Health inspection·May 17, 2023

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (condition that affects the way the heart pumps blood to the body), and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain with no behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS assessment indicated Resident #23 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #23 was independent with bed mobility, transfers, locomotion on and off the unit, eating, and toilet use and required extensive assistance with personal hygiene and limited assistance with dressing. Record review of Resident #23's care plan with a target date of 05/01/2023 did not address the resident's right to access her personal funds. During an interview on 05/15/2023 at 2:56 PM, Resident #23 said she had gone to the BOM last Wednesday to request money, and the BOM told her she did not have cash available to give her. Resident #23 said this had occurred multiple times in the past. During an interview on 05/17/2023 01:24 PM, the BOM said the Administrator and her were responsible for making sure they had cash available to give to the residents when they requested it. The BOM said the residents were not able to get money on the weekends because she was only at the facility Monday-Friday. The BOM said in the previous months she had run out of cash to give to the residents, and she had told Resident #12 and Resident #23 that she did not have cash to give them, and they would have to wait until there was cash available. The BOM said she was having difficulty replenishing the amount of money she had available to the residents because she was not able to go to the bank herself and withdraw money. The BOM said she printed the check, but the Administrator was the only one who could go to the bank to cash the check. The BOM said she did not know if there was an alternative person that could get money from the bank. The BOM said the residents should be able to get cash whenever they asked for it, and it was important for them to be able to access their funds because it was their money. During an interview on 05/17/2023 at 5:34 PM, the Administrator said the residents should be able to withdraw money from their trust fund anytime the business office was open, Monday-Friday 8 AM to 5 PM. The Administrator said she expected the residents to have money available to them on their request. The Administrator said the BOM was responsible for ensuring the residents had access to their personal funds. The Administrator said it was important for the residents to have access to their money on their request because it was their money, and it was their right. Record review of the facility's policy titled, AUTHORIZATION TO HOLD, SAFEGUARD, & MANAGE PERSONAL FUNDS Policy on Protection of Resident Funds, last revised January 27, 2005, did not address the residents access to their personal funds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 2 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 1 resident (Resident #20) reviewed for Medicare/Medicaid coverage. Residents Affected - Few The facility failed to ensure Resident #20 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. Resident #20 did not incur any out-of-pocket cost. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #20's face sheet, dated 05/17/2023, indicated Resident #20 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes (blood sugar disorder), chronic kidney disease (loss of kidney function) and metabolic encephalopathy (chemical imbalance in the blood that effects the brain). Record review of Resident #20's comprehensive MDS assessment, dated 04/04/2023, indicated Resident #20 understood others and made himself understood. The assessment indicated Resident #20 was cognitively intact with a BIMS score of 15. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #20 was receiving Medicare Part A services starting on 03/22/2023 and the last covered day of Part A services was 04/21/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #20 of the option to continue services at the risk of out-of-pocket cost. Resident #20 remains in the facility and was not charged for additional days. During an interview on 05/16/2023 at 3:52 p.m., the Administrator stated she was responsible for ensuring Resident #20 was issued the form, but she was not aware that a form needed to be completed at that time since Resident #20 remained in long term care. The Administrator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated there was no process in place for making sure the form was completed. The Administrator stated the negative outcome for not receiving the SNF ABN form would be Resident #20 not being aware of the services not covered by Medicare Part A. Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 3 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 13 residents (Resident #30) reviewed for admission physician orders. Residents Affected - Few The facility failed to ensure Resident #30 had a physician order for a condom catheter. This failure could place resident at risk for not receiving appropriate care, treatment services, and at risk for infection. Findings included: Record review of Resident # 30's face sheet dated 05/16/23 revealed Resident #30 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease (disease of the brain), type 2 diabetes (blood sugar disorder) and hypertension (high blood pressure). Record review of Resident #30's comprehensive MDS dated [DATE] indicated Resident #30 made himself understood and was able to understand others clearly. Resident #30 had a BIMS score of 15 indicating he was cognitively intact. Section H of the MDS indicated Resident #30 had an indwelling catheter and an external catheter. Record review of the order summary report dated 05/17/23, revealed Resident #30 did not have an order for a condom catheter. During an observation and interview on 05/16/23 at 09:43 AM, Resident #30 had a catheter in place and had a small amount of yellow urine noted in the bag. Resident #30 denied having any issues with the catheter. During an interview on 05/17/23 at 1:45 PM, LVN A stated she was the charge nurse for Resident #30. LVN A stated she knew Resident #30 had a catheter because it was on her 24-hour report, but she was not aware there was not a physician order for the catheter. LVN A stated the MDS coordinator was responsible for putting in physician orders when residents were admitted . LVN A stated there should have been a physician order for Resident #30's catheter so staff would be aware of how to care for the resident. LVN A stated not having a physician order for Resident #30's catheter could have resulted in sepsis or a UTI. During an interview on 05/17/23 at 1:53 PM, the MDS coordinator stated the charge nurse was responsible for admit orders and the DON was responsible for reviewing the orders and making sure they were correct. The MDS coordinator stated there should have been an order for Resident #30's catheter to make sure staff was aware of it. The MDS coordinator stated the importance of having an order was to make sure that nothing went wrong with the catheter and prevent infection. During an interview on 05/17/23 at 10:56 AM, the ADON, stated he was responsible for overseeing the physician orders when residents were admitted . The ADON stated he was aware that Resident #30 had a catheter and there should have been an order for it. The ADON stated the importance of having an order for the catheter was to make sure the nurses were aware of what care Resident #30 needed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 4 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0635 the care was being carried out. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/23 at 4:53 PM, the DON stated she was responsible for looking over the physician orders and making sure they were correct. The DON stated Resident #30 should have had an order for his catheter so the nursing staff would know how to care for the resident. The DON stated not having an order would result in Resident #30 not receiving the care he was supposed to get. Residents Affected - Few During an interview on 05/17/23 at 6:06 PM, the Regional Nurse stated the catheter should have had an order upon admission. The Regional nurse stated the LVN charge that completed the admission visit was responsible for making sure there was an order for the catheter and the ADON and DON were responsible for double checking the orders. The Regional nurse stated the importance of having the order was to ensure how to use the catheter and how often to change it. During an interview on 05/17/23 at 4:19 PM, the Administrator stated she expected the catheter to have an order and the ADON and DON were responsible for making sure the orders were correct. The Administrator stated if there was not order, then the catheter could be missed by direct care staff and not properly cared for or cleaned. Record review of the facility's policy titled, Physician's Orders, dated 2015, did not address admission physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 5 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 13 residents (Resident #9) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #9's medications on the MDS assessment on 04/15/2023 when the MDS reflected Resident #9 was on the antidepressant and Resident #9 had no order for an antidepressant. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) and hemiplegia (weakness on one side of the body). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated Resident #9 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS indicated Resident #9 sometimes made herself understood and sometimes had the ability to understand others. The MDS indicated Resident #9 had depression and received antidepressants over the last 7 days. Record review of Resident #9's care plan revised on 04/18/23 revealed Resident #9 required antidepressant medication. The Interventions included to give the medication ordered by the physician and to monitor/document side effects and effectiveness. Record review of Resident #9's order summary report dated 05/17/23 did not reveal Resident #9 was taking antidepressants. During an interview on 05/17/23 at 1:53 PM, the MDS coordinator stated she was responsible for completing the MDS. The MDS coordinator stated the physician orders are reviewed in the morning meetings by the DON and herself. The MDS coordinator stated she was trained by the previous MDS coordinator two months ago and must have just missed it. The MDS coordinator stated the importance of making sure the MDS was correct, was to ensure Resident #9 received the correct care and the nursing facility's payment was correct. The MDS coordinator stated if the facility's payment was not correct, then the facility could have gotten into big trouble. During an interview on 05/17/23 at 6:06 PM, the Regional nurse stated the MDS coordinator was responsible for making sure the MDS was correct. The Regional nurse stated the MDS should be correct to reveal a true picture of Resident #9 and capture the residents care needs and reimbursement. The Regional nurse stated that if the MDS was not correct, then it would reveal inaccurate data for Resident #9 and not a true pic of the resident. During an interview on 05/17/23 at 4:19 PM, the Administrator stated the MDS coordinator was responsible for completing the MDS and she expected it to be done correctly. The Administrator stated If the MDS was not correct, then nursing staff could have been documenting something that was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 6 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0641 occurring, and it could have impacted reimbursement. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/15/23 at 1:20 PM, the facility's policy on Minimum Data Set (MDS) was requested from the Regional nurse and she stated the facility followed the RAI manual. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 7 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 3 of 5 (Resident #9, Resident #12, and Resident #25) residents reviewed for PASRR. The facility failed to ensure Resident #9 had quarterly PASRR IDT meetings. The facility failed to ensure Resident #12 had quarterly PASRR IDT meetings. The facility failed to convene Resident #25's initial PASRR IDT meeting. These failures could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: 1.Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) and hemiplegia (weakness on one side of the body). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated Resident #9 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS indicated Resident #9 sometimes made herself understood and sometimes had the ability to understand others. The MDS indicated Resident #9 had depression and Non-Alzheimer's dementia. The MDS indicated Resident #9 received antidepressants over the last 7 days. Record review of Resident #9's care plan revised on 04/18/23 revealed Resident #9 required antidepressant medication. The Interventions included to give the medication ordered by the physician and to monitor/document side effects and effectiveness. Resident #9's care plan revised on 08/18/22 revealed she was PASRR positive. The goal indicated Resident #9 would have specialized services recommended by the local authority per PASRR as needed. The interventions indicated Resident #9 would have Specialized services provided and an annual care plan meeting for review of Specialized services. Record review of the PASRR Level 1 screening dated 05/15/13 indicated in section C0100 that Resident #9 had a Mental Illness (MI) and indicated in section C0300 that Resident #9 had a Developmental Disability. Record review of Resident #9's PASRR Evaluation completed on 08/14/2013. Record review of Resident #9's Comprehensive Service Plan Form dated 05/17/2022 indicated Resident #9 wished to continue with PASRR MI services. During an interview on 05/17/23 at 1:10 PM, the PASRR manager H indicated the IDT meetings were required quarterly to confirm if individuals wanted to keep services and to offer other services available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 8 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/17/23 at 1:53 PM, the MDS coordinator stated she was responsible for overseeing the PASRR's. The MDS coordinator stated she was trained in 03/2023 on MDS and PASRR and she did not get much training on the PASRR and that she was still learning. The MDS coordinator stated she did not know quarterly meetings were required if residents received MI services, and she did not know it was her responsibility to set up the quarterly meetings. The MDS coordinator stated the importance of the quarterly meeting was to make sure all of Resident #9's services were getting done and all of Resident #9's needs were being met. The MDS coordinator stated not completing the quarterly meetings could have resulted in Residnent#9 not having all her needs met. The MDS coordinator stated, The regional people trained me and the other MDS person helped me for 3 weeks with learning the MDS before she left. The MDS coordinator denied attending any trainings on PASRR and denied having a process in place to make sure the IDT meetings were getting done. During an interview on 05/17/23 at 4:19 PM, the Administrator stated the MDS coordinator was responsible for completing the PASRR's and making sure the quarterly meetings were scheduled. The Administrator stated she expected the quarterly meetings to be done if residents were receiving services. The Administrator denied having a process in place and stated if the quarterly meetings were not done, the resident could have missed the opportunity to accept needed services. During an interview on 05/17/23 at 6:06 PM, the Regional nurse stated the MDS coordinator was responsible for the PASRR and making sure the IDT meetings were completed. The Regional nurse stated the MDS coordinator was responsible for contacting the local authority to have the IDT meetings scheduled. The Regional nurse stated the process was for the social worker at the facility to double check that meetings were being done, but the facility's social worker only worked one day a week and was not able to double check. The Regional nurse stated the importance of the quarterly IDT meetings was to make sure Resident #9 received all the services she was needing and to be offered the opportunity to deny or accept other needed services. 2. Record review of a face sheet dated 05/17/2023 indicated Resident #12 was a [AGE] year old female initially admitted to the facility 06/12/2018 and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel resulting in high blood sugars), hypertensive heart disease with heart failure (high blood pressure with a condition that affects the way the heart pumps blood to the body), and peripheral vascular disease, unspecified (circulation issue that results in reduced blood flow to the arms or legs). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #12 was understood and usually understood others. The MDS assessment indicated Resident #12 was considered to have an intellectual disability based on the state level II PASRR process. The MDS assessment indicated Resident #12 had a BIMS score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated she required extensive assistance for bed mobility, dressing, and personal hygiene, total dependence for transfers, toilet use, supervision for eating, and independent for locomotion on and off the unit. Record review of Resident #12's care plan with a target date of 06/27/2023, indicated a focus that she had an intellectual disability and was PASRR positive. The care plan goal indicated Resident #12 would have the specialized services recommended by the local authority per the PASRR specialized services program as needed. The care plan interventions indicated she had a specialized wheelchair provided through PASRR services with a special cushion, specialized services would be provided per local authority recommendations, and the local authority would be invited annually to the care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 9 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0644 meeting for review of specialized services. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #12's PASRR Level 1 Screening completed on 04/01/2021 indicated in section C0200 that there was evidence or an indicator that this individual had an intellectual disability. Residents Affected - Some Record review of Resident #12's PASRR Evaluation dated 04/27/2021 revealed she had an Intellectual Disability which manifested before the age of 18. The recommended services provided/coordinated by the Local Authority included alternate placement services, service coordination, independent living skills training and service to be provided by the facility was specialized occupational therapy. Record review of the PASRR Comprehensive Service Plan Forms provided by the facility for the past year for Resident #12 indicated IDT meetings with the Local Authority on 04/05/2022, 02/15/2023, and 05/04/2023. No quarterly IDT meetings were provided from 04/05/2022 to 02/15/2023. 3. Record review of a face sheet dated 05/17/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #25 was considered to have a serious mental illness based on the state level II PASRR process. The MDS assessment indicated Resident #25 was able to make herself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment in the section of psychiatric/mood disorder indicated, Resident #25 had diagnoses of bipolar disorder and psychotic disorder. Record review of Resident #25's care plan initiated on 04/13/2023, indicated she had a mood disorder related to bipolar disorder. The care plan for Resident #25 did not address Resident #25's PASRR status. Record review of Resident #25's PASRR Level 1 Screening completed on 03/28/2023 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. Record review of Resident #25's PASRR Evaluation dated 03/30/2023 revealed he had mood disorder (bipolar disorder, major depression, or other mood disorder). For Resident #25 the PASRR Evaluation question based on the QMHP assessment, does this individual meet the PASRR definition of mental illness was answered yes. Resident #25's PASRR Evaluation indicated the recommended services provided/coordinated by the local authority were routine case management. During an interview on 05/16/2023 at 3:40 PM, the Regional MDS Nurse said the MDS Coordinator had been trying to schedule Resident #25's IDT meeting with the PASRR Manager, but she had been unsuccessful. During a phone interview on 05/16/2023 at 4:05 PM, the PASRR Manager said the MDS Coordinator had reached out to schedule the initial IDT meeting for Resident #25 on 04/28/2023. The PASRR Manager said the facility was responsible for setting up the initial IDT meeting as soon as the received the positive PASRR evaluation. The PASRR Manager said the IDT meeting should take place within 14 days of the residents' admission to the facility. The PASRR Manager said after the initial IDT meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 10 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents that qualified for PASRR services should have a quarterly IDT meeting. The PASRR Manager said it was important to have the IDT meetings to confirm if the residents wanted services and to offer them services available to them. During an interview on 05/17/2023 at 5:15 PM, the MDS Coordinator stated she was responsible for coordinating PASRR services. The MDS Coordinator stated she was not aware she was supposed to be making sure the meetings for PASRR were scheduled. The MDS Coordinator said she was under the impression the people from the PASRR program contacted her when residents needed a meeting. The MDS Coordinator stated she did not know why Resident #12 was missing IDT meetings from 04/05/2022 to 02/15/2023 that she had moved into the MDS Coordinator position in March 2023. The MDS Coordinator said if the residents were receiving services meetings should take place quarterly. The MDS Coordinator said the initial IDT meeting should take place within 30 days of admission. The MDS Coordinator said it was important for the initial IDT meeting to be conducted so the residents could get services started and receive any needed equipment. The MDS Coordinator said it was important to have quarterly IDT meetings to make sure services are up to date. During an interview on 05/17/2023 at 5:41 PM, the Administrator stated the MDS Coordinator was responsible for making sure PASRR services were coordinated, and the IDT meetings were conducted. The Administrator said it was important for the IDT meetings to be conducted within the required timeframes for the residents to receive what they are eligible for and to provide them with a better quality of life. Record review of the facility's policy on, PASRR Evaluation PE Policy and Procedure, dated 10/30/2017, indicated . Specialized Services Reviewed at the IDT Meeting: All PASRR services mapped to Sections B0500, B0600 and C1000 need to be discussed at the IDT meeting, all services must be implemented and have an assessment completed, and an assessment is also needed if it is determined services would not benefit the individual. Record review of the facility's policy dated 10/30/2017, titled, PASRR Evaluation PE Policy and Procedure, did not address the timeframes for the initial IDT meeting or the quarterly IDT meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 11 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 2 residents (Resident #25) reviewed for baseline care plans. The facility failed to ensure Resident #25 had a baseline care plan completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 05/17/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). Record review of Resident #25's Baseline Care Plan Acknowledgment indicated an effective date of 04/13/2023 and an admission date of 04/06/2023. Record review of Resident #25's electronic health record revealed there was no baseline care plan. During an interview on 05/17/2023 at 4:16 PM, the ADON said the charge nurse could complete the baseline care plans, but he was under the impression the DON was doing them. The ADON said the DON was responsible for overseeing the completion of the baseline care plans. The ADON said the baseline care plans should be completed on admission. The ADON said he had recently taken the position as ADON, in March 2023, and he did not know where the baseline care plans were located. The ADON said the MDS Coordinator would know because she was the previous ADON. The ADON said it was important for the baseline care plans to be completed on admission because it gave the staff a basis of the needs the residents needed to be met and the level of care the residents required. During a phone interview on 05/17/2023 at 4:45 PM, the DON said the baseline care plan should be completed upon admission. The DON said when the baseline care plan was completed the Baseline Care Plan Acknowledgement was completed. The DON said she was responsible for ensuring the baseline care plans were completed on admission. The DON said she did not remember if Resident #25's baseline care plan was done on admission. The DON said it was important for the baseline care plan to be completed on admission so the staff would know the plan they were going by to take care of the resident. During an interview on 05/17/2023 5:27 PM, the MDS Coordinator said the nurse on admission, or the DON were supposed to complete the baseline care plan. The MDS Coordinator said the DON monitored the completion of the baseline care plans. The MDS Coordinator said the Baseline Care Plan Acknowledgement was the proof that the baseline care plan was completed. The MDS Coordinator said she thought the baseline care plan was supposed to be completed within 24 hours of admission. The MDS Coordinator said Resident #25's baseline care plan was not completed on time, and she did not know why it was not completed timely. The MDS Coordinator said it was important for the baseline care plan to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 12 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0655 completed timely, so the staff had a basic knowledge of what the resident needed. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/2023 at 5:43 PM, the Administrator said the baseline care plan should be completed by the charge nurse on admission. The Administrator said the baseline care plan should be completed within 48 hours of admission. The Administrator said she expected the nurses to complete the baseline care plan timely, and the nurse managers were responsible for ensuring this happened. The Administrator said it was important for the baseline care plan to be completed timely because it gave the staff a good picture of the resident on admission and how to move forward with the resident's care. Residents Affected - Few Record review of the facility's undated policy titled, Base Line Care Plans, indicated .This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will-Be developed within 48 hours of a resident's admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 13 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 13 residents (Resident #25, Resident #28, and Resident #30) reviewed for care plans. The facility failed to care plan that Resident #25 and Resident #28 were PASRR positive. The facility failed to ensure Resident #30's care plan reflected he had a condom catheter. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/17/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #25 was considered to have a serious mental illness based on the state level II PASRR process. The MDS assessment indicated Resident #25 was able to make herself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment in the section of psychiatric/mood disorder indicated, Resident #25 had diagnoses of bipolar disorder and psychotic disorder. Record review of Resident #25's PASRR Level 1 Screening completed on 03/28/2023 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. Record review of Resident #25's PASRR Evaluation dated 03/30/2023 revealed she had mood disorder (bipolar disorder, major depression, or other mood disorder). For Resident #25 the PASRR Evaluation question based on the QMHP assessment, does this individual meet the PASRR definition of mental illness was answered yes. Resident #25's PASRR Evaluation indicated the recommended services provided/coordinated by the local authority were routine case management. Record review of Resident #25's care plan initiated on 04/13/2023, indicated she had a mood disorder related to bipolar disorder. The care plan for Resident #25 did not address Resident #25's PASRR status or routine case management. 2. Record review of Resident #28's Order Summary Report indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (left side weakness and paralysis due to a stroke), and unspecified dementia, unspecified severity, without behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 14 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was considered to have a serious mental illness based on the state level II PASRR process. The MDS assessment indicated Resident #28 was able to make himself understood and understood others. The MDS assessment indicated Resident #28 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, and total dependence for transfers. The MDS assessment in the section of psychiatric/mood disorder indicated, Resident #28 had diagnoses of depression. Record review of Resident #28's PASRR Level 1 Screening completed on 02/02/2023 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. Record review of Resident #28's PASRR Evaluation dated 02/07/2023 revealed he had schizophrenia and mood disorder (bipolar disorder, major depression, or other mood disorder). For Resident #28 the PASRR Evaluation question based on the QMHP assessment, does this individual meet the PASRR definition of mental illness was answered yes. Resident #28's PASRR Evaluation indicated the recommended services provided/coordinated by the local authority were individual skills training. Record review of Resident #28's care plan initiated on 02/20/2023, indicated the care plan for Resident #28 did not address his PASRR positive status or his individual skills training. During an interview on 05/17/2023 at 5:22 PM, the MDS Coordinator said she was responsible for making sure PASRR positive residents had PASRR care planned. The MDS Coordinator said Resident #25 did not have PASRR care planned because she failed to include it in her care plan when she completed it. The MDS Coordinator said she was not sure why Resident #28's PASRR status was not care planned. The MDS Coordinator said she audited care plans to ensure they were complete when she completed a resident's MDS assessment. The MDS Coordinator said it was important for the residents PASRR status to be care planned so that everybody knew it was something they received and knew how to take care of them. During an interview on 05/17/2023 at 5:45 PM, the Administrator said the MDS Coordinator was responsible for ensuring PASRR status was included in the residents' care plans. The Administrator said she expected this to be care planned. The Administrator said it was important to include PASRR status in the residents' care plans because it was another piece of information to provide the residents the care they needed. 3. Record review of Resident #30's face sheet dated 05/16/23 revealed Resident #30 was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease of the brain), type 2 diabetes (blood sugar disorder) and hypertension (high blood pressure). Record review of Resident #30's comprehensive MDS dated [DATE] indicated Resident #30 made himself understood and was able to understand others clearly. Resident #30 had a BIMS score of 15 indicating he was cognitively intact. Section H of the MDS indicated Resident #30 had an indwelling catheter and an external catheter. Record review of the order summary report dated 05/17/23, revealed Resident #30 did not have an order for a condom catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 15 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #30's care plan initiated 04/23/23 did not reveal Resident #30 had a condom catheter. During an observation and interview on 05/16/23 at 09:43 AM, Resident #30 had a catheter in place and had a small amount of yellow urine noted in the bag. Resident #30 denied having any issues with the catheter. During an interview on 05/17/23 at 1:45 PM, LVN A stated she was the charge nurse for Resident #30. LVN A stated she knew Resident #30 had a catheter because it was on her 24-hour report, but she was not aware that the catheter had not been care planned. LVN A stated the MDS coordinator was responsible for making sure the care plans were accurate. LVN A stated Resident #30's catheter should have been care planned so that staff would be aware of how to care for the resident. LVN A stated not having a care plan on Resident #30's catheter could have resulted in sepsis or a UTI. During an interview on 05/17/23 at 4:53 PM, the DON stated that the MDS coordinator and herself updated the care plans, but she was mainly responsible for making sure the care plans were correct. The DON stated she pulled the care plans at random to make sure they were correct when random changes were noticed. The DON stated Resident #30's catheter should have been care planned so that nursing staff would know how to take care of Resident #30. The DON stated that not care planning the catheter could result in nursing staff not taking care of Resident #30 the way they were supposed to. During an interview on 05/17/23 at 6:06 PM, the Regional nurse stated Resident #30's catheter should have been care planned and the DON was responsible for making sure the care plans were correct. The Regional nurse stated the importance of care planning the catheter was to know the purpose of the catheter and how nursing staff was intended to take care of it. During an interview on 05/17/23 at 4:19 PM, the Administrator stated she expected Resident #30's catheter to be care planned and the nurse managers were responsible for making sure the care plans were correct. The Administrator stated if the catheter was not care planned, then it could have been missed by direct care staff and not properly cared for or cleaned. Record review of the facility's undated policy titled, Comprehensive Care Planning, indicated The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASAR . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 16 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 13 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan was updated and revised to reflect she was not taking any antidepressant medications. These failures could cause the resident to not receive the correct care impacting the patient's health and/or serious illness. Findings include: Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) and hemiplegia (weakness on one side of the body). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated Resident #9 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS indicated Resident #9 sometimes made herself understood and sometimes had the ability to understand others. The MDS indicated Resident #9 had depression and Non-Alzheimer's dementia. The MDS indicated Resident #9 received antidepressants over the last 7 days. Record review of Resident #9's order summary report dated 05/17/23 did not reveal Resident #9 was taking antidepressants. Record review of Resident #9's care plan revised on 04/18/23 revealed Resident #9 required antidepressant medication. The Interventions included to give the medication ordered by the physician and to monitor/document side effects and effectiveness. During an interview on 05/15/2023 at 11:16 AM, Resident #9 stated she was not taking any antidepressant medications at this time, and she did not require any. During an interview on 05/17/23 at 1:53 PM, the MDS coordinator stated the DON was responsible for making sure the care plans were correct. The MDS coordinator stated the care plans should be correct to make sure the resident was receiving the correct care. During an interview on 05/17/23 at 4:53 PM, the DON stated that the MDS coordinator and herself updated the care plans, but she was mainly responsible for making sure the care plans were correct. The DON stated she pulled the care plans at random to make sure they were correct when random changes were noticed. The DON stated if the care plan was not correct, it could result in nursing staff not taking care of residents the way they were supposed to. During an interview on 05/17/23 at 6:06 PM, the Regional Nurse stated the DON was responsible for making sure the care plans were correct. The Regional nurse stated the importance of care planning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 17 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 was to inform nursing staff on how to take care of the residents. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/23 at 4:19 PM, the Administrator stated she expected the care plans to be correct and the nurse managers were responsible. Residents Affected - Few Record review of the facility's policy on, Comprehensive Care Planning (no date) indicated . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 18 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 13 residents reviewed for ADLs (Resident #16, Resident #17, and Resident #23). Residents Affected - Some The facility failed to provide assistance with facial hair removal for Resident #16. The facility failed to ensure Resident #17, and Resident #23 received showers or bed baths as scheduled. These failures could place residents at risk of not receiving services and care, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/17/2023, indicated Resident #16 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), essential hypertension (high blood pressure), and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (left side weakness and paralysis due to a stroke). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #16 was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #16 required the staff assessment for mental status, which indicated Resident #16 had a memory problem and her cognitive skills for daily decision making were severely impaired. The MDS assessment indicated Resident #16 required extensive assistance with bed mobility, dressing, eating and personal hygiene, and total dependence for transfers and toilet use. The MDS assessment indicated activity did not occur for bathing. Record review of the care plan with a target date of 06/12/2023 indicated Resident #16 had an ADL self-care performance deficit and included an intervention to assist with personal hygiene as required for hair, shaving, oral care as needed. Record review of Resident #16's Task List Report dated 05/17/2023 indicated Resident #16 bathing schedule was Tuesday, Thursday, and Saturday on the 6 PM- 2 PM shift. Record review of the Bathing Task indicated Resident #16 received all her showers/baths for the month of May 2023. During an observation on 05/15/2023 at 11:05 AM, Resident #16 was sitting by the nurse's station with chin hairs approximately 0.5 an inch long. Resident #16 was non-interviewable. During an observation on 05/16/2023 at 11:50 AM, Resident #16 was sitting in the dining area with chin hairs approximately 0.5 an inch long. During an observation on 05/17/2023 at 8:10 AM, Resident #16 was sitting in the dining area with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 19 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0677 chin hairs approximately 0.5 an inch long. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/2023 at 2:18 PM, CNA C said she was aware Resident #16 had chin hairs and staff normally cuts them. CNA C said Resident #16 had a hospice aide that gave her a bath, but the facility staff also cuts her chin hairs. CNA C said she was not sure why they had not been removed. CNA C said the chin hairs should have been removed, and all the CNAs were responsible for removing the chin hairs. CNA C said it was important to remove them for the residents' self-esteem and self-worth. Residents Affected - Some 2. Record review of a face sheet dated 05/17/2023, indicated Resident #17 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar with nerve damage), essential (primary) hypertension (high blood pressure), and generalized anxiety disorder. Record review of Resident #17's Quarterly MDS assessment dated [DATE], indicated Resident #17 was understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 14, which indicated she was cognitively intact. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, dressing and personal hygiene, and total dependence for transfer and toilet use. The MDS assessment indicated Resident #17 was totally dependent for bathing. Record review of the care plan with a target date of 06/28/2023 indicated Resident #17 had an ADL self-care deficit and interventions included she required assistance by one person for bathing. The care plan did not indicate Resident #17 refused care or bathing. Record review of Resident #17's Task List Report dated 05/17/2023 indicated Resident #17's bathing schedule was Tuesday, Thursday, and Saturday on the 6 PM- 2 PM shift. Record review of the Bathing Task for the month of May indicated Resident #17 received a bed bath on 05/02/2023, 05/04/2023, 05/09/2023, and 05/13/2023. The Bathing task indicated not applicable for 05/06/2023, 05/11/2023, and 05/16/2023. There were no refusals documented for the Month of May 2023. During an observation and interview on 05/15/2023 at 2:38 PM, Resident #17 said she had not had a bath since last Tuesday. Resident #17's skin was dry, flaky and hair was disheveled. Resident #17 said CNA F had told her she would give her a bath in the next couple of days because she had not had time to give her one. Resident #17 said it made her mad when she did not get her baths and it made her feel dirty and hot. During an observation and interview on 05/16/2023 at 3:53 PM, Resident #17 said she had not received her bath today. Her skin appeared dry, flaky and her hair was disheveled. During an observation and interview on 05/17/2023 at 8:55 AM, Resident #17 said she had not received a bath. Her skin appeared dry, flaky and her hair disheveled. During an interview on 05/17/2023 at 2:05 PM, NA E said she had not given Resident #17 a bed bath yesterday (05/16/2023) because she was the only aide on the 6 AM to 2 PM shift. NA E said the CNAs were responsible for making sure the residents received their baths/showers. NA E said it was important for the residents to receive their baths/showers for their skin and so they would not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 20 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some smell. NA E said the residents had a right to get their baths/showers and it could make them feel irritated if they did not get them. During an interview on 05/18/2023 at 3:16 PM, CNA F said she had not given Resident #17 a bed bath on Saturday (05/13/2023) because she was the only CNA for the whole building. CNA F said she signed off the task that she gave a bed bath because she had cleaned her up during incontinent care, but she did not actually give her a bed bath. CNA F said the CNAs were responsible for giving the residents their baths/showers, but it was hard to give them when there was only one CNA working with 30 something people. CNA F said it was important for the residents to get their baths/showers because it could make them feel bad if they did not get one and because the staff was at the facility to care for the residents. 3. Record review of a face sheet dated 05/17/2023, indicated Resident #23 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (condition that affects the way the heart pumps blood to the body), and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain with no behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #23 was understood and understood others. The MDS assessment indicated Resident #23 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #23 was independent with bed mobility, transfers, locomotion on and off the unit, eating, and toilet use and required extensive assistance with personal hygiene and limited assistance with dressing. The MDS assessment indicated Resident #23 required 2+ persons physical assist with bathing. Record review of Resident #23's care plan with a target date of 05/01/2023, indicated Resident #23 had limited physical mobility related to weakness, comorbidities (presence of two or more diseases), and poor endurance and required assistance with ADLs, and interventions included she required 1-person limited assistance with bathing. The care plan did not indicate Resident #23 refused care or bathing. Record review of the Bathing Task for the month of May indicated Resident #23 received a shower on 05/02/2023 and 05/16/2023. The Bathing task indicated not applicable for 05/04/2023, and 05/09/2023. Documentation was missing for 05/06/2023, 05/11/2023, and 05/13/2023. There were no refusals documented for the month of May 2023. During an observation and interview on 05/15/2023 at 10:48 AM, Resident #23 said she had not had a bath since last Tuesday. Resident #23's hair was greasy. During an interview on 05/15/2023 at 2:50 PM, Resident #23 said she had not had a bath since last Tuesday, and she usually had to ask to get one. Resident #23 said sometimes when she asked, she got it but sometimes the staff told her they were too busy and could not do it. Resident #23 said not getting a shower makes her feel gross. During an interview on 05/16/2023 at 5:27 PM, Resident #23 said she received a shower today because she asked for one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 21 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/17/2023 at 4:22 PM, the ADON said the CNAs were responsible for giving the baths/showers, and he was responsible for overseeing that the baths/showers were given. The ADON said he had not been able to monitor the CNAs as he should because he was having to work the floor due to staffing issues. The ADON said Resident #23 had told him she was not getting her showers. The ADON said Resident #17 refused her bed baths at times. The ADON said he was not aware the CNAs did not have time to give bed baths/showers. The ADON said it was important for the residents to receive their baths/showers so they could be clean and stay healthy. The ADON said Resident #16 was on hospice and the hospice CNAs were supposed to shave her. The ADON said the CNAs at the facility were also responsible for removing Resident #16's chin hairs. The ADON said it was important for Resident #16 to get her facial hair removed for her self-esteem, confidence, and integrity. During a phone interview on 05/17/2023 at 4:53 PM, the DON said the CNAs were responsible for ensuring they gave the residents their baths/showers. The DON said the ADON, DON, and Administrator were supposed to monitor that this was done. The DON said she was not aware Resident #17 and Resident #23 were not receiving their baths/showers. The DON said it was important for the residents to get a bath/shower for infection control and their well-being. The DON said female residents should have their facial hair removed. The DON said she was not aware Resident #16 had chin hairs. The DON said the CNAs should have removed Resident #16's chin hairs. The DON said it was important for female residents to have their facial hair removed for their dignity. During an interview on 05/17/2023 at 5:47 PM, the Administrator said the DON and ADON were responsible for making sure the CNAs gave the residents baths/showers. The Administrator said she expected for the residents to get their baths. The Administrator said it was important for them to get their baths/showers so they could have good hygiene and health, and the residents not receiving their baths/showers was a dignity issue. The Administrator said the CNAs should be shaving female residents. The Administrator said not removing female residents' facial hair was a dignity issue. The Administrator said she was aware there were days when there was only one CNA to care for the residents, but management staff was sent to assist with providing care for the residents to ensure their needs were met. Record review of the facility's policy titled, Bath, Tub/Shower, from the Nursing Policy & Procedure Manual 2003, indicated, Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level . Record review of the facility's policy titled, Shaving, Electric/Safety Razors, from the Nursing Policy & Procedure Manual 2003, did not address female facial hair removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 22 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #28) reviewed for incontinence. The facility failed to ensure Resident #28 was provided prompt incontinent care. This failure could place residents at risk for urinary tract infections, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #28's Order Summary Report dated 5/15/2023 indicated he was a [AGE] year-old male readmitted to the facility on [DATE], initially admitted [DATE], with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (left side weakness and paralysis due to a stroke), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was able to make himself understood and understood others. The MDS assessment indicated Resident #28 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, and total dependence for transfers. The MDS assessment in the section bladder and bowel indicated Resident #28 was frequently incontinent of bladder and bowel. Record review of the care plan with date initiated 02/20/2023, indicated Resident #28 had bladder incontinence and interventions included incontinent care at least every 2 hours and apply moisture barrier after each episode. The care plan indicated Resident #28 was at risk for pressure ulcer development and interventions included to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #28's discharge summary from the hospital dated 03/22/2023, indicated he was hospitalized [DATE] to 03/22/2023 and discharge diagnoses included sepsis due to urinary tract infection (infection in the blood stream caused by an untreated urinary tract infection). During an observation and interview on 05/15/2023 at 3:10 PM, Resident #28 said he was very cold because he was wet. Resident #28 said his brief had not been changed all day. Resident #28 said this happened frequently and the staff did not check on him frequently throughout the day. Surveyor asked Resident #28 if he would allow for his blanket to be removed, and Resident #28 agreed. Upon removal of blanket surveyor noticed a dark brown ring extending out from underneath Resident #28's bottom up to his back. During an observation and interview on 05/15/2023 starting at 3:55 PM, CNA C said she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 23 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for providing care to Resident #28. CNA C said her shift started at 2:00 PM and she had not had a chance to check on Resident #28 because she was busy working on the other hall. CNA C said she usually rounds on all the residents at the start of her shift, but she had not been able to today. Surveyor informed CNA C Resident #28 required incontinent care. CNA B and CNA C provided incontinent care to Resident #28. CNA B and CNA C agreed Resident #28 had a dark brown ring of urine underneath him. CNA B removed Resident #28's dirty blanket, placed it in a trash bag, and put the bag at Resident #28's foot of the bed, removed her gloves and applied clean gloves. CNA B did not perform hand hygiene before applying the clean gloves. CNA B then cleaned Resident #28's front peri area and then turned Resident #28 on his side and cleaned his buttocks no redness noted to buttocks. After cleaning Resident #28's buttocks CNA B removed the dirty sheet and tucked the dirty sheet and dirty adult brief under Resident #28, while he was still on his side. CNA B then applied a clean sheet to the uncovered half of the bed and a clean adult brief. CNA B used her dirty gloves when she applied the clean sheet and adult brief. She did not change her gloves or perform hand hygiene. CNA B and CNA C turned Resident #28 on his other side and CNA C removed the dirty adult brief and handed it to CNA B. CNA B placed the dirty adult brief in a trash bag and put it on Resident #28's overbed table. CNA C pulled out the dirty sheet and put it in the bag at Resident #28's foot of the bed. CNA C then pulled out from underneath Resident #28's clean sheet and clean adult brief and fastened it onto Resident #28. CNA C did not change gloves or perform hand hygiene after removing the dirty sheet and adult brief. After fastening Resident #28's clean adult brief, CNA B and CNA C removed their dirty gloves and applied clean gloves to change Resident #28's clothes. CNA B and CNA C did not perform hand hygiene after glove removal. During an interview on 05/17/2023 at 3:16 PM, CNA F said on Monday, 5/15/2023, she worked the 6 AM to 2 PM shift and she was responsible for providing care for Resident #28. CNA F said the residents should be checked on every 2 hours. CNA F said she had not had a chance to check on the residents every 2 hours on Monday because she was the only certified nurse aide in the building. CNA F said she believed the last time she provided incontinent care to Resident #28 was between 1 PM and 1:30 PM. CNA F said it was important to provide prompt incontinent care for the residents to feel good and to prevent skin breakdown. During an interview on 05/17/2023 at 4:10 PM, the ADON said when the CNAs arrive for their shift, they should get report from the CNAs leaving and then make rounds on all the residents. The ADON said the CNAs should check on the residents at least every 2 hours, and they should check more often if they knew the resident was a frequent wetter. The ADON said a dark brown ring underneath a resident indicated the resident had probably not been checked on within 2 hours. The ADON said nurse management was responsible for ensuring the CNAs were providing prompt incontinent care. The ADON said it was important to provide prompt and frequent incontinent care for the residents' skin integrity. The ADON said not providing prompt and frequent incontinent care could result in a urinary tract infection and pressure ulcers. During a phone interview on 05/17/2023 at 4:57 PM, the DON said when the CNAs start their shift, they should round on all the residents. The DON said the CNAs were responsible for providing incontinent care to the residents. The DON said a dark brown ring under Resident #28 meant he had not been checked on frequently by the CNAs. The DON said the CNAs should be checking on the residents when they came on their shift, off their shift, and periodically in between the shift. The DON said not providing frequent incontinent care could result in skin breakdown and urinary tract infections. During an interview on 05/17/2023 at 5:54 PM, the Administrator said she expected the CNAs to provide prompt and frequent incontinent care, and the charge nurses should ensure the CNAs did this. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 24 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator said it was important for the residents to receive prompt and frequent incontinent care for their dignity and for infection control issues. Record review of the facility's policy titled, Perineal Care, with an effective date of 05/11/2022, indicated, An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations . Event ID: Facility ID: 675105 If continuation sheet Page 25 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 10.34%, based on 3 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #10) reviewed for medication administration. Residents Affected - Few The facility failed to ensure Resident #10 received Methocarbamol (treat muscle spasms/pain, and Tylenol (treat aches and pain). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #10's order summary report, dated 05/16/2023, indicated Resident #10 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and osteoarthritis (degeneration of joint cartilage and the underlying bone). Further review of the Resident 10's order summary report, dated 05/16/2023, indicated Resident #10 was prescribed Methocarbamol tablet, 750 mg by mouth four times a day for muscle weakness with a start date 01/12/2023, and Tylenol tablet, 500 mg by mouth TID for pain with a start date 02/17/2023. Record review of the MAR dated 05/01/2023-05/31/2023 indicated Resident #10 had an order for Methocarbamol 750 mg to be given at 8:00 a.m., 12:00 p.m., 6:00 p.m. and 10:00 p.m. Record review of the MAR dated 05/01/2023-05/31/2023 indicated Resident #10 had an order for Tylenol 500 mg to be given at 8:00 a.m., 1:00 p.m. and 8:00 p.m. During an observation and interview on 05/16/2023 beginning at 11:00 a.m., the MDS Coordinator stated she had to omit Resident #10's 8:00 AM dose of Methocarbamol and Tylenol because it was too close to next scheduled dose. The MDS Coordinator administered the 1:00 PM dose of Methocarbamol to Resident #10. During an interview and observation on 05/16/2023 beginning at 11:39 a.m., Resident #10 was unable to state if there was an issue with receiving his medications on time. There was no s/s noted of adverse rection. During an interview on 05/17/2023 at 10:45 a.m., the MDS Coordinator stated the Tylenol and Methocarbamol should have been given between 7:00 a.m. and 9:00 a.m. The MDS Coordinator stated medications were not given as ordered due to the nurse that was assisting from a sister facility was new to the routine (medication administration) for this building. The MDS Coordinator stated it required her to take a little bit longer to verify residents which then required the nursing managers to step in ensuring medication was given timely. The MDS Coordinator stated the failure of not administering the Tylenol and Methocarbamol on time could cause an acute onset of disease process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 26 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/17/2023 at 11:00 a.m., the Regional Compliance Nurse stated she expected medications to be given as ordered. The Regional Compliance Nurse stated the MAR was pulled from the physician order and the time frame was set depending on the frequency of the medication ordered to ensure time spacing between doses. The Regional Compliance Nurse stated the nurse on duty was taking more time verifying the 5 rights of medication pass because this was her first medication pass for the building. The Regional Compliance Nurse stated there was an audit that can be ran daily that shows any missed or late medication administration and PCC dashboard showed medication passes in the last 24 hours. The Regional Compliance Nurse stated she did random audits for compliance during her visits. The Regional Compliance Nurse stated her last audit was on 3/6/23 and did not notice any issues. The Regional Compliance Nurse stated the failure of not administering medications on time could potentially put residents at risk for increased signs and symptoms of disease exacerbations. During an interview on 05/17/2023 at 4:10 p.m., the Administrator stated she expected medications to be given on time. The Administrator stated this failure could put residents at risk for adverse effects. Record review of the facility's policy titled, Physician Orders, dated 2015 indicated, .Purpose: To monitor and ensure the accuracy and completeness of the medication orders . Record review of the facility's policy titled, Medication Administration Procedures revised on 10/25/2017 indicated, . 20. The five rights of medication should always be adhered to, right drug, right dose, right resident, right time, right route . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 27 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Hall 6/8/9) reviewed for storage of medications. The facility failed to ensure Hall 6/8/9 medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings included: During an observation on 05/16/2023 at 10:25 a.m., the DON left Hall 6/8/9 medication cart unlocked and out of sight, facing Resident #82's room, while administering Resident #82's medication. During an interview on 05/16/2023 at 11:15 a.m. the DON stated she should have locked the medication cart prior to going in Resident #82's room. When asked why she did not lock the cart, she stated, I forgot. The DON stated this failure allowed residents, staff, and visitors access to other residents' medication. During an interview on 05/17/2023 at 11:00 a.m., the Regional Compliance Nurse stated she expected medication carts to be locked when unattended. The Regional Compliance Nurse stated the direct care staff that was assigned to the cart was responsible for maintaining the cart locked. The Regional Compliance Nurse stated the DON or nurse managers were responsible for monitoring compliance. The Regional Compliance Nurse stated she did random checks for medication carts being locked during facility visits. The Regional Compliance Nurse stated that was the first occurrence she was aware of. The Regional Compliance Nurse stated on previous visits when the DON worked the floor her cart has been in compliance. The Regional Compliance Nurse stated this failure could potentially allow others access to medication and supplies on cart. During an interview on 05/17/2023 at 4:10 p.m., the Administrator stated she expected medication carts to be locked when unattended. The Administrator stated this failure allowed others access to residents' medication. Record review of the facility's Medication Administration Procedures policy, last revised in 10/25/2017, revealed . 8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 28 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 staff (CNA B, CNA C, LVN D, and the Housekeeping Supervisor) reviewed for infection control. Residents Affected - Some The facility failed to ensure the Housekeeping Supervisor covered the clean linen cart while passing out resident's personal laundry. The facility failed to ensure CNA B and CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure LVN D changed gloves while providing wound care to Resident #20. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation on 05/15/2023 starting at 3:26 PM, the Housekeeping Supervisor was passing out clean linen on hall 500. The clean linen cart was not covered. The clothes hanging from the cart were completely exposed. During an interview on 05/17/2023 at 5:04 PM, the Housekeeping Supervisor said he was responsible for overseeing the laundry. The Housekeeping Supervisor said when passing clothes to the residents the linen carts should be covered. The Housekeeping Supervisor said he should have covered the linen cart when passing out the residents' clothes on hall 500. The Housekeeping Supervisor said he usually does not pass the clothes with the linen cart uncovered, but he only had a few clothes to pass out, so he did not cover the cart. The Housekeeping Supervisor said it was important to cover the linen carts when passing out the residents' personal laundry, so it did not get cross contaminated. 2. During an observation on 05/15/2023 starting at 3:55 PM, CNA B and CNA C provided incontinent care to Resident #28. CNA B removed Resident #28's dirty blanket, placed it in a trash bag, and put the bag at Resident #28's foot of the bed, removed her gloves and applied clean gloves. CNA B did not perform hand hygiene before applying the clean gloves. CNA B then cleaned Resident #28's front peri area and then turned Resident #28 on his side and cleaned his buttocks. After cleaning Resident #28's buttocks CNA B removed the dirty sheet and tucked the dirty sheet and dirty adult brief under Resident #28, while he was still on his side. CNA B then applied a clean sheet to the uncovered half of the bed and a clean adult brief. CNA B used her dirty gloves when she applied the clean sheet and adult brief. She did not change her gloves or perform hand hygiene. CNA B and CNA C turned Resident #28 on his other side and CNA C removed the dirty adult brief and handed it to CNA B. CNA B placed the dirty adult brief in a trash bag and put it on Resident #28's overbed table. CNA C pulled out the dirty sheet and put it in the bag at Resident #28's foot of the bed. CNA C then pulled out from underneath Resident #28's clean sheet and clean adult brief and fastened it onto Resident #28. CNA C did not change gloves or perform hand hygiene after removing the dirty sheet and adult brief. After fastening Resident #28's clean adult brief, CNA B and CNA C removed their dirty gloves and applied clean gloves to change Resident #28's clothes. CNA B and CNA C did not perform hand hygiene after glove removal. After putting on Resident #28's clothes CNA B and CNA C transferred Resident #28 from his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 29 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 - Minimal harm or potential for actual harm Residents Affected - Some bed to the wheelchair. After transferring Resident #28 to his wheelchair CNA B removed her gloves and combed Resident #28's hair. CNA B did not perform hand hygiene after removing her gloves. CNA B then wheeled Resident #28 out of his room and down the hall. CNA B stopped and washed her hands in the shower room at the end of the hall. CNA C made Resident #28's bed, gathered the trash bag and dirty linen bag and then removed her gloves. CNA C exited Resident #28's room, disposed of the trash and dirty linen in the bins in the hallway outside of Resident #28's room and performed hand hygiene with hand sanitizer located in the hallway. During an interview on 05/15/2023 at 4:13 PM, CNA B said she should not have placed the trash bag with the dirty adult brief on Resident #28's overbed table. CNA B said hand hygiene should be performed prior to providing care, during care, and after glove removal. CNA B said gloves should be removed and hand hygiene performed after removing dirty sheets and before applying the clean sheets. CNA B said she should have washed her hand prior to leaving Resident #28's room. CNA B said she had placed the trash bag on the overbed table, not performed hand hygiene adequately and changed her gloves when she was supposed to because she was nervous and not prepared. CNA B said she could not remember when she was last trained on performing incontinent care. CNA B said proper hand hygiene and glove changes were necessary during incontinent care to prevent cross contamination. During an interview on 05/15/2023 at 4:19 PM, CNA C said she should have changed gloves and performed hand hygiene after removing the dirty sheets and before applying the clean ones. CNA C said gloves should be changed and hand hygiene performed after touching any dirty briefs or dirty sheets. CNA C said the trash bag with dirty items did not go on the overbed table it should be placed on the floor. CNA C said hand hygiene should be performed before and after patient care and in between glove changes. CNA C said her last training on incontinent care might have been a month ago, but she could not remember. CNA C said it was important to perform appropriate glove changes and hand hygiene to prevent cross contamination. 3. During an observation and interview on 05/16/2023 starting at 10:36 AM, LVN D provided wound care to Resident #20. LVN D applied gloves and cleaned off Resident #20's overbed table. LVN D removed her gloves and applied clean gloves. LVN D did not perform hand hygiene after removing her gloves. LVN D prepared all her wound care suppled and remove gloves and performed hand hygiene. LVN D applied clean gloves and took off Resident #20's dressing from her right foot. Then she cleaned the area with normal saline, applied calcium alginate, and covered it with the new dressing. LVN D removed her gloves and performed hand hygiene. LVN D did not change her gloves or perform hand hygiene after removing the dirty dressing and prior to applying the new dressing. LVN D said gloves should be changed and hand hygiene performed after removing the dirty dressing. LVN D said she should have changed gloves and performed hand hygiene after cleaning the wound and before applying the new dressing. LVN D said hand hygiene should be performed before and after providing care and in between glove changes. LVN D said her last training on wound care was when she was in nursing school, and she did not usually work at the facility that she was from a sister facility. LVN D said she did not perform appropriate glove changes and hand hygiene while performing wound care because she forgot, and she was flustered. LVN D said it was important to perform appropriate glove changes and hand hygiene for infection control. During an interview on 05/17/2023 at 3:59 PM, the ADON said he was responsible for ensuring the CNAs provided proper incontinent care. The ADON said a few months ago he had done skills check offs on incontinent care and everybody had passed. The ADON said he was having to work the floor, so he had not had time to oversee and monitor the CNAs adequately. The ADON said when providing incontinent care, the CNAs should perform hand hygiene when they enter the room, prior to exiting the room, and in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 30 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 - Minimal harm or potential for actual harm Residents Affected - Some between glove changes. The ADON said gloves should be changed when soiled and when moving from dirty to clean. The ADON said the trash bag containing dirty items should not be placed on the over bed table. The ADON said it was important to perform hand hygiene and change gloves appropriately while providing incontinent care to prevent cross contamination and for infection control. The ADON said he was responsible for overseeing wound care, but prior to the last month there had been no wounds in the facility. The ADON said when providing wound care, the nurses should perform hand hygiene when entering the room and prior to starting and after removing gloves. The ADON said gloves should be changed when you are moving from a contaminated area to a clean area. The ADON said gloves should be changed and hand hygiene performed after removing a dirty dressing, after cleaning the wound, and before applying a new dressing. The ADON said it was important to perform proper hand hygiene and glove changes so the wound would not get contaminated. The ADON said not performing hand hygiene and glove changes during wound care would result in hindering the healing process and the wound not healing. During a phone interview on 05/17/2023 at 4:36 PM, the DON said she was responsible for making sure the CNAs provided proper incontinent care. The DON said the CNAs should perform hand hygiene before, during, and after performing care. The DON said gloves should be changed when moving from a dirty to a clean area. The DON said hand hygiene should be performed after glove removal. The DON said the trash bag with dirty items should not be placed on the overbed table. The DON said hand hygiene should be performed when the incontinent care was finished and prior to leaving the room. The DON said she had been doing audits due to an increase in urinary tract infections. The DON said the last audit she had done was a month ago on most of the day shift, including CNA B and CNA C, and she had not found any errors. The DON said it was important to perform hand hygiene and glove changes during incontinent care to prevent the spread of infection. The DON said the ADON monitors the wound care. The DON said she was the infection preventionist and there had not been many wounds in the facility, so no audits had been done. The DON said when providing wound care, gloves should be removed, and hand hygiene performed after removing the dirty dressing and before applying the clean dressing. The DON said hand hygiene should be performed after glove removal. The DON said it was important to perform hand hygiene and glove changes when providing wound care, so the residents did not get an infection and germs were not spread. During an interview on 05/17/2023 at 5:37 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said the CNAs and nurse managers were responsible for ensuring the residents received proper incontinent care. The Administrator said it was important to provide proper incontinent care and perform hand hygiene to prevent the spread of infection. The Administrator said the nurses were responsible for providing proper wound care. The Administrator said she expected the nurses to provided proper wound care, and it was important to prevent infections. The Administrator said the linen cart should be covered when passing the residents personal laundry, and she expected the laundry staff and the Housekeeping Supervisor to cover the linen cart when passing the laundry. The Administrator said the Housekeeping Supervisor was responsible for making sure the linen cart was covered. The Administrator said it was important for the linen cart to be covered when passing the residents personal laundry for infection control. Record review of the facility's policy titles, Linens, from the facility's Infection Control Policy & Procedure Manual 2018, indicated, . Transport bulk clean linen to residents' rooms in a clean, covered cart . Record review of the facility's policy titled, Perineal Care, with an effective date of 05/11/2022, indicated, . 10) Perform hand hygiene 11) [NAME] gloves and all other PPE per standard precautions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 31 of 32 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 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 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 - Minimal harm or potential for actual harm Residents Affected - Some . 20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach . 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Always perform hand hygiene before and after glove use . Record review of the facility's undated policy titled, Hand Hygiene, indicated, Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident), before and after assisting a resident with toileting (hand washing with soap and water) . Record review of the facility's undated policy titled, Wound Treatment Management, did not address hand hygiene and glove changed when providing wound care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 32 of 32