Health inspection·December 25, 2023

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pe (heart forced to work harder than normal), acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs), and unspecified systolic congestive heart failure (heart failure that occurs in the heart's left ventricle). Record review of Resident #4's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), personal history of Covid-19, and major depressive disorder (sadness). Record review of Resident #5's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including major depressive disorder (sadness), atherosclerotic heart disease of native coronary artery without angina pectoris (heart forced to work harder than normal), and unspecified systolic congestive heart failure (heart failure that occurs in the heart's left ventricle). Record review of Resident #6's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including major depressive disorder (sadness), essential primary hypertension (abnormal high blood pressure), and anxiety disorder (pounding or racing heart). Record review of Resident #7's undated face sheet revealed resident is an [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (sadness) and Alzheimer's (brain disorder destroying memory and thinking skills). Record review of Resident #8's undated face sheet revealed resident is an [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (airflow blockage and breathing-related problem), dementia (memory loss), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #9's undated face sheet revealed resident is an [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including dementia (memory loss) paroxysmal atrial fibrillation (irregular rapid heartbeat causing poor blood flow), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #10's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (heart forced to work harder than normal) acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #11's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), major depressive disorder(sadness), and peripheral vascular disease (narrowed blood vessels reducing blood flow of limbs). Record review of Resident #12's undated face sheet revealed resident is a [AGE] year-old Female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 2 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admitted to the facility on [DATE] with mild cognitive impairment (early-stage memory loss), cerebral palsy (congenital disorder of movement, muscle tone, or posture), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #13's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including essential primary hypertension (abnormal high blood pressure), dementia (loss of memory), and major depressive disorder (sadness). Record review of Resident #14's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (loss of memory) diabetes (sugar in the blood high glucose), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #15's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (memory loss), chronic obstructive pulmonary disease (airflow block with difficulty breathing, and anxiety (feeling of worry). Record review of Resident #16's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (loss of memory), chronic kidney disease (unable to filter blood), and shortness of breath. Record review of Resident #17's undated face sheet revealed resident is an [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (blocked airflow with difficulty breathing), diabetes (sugar in blood high glucose), and hypertension (pressure in blood vessels to high). Record review of Resident #18's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including edema (swelling), essential primary hypertension (abnormal high blood pressure), and chronic kidney disease (not able to filter blood). Record review of Resident #19's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including hypertension (pressure in blood vessels to high), major depressive disorder (sadness), and chronic embolism (blockage of pulmonary arteries). Record review of the facility list of COVID positive residents revealed that Resident #1 through Resident #19 were positve for COVID on 12/12/23 through 12/19/23. In an observation on 12/22/23 between 11:50 PM and 12:00 PM staff were observed with no N-95 mask on assisting residents with room doors open. Observed staff with no faceshields assiting COVID positive residents. Observed staff going into COVID positive rooms with surgical masks and PPE gowns not placed on correctly with no face shields. Observed no N-95 mask worn by staff assisting residents with COVID. Observed COVID positive resident's doors were open along with non-COVID residents while staff was assisting in between residents. Observed no PPE set up at the doors of the COVID positive residents on Halls 1,2, and 3. In an interview with the Business Office Manager on 12/22/22 at 12:00 PM, she stated there were 18 residents positive for COVID-19 and the outbreak started on 12/12/23. There were no warm or hot halls and all the residents in the facility were in their rooms. The Business Office Manager stated the surgical mask was what staff had been wearing to care for the residents and the surgical mask was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 3 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the only mask available to the staff. The Business Office Manager could not give a reason as to why the N-95 mask or face shields was not available to staff and that she was filling in to help since the interim Administrator, the DON, and the ADON were out sick. In an interview with CNA A on 12/22/22 at 12:18 PM, she stated on 12/08/23 the DON/ADON locked the COVID tests in the office as they did not want to test residents and follow the COVID guidelines of wearing masks and PPE. The residents were showing signs of illness and symptoms on 12/08/23 and the DON and the ADON were notified. CNA A stated the breakout of COVID began on 12/12/23 and there were currently 18 residents positive. CNA A stated during the outbreak PPE was not encouraged to be worn and some staff were seen not using masks or protective gear when the outbreak occurred. Staff had to redirect the COVID positive residents back into their rooms when they came out into the halls without masks. CNA A stated no staff in the building were wearing N-95 masks or face shields during the outbreak or while caring for residents. CNA A stated that there were no N-95 masks in the building and did not know why. CNA A stated she had not had any recent training on Infection Control or protocol to follow during the outbreak. In observations on 12/22/23 between 1:05 PM and 1:30 PM, the Rehab Director was passing out food trays on hall 5 to COVID positive and non-COVID positive residents without an N-95 mask, no face shield, PPE gown was not properly fastened, and without gloves. In an interview with The Rehab Director on 12/22/23 at 1:30 PM, stated the surgical mask that she was wearing was the only mask they had in the building. The Rehab Director stated the surgical mask was what she had been using to care for the residents with COVID. The Rehab Director could not give me a reason as to why there were not any N-95 masks, or face shields in the building or who the Infection Control Preventionist was. The Rehab Director stated she did not have face a shield on passing trays to Covid positive residents as there were not any in the building and she stated she used hand sanitizer when she came out of resident's rooms. The Rehab Director stated she had not had any recent training in infection control. In observations on 12/22/23 between 1:45 PM and 2:00 PM revealed LVN A without an N-95 mask, face shield, and PPE gown not properly fastened on hall 1 assisting COVID positive residents. In an interview with LVN A om 12/22/23 at 2:00 PM stated that she did not want to be named in fear of retaliation. LVN A stated it was known that COVID Positive residents were on the same hall as non-COVID residents. LVN A stated she had not had any training recently on COVID. LVN A stated the surgical mask that she was wearing was the only mask they had in the facility. There were no N-95 masks in the facility or face shields. The surgical mask is what she used when she cared for COVID positive residents. LVN A stated around December 8th, 2023 the DON and the ADON withheld COVID testing. The DON/ADON were aware that residents had become ill. LVN A stated she felt that the DON and the ADON did not want to deal with testing the residents. LVN A stated she observed staff not wearing PPE or surgical masks during the outbreak. LVN A stated that when she was given direction by the DON/ADON to test residents that was when she tested the residents. LVN A stated she last tested residents for COVID on 12-19-2023. 18 were positive on 12-19-2023. LVN A stated she did not know who the infection control preventionist was and she believed the COVID transmission came from not wearing the proper PPE during the outbreak. Attempted to interview on 12/22/23 between 2:44 PM and 3:29 the interim Administrator, the DON, and the ADON. The Business Office Manager stated they were all out sick. Left voice mail messages for a return call with no call returned while in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 4 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an interview with LVN B on 12/22/23 at 4:18 PM, she stated the surgical masks were what staff used to care for the residents. There were no N-95 masks and did not know the reason why there were not any in the facility with the outbreak. LVN B observed staff not wearing PPE properly. Residents with COVID were redirected back in their rooms when they came out in the halls. In an interview with The Regional Director on 12/22/23 at 4:47 PM, she stated that the facility followed the CDC guidelines along with the facility policy. The Regional Director stated she was on the road driving and unsure and unable to quote the policy on isolation of residents and the surgical masks being worn during the outbreak. The Regional Director stated the Infection Control Preventionist at the facility was the DON/ADON. Record review of the policy on hand hygiene dated (revised August 2019) revealed hand hygiene was the primary means of preventing the spread of infection. Hand hygiene should be done before and after direct contact with residents. Record review of the undated policy on donning and doffing revealed 1. Identify and gather the proper PPE to DONN 2. Perform hand hygiene using hand sanitizer 3. Put on isolation gown 4. Put on approved N-95 filtering facepiece respirator or higher 5. Put on face shield or goggles 6. Put on gloves 7 Health care professional may now enter patient room. To DOFF 1. Remove gloves 2. Remove gown, 3. Health care professionals may now exit patient room. 4. Perform hand hygiene 5. Remove face shield or goggles 6. Remove and discard respirator (or facemask if used instead of respirator) 7. Perform hand hygiene after removing the respirator/facemask. Record review of the policy on infection prevention and COVID-19 revised 09/15/23 revealed, an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Source control healthcare personnel will wear recommended PPE when caring for those in transmission base precaution status regardless of community transmission rates or outbreak status. For all Quarantine and isolation rooms 1. Post signs on the door or wall outside the resident's room that clearly describe the type of precautions needed and require PPE. 2. All PPE is single use per room encounter 3. Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room [ROOM NUMBER]. Perform hand hygiene upon exiting patient room [ROOM NUMBER]. Minimize contact with Quarantine and Isolated residents by bundling time in the room, utilizing technology when feasible and applicable avoiding creating unnecessary isolation or unnecessary mobility limitations. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 6:13 PM. The corporate nurse was notified. The corporate nurse was provided with the IJ template on 12/22/23 at 6:13 PM The following Plan of Removal submitted by the facility was accepted on 12/24/23 at 3:37 PM: Immediately on December 22, 2023, N-95 masks were brought to the facility and made available to all staff. All staff were given an N-95 mask and staff working confirmed to be wearing by Corporate Clinical Specialist (CCS). The staff were required to wear N-95 masks while providing care or working with COVID 19 residents. An order for additional masks was placed by Regional [NAME] President of Operations. The DON will be responsible for ordering PPE for the facility and tracking via par levels. PPE will be kept in a centralized storage room on hall 100 as of December 22, 2023, and ongoing. All staff will be inserviced on location of PPE on December 22, 2023. They will be inserviced before the start of their next shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 5 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately on December 22, 2023, the doors to the COVID rooms were closed. Corporate Clinical Specialist was responsible for ensuring doors were closed and completed on December 22, 2023 Immediately on December 22, 2023, the COVID 19 residents were moved from the non-COVID 19 residents. Corporate Clinical Specialist was responsible and completed on December 22, 2023. Immediately on December 22, 2023, CCS in-serviced the DON and the LNFA on Infection Control policy and procedures to include proper masks required for COVID 19 outbreak, PPE, and the protocol for closing of the doors for the COVID 19 positive residents. In-service was completed on December 22, 2023. The Medical Director was notified of the Immediate Jeopardy and the plan of removal by Corporate Clinical Specialist on December 22, 2023. The Medical Director did not have any further recommendations. On December 22, 2023, the CCS initiated in-services with the staff. In-services included the following: Infection control policy and procedures to include masking when in outbreak, PPE, and the protocol for closing of the doors for COVID 19 positive residents. The completion date for staff in-services and competency evaluations was December 22, 2023. Nursing staff will not be allowed to work until in-service has been completed. In-services was completed on December 22, 2023. The above training material which included the Infection Control policy and procedures to include proper masks required for COVID 19, PPE, location of PPE, and the protocol for closing of the doors for COVID 19 positive residents will be incorporated into the new hire nursing orientation by the CCS, effective December 22, 2023, and ongoing. PRN staff and agency staff will be trained by the DON/Designee prior to being allowed to work the floor. In order to monitor the current residents for potential risk, the DON/designee will monitor the facility COVID status daily and masking of employees starting December 22, 2023 and will continue for 90 days. The DON compliance will be monitored weekly by Corporate Clinical Specialist for 90 days. The facility QA Committee will meet weekly for the next eight weeks starting December 22, 2023, to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. POR monitoring . In an observation on 12/23/23 at 9:45 AM there was no hand sanitizer in the dispenser next to room [ROOM NUMBER] and the door marked storage. In an interview with LVN C on 12/23/23 at 10:10 AM, LVN C stated that there were only four COVID positive residents in the facility today. All other COVID positive residents came off isolation as of today. LVN C stated today was the 11th day from the date of a positive COVID test. In an interview with Resident #19 on 12/23/23 at 10:15 AM, she stated that staff used gloves, but he had not observed any hand sanitation or handwashing. Resident #19 stated that the facility should have taken COVID seriously a month ago and not just now. Resident #19 stated he had told, unnamed staff and titles unknown, that he wanted a booster and did not get one. Resident #19 stated that when he went to Wal-Mart pharmacy to pick up his glasses, thatwas when he received the COVID immunization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 6 of 10 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 12/25/2023 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 0880 In an observation on 12/23/23 at 10:24 AM all staff were seen wearing N-95 masks. Level of Harm - Immediate jeopardy to resident health or safety In an interview with ADON B on 12/23 23 at 11:26 AM, she stated there were approximately seven staff overall who had not been in-serviced on COVID policy/procedures, PPE, and hand hygiene at this time. ADON B stated the DON is in-servicing staff by phone from home and she did not have the exact number of staff left that needed to be in-serviced. Residents Affected - Some Record review on 12/23/23 at 11:30 AM revealed in-service content and sign-in sheet, employee check-off sheets on hand hygiene, use of PPE, and the in-service post-test. In an interview with CNA B on 12/23/23 at 11:55 AM, she stated that she received the in-service training on PPE and hand hygiene. CNA B stated that the PPE were kept outside the COVID-19 positive resident's doors. CNA B was able to state who to notify when PPE runs low when caring for COVID residents. CNA B stated that she needed to wear an N-95 mask when caring for COVID positive residents. In an interview with LVN C on 12/23/23 at 11:56 AM, she stated she checked off on FaceTime video 12/22/23 for in-service on hand hygiene and the use of PPE with the DON. LVN C stated the facility had enough PPE and she knew who to notify when PPE was low. In an interview with Housekeeper A on 12/23/23 at 12:00 PM, she stated the facility had enough PPE and she was aware who to notify when supplies ran low. Housekeeper A stated she was in-serviced this morning on hand hygiene and applying PPE. Housekeeper A stated she had been trained to wear an N-95 mask when treating COVID positive rooms. In an interview with Housekeeper B on 12/23/23 at 12:05 PM, she stated that she was in-serviced this morning on hand hygiene and applying PPE. Housekeeper B stated she had the PPE necessary to clean COVID positive rooms. Housekeeper B stated she was trained to wear an N-95 mask when there were COVID positive residents in the facility. In an interview with ADON B on 12/23/23 at 12:15 PM, she stated she had confirmed that there were seven staff left to be in-serviced. ADON B stated messages had been left for those staff to indicate that they would not work again until they had been in-serviced. In an observation on 12/23/23 at 12:24 PM ADON B was able to show what the equipment was cleaned with. The equipment was cleaned with Micro-Kill one germicidal alcohol wipes. ADON B was able to show the supply of containers available. In an observation on 12/23/23 at 12:30 PM all hand sanitizers that were wall-mounted outside the doors of each room was found to be working with the exception of the one outside room [ROOM NUMBER] that was observed earlier. CNA B was observed using disinfecting wipes to wipe down the Hoyer lift. CNA B stated that the equipment was wiped down after use so that it was clean for the next resident. CNA B stated the disinfecting wipes were used to wipe down equipment on multiple residents. In an observation on 12/25/23 at 11:50 AM of PPE supply in the facility: 3 COVID Positive Rooms: There were plastic bins placed outside of the rooms filled with PPE. Inside of the rooms are biohazard boxes (one for trash and one for laundry). Storage Rooms: On Hall 100, there were 3 different storage rooms. One for PPE, one for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 7 of 10 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 12/25/2023 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 0880 biohazard materials, and one for supplies. Level of Harm - Immediate jeopardy to resident health or safety Positive Resident's Doors Residents Affected - Some Record review of the below In-service Training Reports and Sign-In Sheets for: The doors were observed to be closed with bins located outside of the rooms stocked with PPE. 1) PPE - COVID - Droplet Precaution - 12/22/2023 2) Handwashing - Hand Sanitizer - 12/22/2023 3) COVID/Infection Control (COVID-19 Policy and Procedures) - 12/22/2023 4) Handwashing, PPE, and Infection Control Policy, Proper Masking During COVID - 12/22/2023 5) PPE - COVID+ Residents and location - 12/22/2023 6) COVID In-service: -N-95 masks must be worn at all times -Proper PPE when entering positive COVID residents' rooms -Remove PPE prior to leaving positive COVID residents' rooms -N-95 must be changed as well -Proper hand hygiene -Encourage all residents' doors to remain closed with Positive COVID status -Donning/Doffing -Proper wearing of PPE Training Material: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 8 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observed the Clinical Performance Evaluation Checklist: Handwashing completed and signed on 12/22/2023 and 12/23/2023. Each staff member received a satisfactory checkmark. In an interview with The Activities Director on 12/25/23 at 12:20 PM, she stated that she was contacted by phone on 12/22/23 and was in-serviced on COVID protocol. The Activities Director stated she was contacted by the DON and that she did not learn anything new it was a refresher to her. The Activities Director stated she had passed the quiz and when she worked with a COVID resident she used full PPE. The activities Director stated prior to the exit of the resident's room she doffed inside the room and disposed of all the PPE in the biohazard box. The Activities Director stated everyone that was positive should have been moved to one hall to control the spread. The Activities Director stated they should not have allowed a positive resident to remain in the room with their negative roommate. The Activities Director stated she was told to pull the curtain as that was going to protect the negative resident. In an interview with RN A on 12/25/23 at 12:35 PM, she stated she was in-serviced on handwashing policies and procedures. RN A stated you must separate positive residents from negative residents and wear N-95 masks whenever there is an outbreak. RN A stated she completed the in-service with the DON and completed a quiz. RN A stated she learned to put her gown, mask, face shield, and gloves on. In an interview with LVN D on 12/25/23 at 12:50 PM, she stated she was in-serviced on wearing N-95 masks at all times during a COVID outbreak. LVN D stated that residents cannot be commingled with positive and negative. LVN D stated the door must remain closed for all positive residents and PPE is kept outside of each room. LVN D stated handwashing and proper hand hygiene must be ongoing. LVN D stated you must Donn in full PPE prior to entering the room and Doff prior to exiting. In an interview with CNA C on 12/25/23 at 1:05 PM, she stated she was in-serviced on handwashing, properly wearing PPE, and Infection Control procedures. CNA C stated she completed the in-service with the DON. CNA C stated she did not learn anything new and that it was more of a refresher. CNA C stated although she already knew these things, they were not being implemented in the facility. In an interview with Housekeeper C on 12/25/23 at 1:15 PM, she stated prior to entering the resident's rooms she must suit up in full PPE. Housekeeper C stated she wiped down all high-touch areas in the rooms, especially the bedside tables. Housekeeper C stated before exiting the room she would unsuit and leave all the used PPE in the biohazard box. Housekeeper C stated she kept hand sanitizer on her cart at all times. Housekeeper C stated the in-service was a refresher for her. In an interview with The Dietary Manager on 12/25/23 at 1:30 PM, she stated she was in-serviced on separating positive residents from negative residents, proper PPE, handwashing, Infection Control, and COVID Protocol. The Dietaryy Manager stated she did not learn anything new and it was more of a reeducation for her. The Dietary Manager stated her in-service was completed by the DON. In an interview with the interim Administrator on 12/25/23 at 1:40 PM, she stated since the IJ was called they completed in-services for everyone and made sure N-95 masks were in the building. The interim Administrator stated they have completed a QAPI via phone. The interim Administrator stated they have completed a competency on handwashing, closing doors, proper isolation, and completed a 5-question Quiz. The interim Administrator stated they will monitor for the next 8 weeks to ensure everything is done correctly. The interim Administrator was informed the Immediate Jeopardy (IJ) was removed on 12/24/23 at 3:37 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 9 of 10 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 12/25/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety PM. The facility remained out of compliance at a severity level of actual harm to resident health or safety and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 10 of 10