm 3. Right time 4. Right route Residents Affected - Few 5. Right dosage LVN A attended this in-service. Record Review of the facility policy on Administering Medications dated 04/2019 reflected the following: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The individual administering medications verifies the resident's identity before giving the resident his/her medications. 3. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. The individual administering the medication initials the resident's medication administration records in the resident's medical record: the date and time the medication was administered, the dosage, the route of the administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and title of the person administering the drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 47 of 47