Health inspection·October 12, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few involves: o neglect o exploitation o a missing resident o misappropriation o drug theft o fire o emergency situations that pose a threat to resident health and safety o a death under unusual circumstances Immediately, but not later than 24 hours after the incident occurs or is suspected . Record review of the face sheet dated 10/12/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes, muscle weakness, and muscle spasms. Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by other and understood others. The MDS indicated Resident #1 had BIMS of 14 and was cognitively intact. The MDS indicated Resident #1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of the care plan revised 8/8/23 indicated Resident #1 was at risk for falls, used bed rails to assist themselves with activities of daily living, and had an activities of daily living self-care deficit. Record review of the nursing progress note dated 9/21/23 at 5:03 p.m. written by the DON indicated Resident #1 reported a knot on the side of her head, about an inch above her right ear and it is throbbing. The progress note indicated the area was slightly red and raised and circular in shape. Record review of the nursing progress note dated 9/21/23 at 8:00 p.m. written by RN A indicated she felt a bump on Resident #1's head. The progress note indicated the bump on Resident #1's head had no discoloration noted, was slightly soft, and Resident #1 said it was sore/tender. The progress note indicated Resident #1 said she did not remember or know how it happened. The progress note indicated Resident #1 was transferred to the emergency department. Record review of the hospital records date 9/22/23 indicated Resident #1 had a diagnoses of scalp hematoma. The hospital records indicated the cat scan results indicated Resident #1 had right parietal (lobe of the brain) soft tissue swelling. Record review in TULIP (website used for tracking facility reported incidents and complaints) dated 10/12/23 indicated the facility had not reported to the state agency Resident #1's scalp hematoma. During an interview on 10/10/23 at 2:08 p.m. Resident #1 said she had a hematoma to the back of her head when she went to the hospital but did not remember how the hematoma occurred. During an interview on 10/12/23 at 11:46 a.m. the NP said she was familiar with Resident #1. The NP said she examined Resident #1 on 9/21/23 but did not palpate her entire head. The NP said later that day she was informed about Resident #1 having a knot to her head. The NP said she asked if it appeared as a sebaceous cyst (a small, slow growing, noncancerous bump beneath the skin) as Resident #1 was prone to these types of cysts. The NP said facility staff denied Resident #1 falling or hitting her head. During an interview and record review on 10/12/23 at 12:58 p.m. the DON said she evaluated Resident #1 for the knot on her head on 9/21/23. The DON said the spot on her head was a circular red spot that was not raised. When reviewing her nursing progress note dated 9/18/23 at 5:03 p.m. she indicated the spot to Resident #1's head was raised. The DON said she meant raised like psoriasis not like a bump. The DON said the way the documentation was worded in the progress note it could not be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 2 of 8 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 10/12/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few determined what type of raised area was identified. The DON said she reviewed the emergency department paperwork for 9/22/23 but did not recall a diagnoses of scalp hematoma. The DON said hematomas were usually the result of trauma or being hit. The DON said she was not aware of Resident #1 having trauma of her head, falling, or being hit. The DON said if she had seen the diagnoses of scalp hematoma she would have investigated with her staff to try to determine what happened. The DON said a hematoma without known trauma would be considered an injury of unknown origin and was reportable to state agency if it had been identified on assessment. The DON said a hematoma could develop over times after a trauma. The DON reviewed with the surveyor the nurse note dated 9/18/23 at 8:00 p.m. where the RN A identified a bump to Resident #1's head. The DON said it was possible since there were no other documented assessments between 5:03 p.m. and 8:00 p.m. the hematoma could have developed. The DON said the Administrator was responsible for submitting reportable incidents to the state agency. During an interview attempt on 10/12/23 at 1:52 p.m. RN A did not answer the phone and the surveyor was unable to leave a message During an interview on 10/12/23 at 1:53 p.m. the Administrator said RN A was no longer employed at the facility. During an interview on 10/12/23 at 2:45 p.m. the Administrator said on 9/21/23 she overheard Resident #1 was complaining about her head. The Administrator said the DON assessed Resident #1 and reported the area to Resident #1's head was like a skin irritation more than a bump. The Administrator said she was not clinical so she did not know for sure. The Administrator said the NP did say Resident #1 had a history of sebaceous cysts. The Administrator said the evening of 9/21/23 when Resident #1's family had been at the facility they reported her having a bump to her head. The Administrator said she had seen the reports from the hospital regarding Resident #1 having a scalp hematoma. The Administrator said she could see where the hematoma could be reportable but she was not sure the hematoma came from the facility. The Administrator said by the time she found out about the hematoma she knew Resident #1 was not returning to her facility and since she was no longer going to be a resident of the facility she did not know if she needed to report the hematoma. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 3 of 8 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 7 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report Resident #1's Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel) that was discovered on 09/21/23 to the state agency. This failure could place residents at risk of injuries, abuse, and/or neglect due to staff not reporting incidents as required. Findings include: Record review of the face sheet dated 10/12/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes, muscle weakness, and muscle spasms. Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by other and understood others. The MDS indicated Resident #1 had BIMS of 14 and was cognitively intact. The MDS indicated Resident #1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of the care plan revised 8/8/23 indicated Resident #1 was at risk for falls, used bed rails to assist themselves with activities of daily living, and had an activities of daily living self-care deficit. Record review of the nursing progress note dated 9/21/23 at 5:03 p.m. written by the DON indicated Resident #1 reported a knot on the side of her head, about an inch above her right ear and it is throbbing. The progress note indicated the area was slightly red and raised and circular in shape. Record review of the nursing progress note dated 9/21/23 at 8:00 p.m. written by RN A indicated she felt a bump on Resident #1's head. The progress note indicated the bump on Resident #1's head had no discoloration noted, was slightly soft, and Resident #1 said it was sore/tender. The progress note indicated Resident #1 said she did not remember or know how it happened. The progress note indicated Resident #1 was transferred to the emergency department. Record review of the hospital records date 9/22/23 indicated Resident #1 had a diagnoses of scalp hematoma. The hospital records indicated the cat scan results indicated Resident #1 had right parietal (lobe of the brain) soft tissue swelling. Record review in TULIP (website used for tracking facility reported incidents and complaints) dated 10/12/23 indicated the facility had not reported to the state agency Resident #1's scalp hematoma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 4 of 8 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/10/23 at 2:08 p.m. Resident #1 said she had a hematoma to the back of her head when she went to the hospital but did not remember how the hematoma occurred. During an interview on 10/12/23 at 11:46 a.m. the NP said she was familiar with Resident #1. The NP said she examined Resident #1 on 9/21/23 but did not palpate her entire head. The NP said later that day she was informed about Resident #1 having knot to her head. The NP said she asked if it appeared as a sebaceous cyst (a small, slow growing, noncancerous bump beneath the skin) as Resident #1 was prone to these type of cysts. The NP said facility staff denied Resident #1 falling or hitting her head. During an interview and record review on 10/12/23 at 12:58 p.m. the DON said she evaluated Resident #1 for the knot on her head on 9/21/23. The DON said the spot on her head was a circular red spot that was not raised. When reviewing her nursing progress note dated 9/18/23 at 5:03 p.m. she indicated the spot to Resident #1's head was raised. The DON said she meant raised like psoriasis not like a bump. The DON said the way the documentation was worded in the progress note it could not be determined what type of raised area was identified. The DON said she reviewed the emergency department paperwork for 9/22/23 but did not recall a diagnoses of scalp hematoma. The DON said hematomas were usually the result of trauma or being hit. The DON said she was not aware of Resident #1 having trauma of her head, falling, or being hit. The DON said if she had seen the diagnoses of scalp hematoma she would have investigated with her staff to try to determine what happened. The DON said a hematoma without known trauma would be considered an injury of unknown origin and was reportable to state agency if it had been identified on assessment. The DON said a hematoma could develop over times after a trauma. The DON reviewed with the surveyor the nurse note dated 9/18/23 at 8:00 p.m. where the RN A identified a bump to Resident #1's head. The DON said it was possible since there were no other documented assessments between 5:03 p.m. and 8:00 p.m. the hematoma could have developed. The DON said the Administrator was responsible for submitting reportable incidents to the state agency. During an interview attempt on 10/12/23 at 1:52 p.m. RN A did not answer the phone and the surveyor was unable to leave a message During an interview on 10/12/23 at 1:53 p.m. the Administrator said RN A was no longer employed at the facility. During an interview on 10/12/23 at 2:45 p.m. the Administrator said on 9/21/23 she overheard Resident #1 was complaining about her head. The Administrator said the DON assessed Resident #1 and reported the area to Resident #1's head was like a skin irritation more than a bump. The Administrator said she was not clinical so she did not know for sure. The Administrator said the NP did say Resident #1 had a history of sebaceous cysts. The Administrator said the evening of 9/21/23 when Resident #1's family had been at the facility they reported her having a bump to her head. The Administrator said she had seen the reports from the hospital regarding Resident #1 having a scalp hematoma. The Administrator said she could see where the hematoma could be reportable but she was not sure the hematoma came from the facility. The Administrator said by the time she found out about the hematoma she knew Resident #1 was not returning to her facility and since she was no longer going to be a resident of the facility she did not know if she needed to report the hematoma. Record review of the facility's Abuse/Neglect policy revised 3/29/18 indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 5 of 8 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Opportunities to prevent abuse/neglect will be managed accordingly . Reporting .Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation .F. Investigation . Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated . Record review of Provider Letter 19-17 dated 7/10/19 indicated, .A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A missing resident, Misappropriation, Drug theft, Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety. The following table describes required reporting timeframes for each incident type: Type of Incident When to Report o abuse (with or without serious bodily injury8); or o neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury Immediately, but not later than two hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury and involves: o neglect o exploitation o a missing resident o misappropriation o drug theft o fire o emergency situations that pose a threat to resident health and safety o a death under unusual circumstances Immediately, but not later than 24 hours after the incident occurs or is suspected . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 6 of 8 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 10/12/2023 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 0610 Respond appropriately to all alleged violations. 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 have evidence that all alleged violations are thoroughly investigated for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. Residents Affected - Few The facility did not provide evidence of a thorough investigation for Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel.) which was first discovered on 9/21/23. This failure could place residents at risk of abuse and neglect due to the facility not performing a thorough investigation to rule out abuse and neglect. Findings include: Record review of the facility's Abuse/Neglect policy revised 3/29/18 indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly . Reporting .Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation .F. Investigation . Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated . Record review of the face sheet dated 10/12/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes, muscle weakness, and muscle spasms. Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by other and understood others. The MDS indicated Resident #1 had BIMS of 14 and was cognitively intact. The MDS indicated Resident #1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of the care plan revised 8/8/23 indicated Resident #1 was at risk for falls, used bed rails to assist themselves with activities of daily living, and had an activities of daily living self-care deficit. Record review of the nursing progress note dated 9/21/23 at 5:03 p.m. written by the DON indicated Resident #1 reported a knot on the side of her head, about an inch above her right ear and it is throbbing. The progress note indicated the area was slightly red and raised and circular in shape. Record review of the nursing progress note dated 9/21/23 at 8:00 p.m. written by RN A indicated she felt a bump on Resident #1's head. The progress note indicated the bump on Resident #1's head had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 7 of 8 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 10/12/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no discoloration noted, was slightly soft, and Resident #1 said it was sore/tender. The progress note indicated Resident #1 said she did not remember or know how it happened. The progress note indicated Resident #1 was transferred to the emergency department. Record review of the hospital records date 9/22/23 indicated Resident #1 had a diagnoses of scalp hematoma. The hospital records indicated the cat scan results indicated Resident #1 had right parietal (lobe of the brain) soft tissue swelling. During an interview on 10/10/23 at 2:08 p.m. Resident #1 said she had a hematoma to the back of her head when she went to the hospital but did not remember how the hematoma occurred. During an interview on 10/12/23 at 11:46 a.m. the NP said she was familiar with Resident #1. The NP said she examined Resident #1 on 9/21/23 but did not palpate her entire head. The NP said later that day she was informed about Resident #1 having a knot to her head. The NP said she asked if it appeared as a sebaceous cyst (a small, slow growing, noncancerous bump beneath the skin) as Resident #1 was prone to these types of cysts. The NP said facility staff denied Resident #1 falling or hitting her head. During an interview attempt on 10/12/23 at 1:52 p.m. RN A did not answer the phone and the surveyor was unable to leave a message. During an interview on 10/12/23 at 1:53 p.m. the Administrator said RN A was no longer employed at the facility. During an interview and record review on 10/12/23 at 12:58 p.m. the DON said she evaluated Resident #1 for the knot on her head on 9/21/23. The DON said the spot on her head was a circular red spot that was not raised. When reviewing her nursing progress note dated 9/18/23 at 5:03 p.m. she indicated the spot to Resident #1's head was raised. The DON said she meant raised like psoriasis not like a bump. The DON said the way the documentation was worded in the progress note it could not be determined what type of raised area was identified. The DON said she reviewed the emergency department paperwork for 9/22/23 but did not recall a diagnoses of scalp hematoma. The DON said hematomas were usually the result of trauma or being hit. The DON said she was not aware of Resident #1 having trauma of her head, falling, or being hit. The DON said if she had seen the diagnoses of scalp hematoma she would have investigated with her staff to try to determine what happened. During an interview on 10/12/23 at 2:45 p.m. the Administrator said on 9/21/23 she overheard Resident #1 was complaining about her head. The Administrator said the DON assessed Resident #1 and reported the area to Resident #1's head was like a skin irritation more than a bump. The Administrator said she was not clinical so she did not know for sure. The Administrator said the NP did say Resident #1 had a history of sebaceous cysts. The Administrator said the evening of 9/21/23 when Resident #1's family had been at the facility they reported her having a bump to her head. The Administrator said she had seen the reports from the hospital regarding Resident #1 having a scalp hematoma. The Administrator said she was not sure the hematoma came from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 8 of 8