Health inspection·June 10, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 had an ADL self-care performance deficit. She was dependent on staff for bed mobility, eating, toileting, oral hygiene, showers, dressing (upper and lower body), personal hygiene, and transfers. Review of Resident #1's hospital records, dated 05/31/2025, reflected Resident #1 was transferred to the emergency room at local hospital on [DATE]. She had x-rays and was assessed by medical doctors. Resident #1 was discharged back to the facility on [DATE] with diagnosis of right anterior superior iliac spine fracture (a break in the bony projection on the front and upper part of the right hip bone), forehead laceration (a jagged or irregular tear or cut in the skin or other soft body tissue), right elbow soft tissue foreign body (refers to the presence of an object, like a splinter, thorn or, metal, that has entered the skin and become embedded in the soft tissues) and right pulmonary nodule (a small, discrete spot or growth in the right lung that appears denser than the surrounding lung tissue). Review of written statement by CNA A reflected on 05/31/2025 at 9:50 AM, Resident #1 was lying in bed receiving peri care from CNA A. There was a lot of loose BM everywhere on the bed. CNA A began to provide peri-care to Resident #1. CNA A had cleaned Resident #1 on one side and needed to be on the side of the bed located against the wall. CNA A moved the bed away from the wall to have easy access to Resident #1. When CNA A was moving the bed, Resident #1 fell off the bed. CNA A confirmed there was loose stool on the alternating air mattress causing the air mattress to be slick. An Immediate Jeopardy (IJ) existed from 05/31/2025-06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented the following actions prior to investigation start: Review of facility's Inservice records, dated 05/31/2025, reflected all nursing staff received in-services on abuse/neglect policies and fall with injury protocol. Review of the facility's accident hazards/supervision devices quiz, completed on 05/31/2025 and was ongoing, reflected all nursing staff completed this quiz and passed. Review of the facility's safe peri care and bed mobility for high-risk resident's quiz, completed on 05/31/2025, reflected all nursing staff had completed the quiz and passed. Review of the facility's interviews with interviewable residents, dated 06/01/2025, reflected 9 residents had received care from CNA A and they all knew CNA A. The following was asked of the residents: 1. Do you know CNA A- Yes 2. Do you know who to report to if you had problems with any staff? - Yes. 3. Has CNA A provided you with care- Yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 2 of 7 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 06/10/2025 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 4. Level of Harm - Immediate jeopardy to resident health or safety Do you feel safe when CNA A provided care for you? Yes Residents Affected - Few Do you feel safe at this facility? Yes 5. Review of the facility's skin assessments, on 06/10/2025, of all Residents after the incident on 05/31/2025. There were no new skin concerns. Review of the facility's maintenance records, on 06/10/2025, reflected all beds were checked for any issues such as locking the bed or any malfunction of the beds. There were no concerns of all Residents beds. Review of Resident #1's medical records, on 06/10/2025, reflected Resident #1 was being monitored for signs of pain post-incident. There was no concerns of pain. Review of Resident #1's Kardex, on 06/10/2025, reflected peri care assistance was added to her Kardex on 05/30/2025. Review of the facility's investigation, on 06/10/2025, reflected all residents Kardex was updated on 05/30/2025 to reflect peri-care assistance. Review of CNA A's personnel record, on 06/10/2025, reflected she was suspended on 05/31/2025 until investigation was completed. CNA A returned to work on 06/06/2025. CNA A's misconduct was up to date and no concerns noted. Observation on 06/10/2025 at 9:05 AM, Resident #1 was lying in bed. She was not interviewable. Resident #1 was lying in bed. She was in a fetal position facing the wall. She made eye contact and did mumble. Resident did not exhibit signs of being in pain such as: grimacing, tense body posture, restlessness, moaning, etc. Resident #1's bed was in lowest position. Interview on 06/10/2025 at 9:18 AM, CNA B stated she did receive in-service on abuse and neglect within the past 2 weeks. She stated she did not recall the exact date. She stated examples of abuse was yelling at a resident, hitting a resident, or can be sexual abuse. CNA B stated neglect was when staff refused to give resident food, water and/or assist resident to the bathroom. CNA B stated she had been in-service on fall protocol. She stated never move a resident when they fall. She stated a nurse was required to assess the resident and give instructions to the CNA after she completed her assessment. CNA B stated she did take a quiz on falls and peri care. She stated she was reminded if a resident was a one person assist, to always ask for assistance if there was a safety issue. CNA B stated staff was never to move a bed during peri-care. She stated if a bed needed to be move this was expected to be completed prior to beginning peri-care and to ask another staff for assistance. CNA B stated peri care assistance was not on the Kardex until after the incident with Resident #1. Interview on 06/10/2205 at 9:40 AM, CNA C stated she had received in-service on abuse and neglect, fall protocol, and peri care end of May. She stated she did not recall the exact date; however, it was the last weekend of May 2025. She stated the following was types of neglect: refusing to give resident a shower, feeding a resident, give resident water, etc. CNA C stated abuse was when someone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 3 of 7 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 06/10/2025 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 hit, cussed, or yelled at a resident. She stated she did take quizzes on falls and peri care. She stated she was a new CNA and she learned to always ask for assistance with a resident required one person assist, if there was any safety concerns. She stated she would never move a bed during peri-care. She stated if a bed needs to be moved to reach one side of the resident, the bed was expected to be moved prior to peri-care and it was always in good practice to have two staff in the room when moving a bed. CNA C stated assistance with peri-care was not on the Kardex until after the incident with Resident #1. Residents Affected - Few Interview on 06/10/2025 at 10:58 AM, CNA D stated she was walking by Resident #1's room and opened the door to check on Resident #1. She stated CNA A was giving peri-care to Resident #1. CNA D stated Resident #1 was on her right side while lying in bed. She stated she exited the room and did not witness Resident #1 fall. She stated she was given quizzes on pericare and falls. CNA D stated she had been in-service on fall protocol and abuse/neglect. She stated abuse was when a staff kicked or yelled at a resident. She stated touching resident in private areas was also considered abuse. CNA D stated neglect was not changing a resident brief, not giving resident food, or not assisting a resident to the bathroom. She stated if a resident fell or was found on the floor only the nurse was trained to assess the resident. She stated the CNA was not to move the resident until the nurse completed all her assessments and gave directions to the CNA of what to do after the assessments. She stated when giving peri care the bed was to remain locked. She stated during the in-service the DON explained if a staff needed assistance for the staff to use call light and walkie talkies would be provided to the staff to use whenever they may need assistance with a resident. CNA D stated if a resident is a one person assist and a staff felt the resident may need more than one person the staff was expected to call for assistance. She stated peri care assistance was not on the Kardex prior to the incident with Resident #1. She stated after the incident with Resident #1 peri care assistance was on all residents Kardex. Interview on 06/10/2025 at 10:35 AM, CNA A stated she began peri-care and cleaning Resident #1 on 05/30/2025 around 9:30 AM. She stated there was a lot of feces and some of it was loose stools. She stated feces were all over the bed. CNA A stated Resident #1 was lying on her back. She stated she needed to be on the right side of Resident #1 to finish cleaning the feces off Resident #1. She stated she rolled Resident #1 to the right side of the bed facing the wall. CNA A stated after she rolled Resident #1 to the right side she walked to the end of the bed and unlocked the bed. CNA A stated she began to move the bed away from the wall and this is when Resident #1 fell off the bed. She stated Resident #1 fell between the bed and the wall. CNA A stated she was at the end of the bed and attempted to catch Resident #1 prior to her falling. CNA A stated she was trained not to move the bed during peri-care. She stated the training was prior to the incident, however, she did not recall the date. CNA A stated she was required to unlock the bed prior to peri care and ask for assistance if there was any issues with giving peri-care. CNA A stated Resident #1 peri care was not on the Kardex. She stated she had given care to Resident #1 several times and she was a one person assist with peri-care. She stated she did ask a nurse a few months ago and this was the nurse's instructions of peri care on Resident #1 being 1 person assist. CNA A did not recall the name of the nurse or the date she questioned Resident #1's peri care. She stated she was in-service on peri-care, fall protocol, abuse, and neglect, prior to her returning from her suspension. CNA A stated neglect was when a staff refused to change a resident dirty brief, refused to feed a resident, refused to give resident water, etc. She stated slapping, yelling, or cussing a resident was abuse. CNA A stated she learned to always ask for assistance when needing to move a bed and never to move a bed during peri-care. She stated only move a bed prior to peri-care and ensure another staff was in the room for any assistance. CNA A stated she was the only witness to the fall of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 4 of 7 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 06/10/2025 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 Resident #1. Level of Harm - Immediate jeopardy to resident health or safety Interview on 06/10/2025 at 2:17 PM, the Director of Nurses stated her expectations for peri care was for each CNA to gather their supplies before they enter a resident's room. She stated the CNAs were expected to position the resident in bed according to what type of peri-care is needed. The Director of Nurses stated the staff may raise the bed to the height level of the staff to provide peri-care. She sated the CNAs were expected to follow PPE guidance during peri-care. The Director of Nurses stated if the staff needed to unlock the bed, the CNA was expected to ensure the resident was stable in the bed. She stated the bed was to be moved prior to giving peri care and it was safe practice to have two staff in the room when moving a bed as a precaution. The Director of Nurses stated one staff would be on the left side of the bed and the other staff would be on the right side of the bed. She stated moving a bed when staff was at the foot of the bed was not best practice. She stated CNA A did not follow the correct protocol when moving the bed. The Director of Nurses stated CNA A was not to move the bed when standing at the foot of the bed and during peri-care. She stated the facility had purchased walkie-talkies for all staff to use when they may need assistance. The Director or Nurses stated she expected the walkie-talkies to be always with the staff and to use them when they are needing assistance with anything related to a resident care. She stated random checks was being completed with CNA A and the other CNAs during peri-care. The Director of Nurses stated the training and in servicing was ongoing. She stated they were beginning unannounced abuse drills, and this would be follow-up in QAPI. Residents Affected - Few Interview on 06/10/2025 at 3:02 PM, the Administrator stated her expectations for peri-care was for staff to ask for assistance, if there was any question about safety concerns. She stated the bed was required to be locked during peri-care. The Administrator stated CNA A was not to move Resident #1's bed during peri-care. She stated if Resident #1's bed needed to be moved, CNA A was expected to move it prior to beginning peri-care. She stated moving Resident #1's bed when CNA A was standing at the end of the bed may have contributed to Resident #1's fall. The Administrator stated the facility's investigation was inconclusive. Facility Policy on Perineal Care, revised 04/16/2024, reflected The Purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. (note: Enhanced Barrier Precautions would be used during peri care if resident has any qualifying condition). Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 5 of 7 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 06/10/2025 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 1. Level of Harm - Immediate jeopardy to resident health or safety Wash basin. Residents Affected - Few Towels 2. 3. Washcloth 4. Soap (or other authorized cleansing agent) or cleaning wipes and 5. Trash bag and personal protective equipment (gowns, gloves, mask, etc., as needed) Steps in the Procedure 1. Place the equipment on the beside stand. Arrange the supplies so they can be easily reached. 2. Explain the procedure to resident. 3. Provide privacy. 4. Wash hands and apply gloves. Toilet resident if on the toileting program and or remove brief. 5. Place bed protector under resident's buttocks. 6. Position resident with legs apart (if possible) avoid unnecessary exposure. Use wet washcloth/ cleaning wipes and apply soap/peri wash. For a Female resident: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 6 of 7 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 06/10/2025 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 a. Level of Harm - Immediate jeopardy to resident health or safety Wet washcloth and apply soap or skin cleansing agent. Residents Affected - Few Wash perineal area (between the anus and the vagina), wiping from front to back. b. (1) Separate labia (the fleshy folds of skin that make up the external female genitalia) and wash area downward from front to back (Note: if the resident has an indwelling catheter, gently wash the juncture tubing from the urethra (the tube that lets urine leave your bladder) down the catheter about three inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same directions, using fresh water and a clean washcloth. (3) Gently Dry perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. Facility Policy on Fall Prevention Program, reviewed on 06/10/2024, reflected a fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident fall off any apparatus/equipment used for transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675065 If continuation sheet Page 7 of 7