Health inspection·August 15, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner for The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner for 1 of 1 facilities reviewed. This failure could place residents at risk of not filing a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance. Findings included:Interview on 08/12/2025 at 2:00PM with six residents during the confidential Resident Council revealed the residents were unaware where grievance forms were located. The residents stated that they did not know how to anonymously file a grievance.Observation of the common areas throughout the facility on 08/12/25 at 2:45PM revealed no grievance forms or a container to place the grievances. Interview on 08/13/25 at 6:20PM, the Activities Director said if anyone wanted to fill out a grievance they go to the Activities Director to get a form. Activities Director revealed she was not sure where else the residents would get a grievance form because she had the forms. The Activities Director revealed if a resident was able to get ahold of a grievance form and wanted to turn it in, they could turn it into the head nurse, same if the Activities Director was not on-site. Activities Director revealed if the resident could not fill out a grievance it would cause mental issues for the resident. Interview on 08/15/2025 at 10:45am with the DON revealed grievances are filled out in the EMR. The Activities Director distributed forms to residents and assisted to fill out the form, if needed. The Activities Directed gave the completed grievance forms to staff, unspecified, to enter in the electronic medical records. The DON revealed she did not know who specifically the Grievance Official was at the facility. DON revealed she was sure where and how to turn in grievances . Review of the facility's policy titled, Grievances dated 11/2/2016 revealed, Procedure1. The facility will notify residents on how to file a grievance orally, in writing, or anonymouslywith postings in prominent locations.2. The grievance official of this facility is the administrator or their designee. The grievance official will:? Oversee the grievance process? Receive and track grievances to their conclusionReview of the Resident's Rights subsection Grievances revealed, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the resident. Page 1 of 20 675105 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #7) of 6 Residents reviewed for abuse.The facility failed to protect Resident #7 from verbal abuse when Resident #16 made mocking statements and gestures regarding Resident #7's personal hygiene, the Administrator, LVN B, DON and Social Worker were aware of the verbal abuse. The verbal abuse led to Resident #7 being fearful, avoiding Resident #16 and Resident #7's withdrawal from former social patterns in refusing to go to the dining room and activities. An IJ was identified on 08/14/25. The IJ template was provided to the facility on [DATE] at 10:13AM. While the IJ was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of RemovalThis failure could result in residents becoming fearful, refusing to go to the dining room, or participate in activities.Findings included: Record review of Resident #7's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old male, who admitted [DATE] with diagnoses of paranoid schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS score of 10 indicating he had moderate cognitive impairment. Record review of Residents #7's care plan dated 4/23/2025 revealed he was on antipsychotic medications for diagnosis of paranoid schizophrenia. Interventions included administration of medication as ordered.Record review of Resident #16's face sheet, dated 08/01/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of depressive, dementia with other behavioral episodes.Record review of Resident# 16's MDS, dated [DATE], revealed he had a BIMS score of 6 indicating severe cognitive impairment.Record review of Resident #16's care plan, dated 08/19/24 and revised 08/12/25, revealed the resident had potential to demonstrate verbally abusive behavior, ineffective coping skills, and yelled loudly at staff, and called them names. Interventions included providing positive feedback for good behavior, assessing, and anticipating the resident's needs. During an interview on 08/12/25 at 12:30PM, Resident# 7 revealed he was scared of what Resident #16 would do to him based on past incidents when Resident #16 pinched his nose, yelled Resident #7 smelled, and followed him around.During an observation on 08/12/2025 at 12:30PM, it revealed the two resident room (Resident #7 and Resident #16) were in proximity/on the same hall/next door to one another. Resident #7 was well groomed, no body odor, or other smells noted. In an interview on 08/12/25 at 12:33PM Administrator revealed he was aware of a previous incident when Resident #7 reported to him Resident #16 said Resident#7 smelled. The administrator stated that he notified the social worker, and the social worker spoke to Resident #7 and Resident #16, and everything seemed to be okay. In an interview on 08/12/2025 at 4:45PM LVN B revealed that Resident #16 and Resident #7 did not like each other. LVN B stated that Resident #16 was the aggressor, he said mean things to people, especially the staff. Resident #7 kept to himself and avoided Resident #16. LVN B stated that he had been in serviced on abuse and neglect. He said the last in service was last pay day on 08/12/2025. He stated that the administrator and the DON were aware of the two Residents not getting along. In an interview on 08/12/25 at 2:58PM the DON revealed she was aware of an incident where that Regional nurse notified the DON that Resident #7 verbalized Resident#16 was holding his own nose yelling that Resident #7 smelled. The DON stated that she spoke with Resident #7 and Resident #16. The DON stated that Resident #16 denied the incident, and Resident #7 acted like nothing happened. No further interventions were implemented. Record review of Grievance, progress notes, social services notes for the 675105 Page 2 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dates of 04/01/25 through 08/15/25 reflected no documentation of the incident and interventions for Resident #7 or Resident #16.In an interview on 08/13/2025 at 11:20AM Social Worker revealed a few weeks ago, the Administrator notified her that Resident #7 reported that Resident #16 told Resident #7 that Resident #7 smelled. The Social Worker stated that she spoke with Resident #16 about him being mean to other residents and he denied it, but Resident #7 said that it did happen. Social Worker stated that she talked to both parties and Resident #7 said he was satisfied that she had talked to Resident #16. Social Worker stated that there was not follow up because it was just a passing conversation, and she did not realize that it was going to be a major issue. Social Worker stated Resident #7 was upset enough to bring it up. Social Worker stated that Resident #7 did not appear to have any psychosocial effects, but he must have been upset enough to report it to the administrator'. Social Worker stated that Resident #7's base line was that he got upset sometimes and he was on psych services. Social Worker stated that on 08/13/2025 the administrator notified her that the same issue came up at breakfast. Social Worker stated that the administrator told her that Resident #16 told Resident #7 that Resident #7 smelled. Social Worker stated that when she spoke to Resident #16, he told her he yelled that he spilled his coffee. Resident #7 said that it did happen, that Resident#16 yelled at him that he smelled. Social Worker stated that Resident #7 and Resident#16 were separated. Social Worker stated that after Resident #7 calmed down, Resident #7 was brought back to breakfast. Social Worker stated she documented the incident in EMR. Social Worker stated the facility moved Resident #16 to another hall Social Worker stated she had made a referral for Psych to evaluate both Resident #7 and Resident #16. Social Worker stated that Resident #16 had been discharged for counselling services, but she was going to restart counselling services. No psychosocial assessments done on him. Social Worker stated that Resident #16 was known to have verbal aggression.In an interview on 08/13/2025 at 3:23PM LVN A, revealed that before breakfast Resident #7 refused to go to the dining room when he saw Resident #16 was in the dining room. Resident #7 agreed to go to the dining room if LVN A was going to be in the dining room. LVN A stated at breakfast on 08/13/25, Resident#16 was holding his nose and yelling at Resident #7 stating that Resident #7 smelled. LVN A separated Resident #7 and Resident #16 and then reported to the administrator. She stated that Resident#16 had been moved to a different hall. LVN A stated Resident #16 always bothered Resident #7 and Resident #7 did not like going anywhere close to Resident #16. She stated that she mentioned to the administration before and that most of the staff were aware that the two residents did not get along. She stated that she had been in serviced on abuse and neglect and that was the reason that she reported the incident at breakfast as soon as it happened,In an interview on 08/13/2025 at 4:20 PM Physician revealed he was not aware of any previous Resident to Resident altercation between Resident #7 and Resident #16. He stated that he was notified by the DON on 08/13/2025 that Resident #16 was verbally aggressive to Resident #7 was reportable. The physician stated that if Resident #7 was upset when Resident#16 yelled that Resident#7 stinks then it was verbal abuse. The physician stated that the NP had a better understanding of the Residents. He stated he was notified that the facility had made plans to ensure that Resident#7 felt safe and had moved Resident#16 to a different hall. An interview was attempted 08/13/2025 at 4:30PM with NP Q but was unsuccessful, a voicemail was left with call back number.In an interview on 08/13/2025 at 3:45PM Activity Director, revealed that Resident #7 refused to attend activities when Resident #16 was in attendance because Resident #7 did not want to be in the same space with Resident #16. The activity Director stated that she thought Resident #7 and Resident #16 did not like each other. She stated that she had been in serviced on abuse and neglect on 08/13/2025.In an interview on 08/13/2025 at 6:51PM NP Q revealed that the DON and NP R had told them that the 675105 Page 3 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some surveyors had inquired about changing Residents # 7s psych medication. NP Q stated that she did not agree to changes to Resident #7s medication because of his diagnosis of schizophrenia. NP Q stated she was concerned that it was the first time she was notified about verbal aggression by Resident #16 to Resident #7. The NP stated that she had known Resident #7 for almost 10 yrs and when she was at the facility Resident #7 always talked to her about what his fears were but had not mentioned Resident #16's verbal aggression. The NP Q stated she had tried to keep Resident #7 on minimum medications to control his paranoia. The NP stated that she was concerned at the number of staff that were aware Resident #7 verbalized verbal aggression from Resident #16 with no interventions. The NP stated that Resident #16 was mean and it would not surprise her that Resident #16 would be verbally aggressive to Resident #7. She stated that verbal aggression could affect Resident #7 psychologically because Resident #7 got fixated on things and he would be fixated on the verbal aggression for a long time. She was concerned the residents' rooms were close to each other. She verbalized the facility should ensure there was no contact between Resident #7 and Resident #16. She stated the staff should be aware to redirect both Residents to avoid them coming into close contact with each other. She stated that she would visit with Resident #7 to assess and give him an opportunity to vent.Record review of the facility policy of undated Abuse/ Neglect revealed: The Resident has the right to be free from abuse, neglect, misappropriation of Resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the Resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other Residents, consultants or volunteers, staff of other agencies serving the Resident, family members or legal guardians, friends, or other individuals.An IT was identified on 08/14/25. The IT template was provided to Administrator on 08/14/25 at 10:13 AM and a plan of removal was requested. The plan of removal was accepted 08/14/25 at 5:36 PM. The plan of removal reflected the following: Resident #16 was placed on 1:1 supervision by facility staff. The Administrator is responsible for ensuring Resident #16 remains on 1:1 until Resident is not exhibiting verbal behaviors. Admin/DON will be responsible for ensuring Resident #16 remains on 1:1 supervision as evidenced by documentation on 1:1 form as well as progress notes in [EMR]. Resident #16 will remain on 1:1 supervision until no signs of verbal behaviors are exhibited and the Resident is cleared to step down 1:1 supervision by the attending physician. The facility staff will be designated by the Admin/DON. The physician will provide the 1:1 discharge order when deemed safe. Completed 8/14/25. Resident #7 and Resident #16 were referred to and evaluated by psychological services on 8/13/25. Psych evaluation was completed for Resident #16 and Resident #7 by Senior Psych NP, NP [NAME] on 8/13/25. Resident #7's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #7 will be weekly or as needed by the Senior Psych NP. Resident #16's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #16 will be weekly or as needed by Senior Psych NP. Completed by 8/14/25. The facility social worker interviewed Resident #7 and Resident #16 and completed a trauma informed care assessment, and no new trauma was identified. Social services will visit Resident #7 and Resident #16 for 1-2 times weekly to rule out emotional distress for 4 weeks and on-going as needed. A head-to-toe skin assessment was completed on Resident #7 on 8/13/25 by the Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. All Residents in the facility who can be interviewed were interviewed by the social worker for any further allegations of abuse on 8/13/25 and reviewed 8/14/25. No additional allegations were noted. The DON reviewed all safe surveys that were completed by the SW. Completed; reviewed on 8/14/25. All Residents in the facility who are not interview able, will 675105 Page 4 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some have a head-to-toe assessment completed for any signs of abuse by the DON/ADON/ Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. The Administrator and DON were in-serviced 1:1 on the following in-services by the Divisional Director of Clinical Services. Completed; reviewed on 8/14/25.oAbuse and Neglect Policy by the Divisional Director of Clinical Services on 8/13/25. The in-service included reporting immediately to the Abuse Coordinator (Admin) for all allegations of abuse and neglect. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse include yelling and chastising a Resident that causes emotional distress or fear.oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents. The interventions will be added to the care plan and available in the POC Kardex. A trauma informed assessment will be completed upon admission based on the past history of trauma that is disclosed on the social history assessment. A trauma informed assessment will also be completed PRN when a Resident is involved in a traumatic event. The assessment will be completed by the social worker or designee. This will begin 8/14/25 and will continue indefinitely. oResident Rights Residents have the right to be free from abuse and neglect, including verbal abuse from other Residents. All allegations of verbal abuse should be reported and investigated immediately by Abuse Coordinator (Administrator) with appropriate interventions in place. oDocumentation Policy: The charge nurse or SW will document in the progress note any Resident-to-Resident behaviors or allegations of abuse after it is reported to Abuse Coordinator/Administrator. Completed 8/14/24. The Medical Director was notified of the immediate Threat situation on 8/14/25 by the Administrator. An ADHOC QAPI meeting was completed with the QA committee to include the Medical Director on 8/14/25 to discuss immediate Threat and the plan of removal. The following in-services were initiated by the DON and Regional Compliance Nurse for all staff. All staff not present beginning 8/13/25 and reviewed on 8/14/25 will be in-serviced prior to the start of their next shift. All new hires will be in-serviced during orientation. All agency staff will in serviced prior to the start of their 8/14/25.oAbuse and Neglect Policy The in-service included reporting guidelines (2hrs) for all allegations of abuse and neglect including verbal abuse. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse includes yelling and chastising a Resident that causes emotional distress or fear. oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents.Monitoring of the facility's Plan of Removal included the following:Interviews with the following staff from 08/15/25 at 06:56 AM to 3:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on abuse and neglect, Residents Rights, and Trauma informed training: LVN A, LVN B, RN C, CNA D, CNA E, LVN F, LVN G , PTA CNA H, CNA I, RN J, LVN K, LVN L, CNA P, NP Q, , Laundry Aide, housekeeping N, housekeeping O, DON, Business office Manager, Dietary Manager, Maintenance Supervisor, Social Services Licensed, and, the Administrator.Record review of a QAPI Agenda, dated 08/14/25, reflected Administrator, MD, and DON were in attendance. Record reviews reflected that on 8/14/25, the Administrator and DON were in-serviced 1:1 by the Divisional Director of Clinical 675105 Page 5 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Services, on the following in-services: Abuse and Neglect Policy, Trauma Informed Care Policy, Resident Rights, Documentation Policy.Record review of in-service sign in sheets, dated 08/13/25, revised 08/14/2025 titled Abuse and Neglect reflected both the DON and Administrator had signed.Record review of Abuse and Neglect policy in-service dated 08/13/25 revised 08/14/2025, reflected 52 staff had been in-serviced. Record review of Trauma Informed policy in-service, dated 08/13/2025 revised on 08/14/25-08/15/2025, reflected 52 staff had been in-serviced.Record review of Residents Rights in-service, dated 08/13/25 revised 08/14/2025 reflected 52 staff had been in-serviced.In an interview on 8/13/2025 at 2:25PM the Administrator revealed that LVN A reported that Resident #16 was holding his nose and told Resident #7 that he smelled. The administrator stated that he was near the dining room, but he did not hear anything. The administrator stated that when he started to investigate Resident #16 stated that he yelled because he got coffee on his clothes. The administrator stated that Resident #7 was fine his only concern was that he was fearful that the state was going to kick him out of the facility. The administrator stated that resident #7 stated that he felt safe and comfortable at the facility, but he was not sure what Resident #16 might do. The administrator stated that he called the cooperate office because once Resident #7 stated that he was fearful the facility had to intervene and make sure he was safe. He stated that Resident #16 was moved to a different hall. He stated that he was reporting the allegation to the state and the facility was meeting the Resident #16's family to discuss finding him a different placement. The administrator stated that psychiatric practitioner had seen both resident and Resident #7 was at his baseline with no psychosocial problems identified.In an interview on 8/15/2025 at 1:34PM with the DON revealed that Resident #16 was in a different hall from Resident #7. She stated that in services on abuse and neglect, Residents rights, and Trauma in formed training were started on 08/13/2025 and revised on 8/14/2025. The in services will continue until all staff have been interviews and no staff will be allowed to start a shift before being in serviced. She stated that staff is aware to make sure that Resident#7 and Resident#16 do not come into close contact. She stated that the facility was trying to find placements for Resident #16 and the family had already been notified. In an interview on 8/15/2025 at 11:30AM Divisional Director of Clinical Services revealed that she was notified by the administrator on 08/12/2025 that Resident #7 had reported that Resident #16 had been verbally aggressive with him. She was again notified of the incident at breakfast on 8/13/2025 that was reported by the LVN A that Resident #16 was holding his nose telling Resident #7 that he smelled. She stated that the facility implemented interventions and moved Resident #16 to a different hall to ensure that Resident #16 and Resident #7 do not come in close contact. She stated that Resident #16 was placed on 1:1 monitoring. She stated that LVN F did a head-to-toe assessment on Resident #7. She stated that the social worker did psychiatric referral for both Resident #7 and Resident #16. Safe surveys were done on all residents and all residents verbalized that they felt safe at the facility. She stated that residents that were not interviewed had skin assessments completed. She stated that in serviced on abuse and neglect, residents right, Trauma informed were initiated and all staff must compete the in-service before returning to their next shift. She stated that she in-service the DON and the administrator on abuse and neglect, trauma informed, residents rights and documentation policies.Record Revies of nurse notes dated 08/13/2025 at 7:30 AM reflected Resident #7 was in DR this morning getting ready to eat breakfast when another Resident started yelling at him and holding his nose telling Resident he stinks. Resident states he is concerned about going in DR when the other Resident is in there. I (LVN A) explained to Resident #7 that as long as am in the DR he has nothing to worry about and then will go eat. Made Administrator aware of the situation this morning. The Adm went and SW the Resident along with SS . 675105 Page 6 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some This entry was written by LVN ARecord review of Social Service Note dated 08/13/2025 7:40 AM reflected Note Text: LMSW was alerted at beginning of work shift regarding concern of previous verbal altercation between two Residents. LMSW recalled initial incident but was unable to substantiate initial occurrence at the time, where Resident one told [Resident #7] that he had odor emitting from his person. At that time, LMSW had spoken with other Resident, who did not confirm incident and wrapped up conversation, advising Resident one to be cognizant of other's feelings, which other Resident acknowledged. This morning at approximately, 07:20 hours, LMSW was alerted that other Resident was being rude to [Resident #7] in dining room. LMSW approached said Resident, who advised loudly (as he his hard of hearing) that he yelled because he spilled his coffee. LMSW then spoke with [Resident #7] who advised the other Resident was yelling at him because he 'stunk' LMSW advised [Resident #7] that she would speak with other Resident again and discuss utilizing kindness with others at facility. [Resident #7] acknowledged solution. LMSW also contacted NP R from Senior Psych Services via telephone updating her on incident. NP R advised she is en route to facility and would speak to both parties. LMSW will continue to follow up with both Residents to ensure comfortable setting for both parties. this entry was written by social worker.An observation on 8/13/2025 at 4PM revealed Resident #16 was on 1:1 supervision with staff on the 600 hall.In an interview on 8/13/2025 at 2:30PM with Resident #7 he thanked the surveyor and stated that Resident #16 had not bothered him since the surveyors intervened.In an interview on 8/14/2025 at 10:38AM NP Q revealed that she was notified of the Immediate Threat, and she stated that the facility had put sufficient interventions to ensure Resident #7 and other Residents remain safe from abuse. She stated that she had been informed by the social worker that they were sending referrals to find Resident #16 placement in another facility. Record review of Resident #7's Weekly Skin Assessment notes dated 08/13/2025 at 3:48 PM reflected Note Text : Skin Color: Normal, Temperature of skin: Warm. Bruise present: No, Skin Tear Present: No, Abrasion present: No, Laceration present: No, Surgical incision present: No, Rash present: No, Moisture Associated Skin Damage present: No, Pressure, venous, arterial, or diabetic ulcer present: No., Other skin findings present: Yes. Other skin findings: Birthmark on L upper arm. This entry was written by LVN F Record review of Resident #7's of Trauma Informed Assessment notes dated 08/13/2025 3:48 PM Note Text: Has a previously documented diagnosis of Mental Disorder. Have a diagnosis of PTSD: No Experiences: Reports no known negative experiences. Has the Resident been in a situation that was extremely frightening: No Has the Resident witnessed any extremely frightening situations: No Does or has the Resident have a close relationship with someone who experienced any extremely frightening situations: No this entry was written by the social worker.Record review of Resident#16 Psychiatric notes dates 08/13/2025 revealed that (Resident#16 name) is being seen today at the request of the [nursing facility] [social worker] and [DON]. He is seen in his room sitting up on the side of the bed. He has significant hearing loss, and his speech is difficult to understand at time. Some questions are asked by the provider writing down, letting the patient read the questions and the allowing the patient to answer the questions. He says he is doing pretty good and denies any concerns at this time. He reports a good appetite and sleeping well. He denies any physical or verbal aggression towards anyone, and he says he gets along well with others. Staff report the patient told another Resident that he smelled bad. [Resident# 16] admits to holding his nose when another Resident walked by him but denies telling him he smelled bad. He says the other Resident has not showered in 30 days. Discussed actions that can be perceived by others as hurtful, such as holding one's nose when someone walks by, and other alternative actions that can be taken to remove oneself from displeasing odors. Patient v/u and states, I'll be nice and agrees to quietly remove himself from odorous areas. HE denies any 675105 Page 7 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some problems with depression, sadness, anxiety, or anger. He denies any AVH or SI/HI. this note was written by NP R.Record review of Resident #7's psychiatric notes dated 08/13/2025 revealed that [Residents#7] is being seen today at the request on [DON] and the facility [social worker]. The patient is seen ambulating in his room. He is pleasant and consents to the interview but presents with increase paranoia. The patient often exhibits increased paranoia with any changes in his normal routines and /or schedule. The reports that earlier, another Resident made fun of him and told him he smelled bad Staff report interventions have been put into place to provide space for both parties. discussed their interventions with [Resident#7] who voices appreciation having a good appetite and says he is sleeping well. He denies any AVH or SI/HI.Record review of Residents#7 psychiatric notes dated 08/13/2025 revealed- [Resident#7] is being seen today for a second time due to the request of [DON] of the facility . [DON] reports that the patients were seen by this provider and made statements of being fearful of another Resident. He is seen via audio and video conference with assistance of [DON]. Resident #7 is please and eager to engage. He consents to audio interviewing. He sates he is doing pretty good and says he is not fearful at this time. he states the staff at Country View make him feel safe and treat him well. He reports having times of being fearful of another Resident in the facility. He states the Resident in question has never physically or verbally threatened him. when asked why he is fearful of the Resident he states, because he I'm afraid he is going to come get me. Again, the patient is asked if the Resident in questions has ever verbally threatened him or been physically aggressive towards him. [Resident#7] responds No. Discussed the Resident in question moved to a different hall away from [Resident#7] and being wheelchair bound reminded patient that he [Resident#7] is ambulatory and can quickly get staff member if he feels threatened or fearful patient v/u and agrees to get a staff member when or if he feels fearful to threatened. Again, the Resident stated that the Resident in question has never been physically or verbally aggressive towards him. [Resident#7] has a long history of paranoia schizophrenia with mild paranoia being the patient's baseline. The patient is well managed under current treatment regimen and is able to function well with steady routine. Patient exhibits increased paranoia with any changed in routine such as state surveyors being in the building or changed in administration. In the past the patient returns to his normal baseline of paranoia, the patient responds well to active listening to his concerns addressing his concerns and therapeutic communication. An interview was attempted on 08/15/2025 at 11:24 AM to interview MD was unsuccessful his office was closed.An IT was identified on 08/14/25. The IT template was provided to the facility on [DATE] at 10:13 AM. While the IT was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. 675105 Page 8 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 3 of 3 areas (1 shower room, and 1 wooden cabinet inside of the shower room and exterior/interior front door), reviewed for accidents and hazards. 1. The facility failed to ensure that the exterior door to the Shower Room in the facility's Secured Unit was locked and secured.2. The facility failed to ensure that the Master lock on the wooden cabinet inside the Shower Room in the facility's Secured Unit was locked and secured.3. The facility failed to ensure that Resident #7 was supervised and did not have access to the Nurses Station and access the red button to open the front door. These failures could place residents at risk of accidents, injury, elopement, and consuming hazardous products. Findings Include:Record review of Resident #7's admission face sheet dated 08/13/25 reflected he was a [AGE] year-old male was originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: paranoid schizophrenia, hallucinations, psychotic disorder without hallucinations due to known physiological condition, brief psychotic disorder, major depressive disorder, single episode (unspecified), anxiety, unspecified intellectual disabilities, mild intellectual disabilities, and unspecified symptoms and signs involving cognitive functions and awareness . Record review of Resident #7's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 11 indicating that he had moderate cognitive impairment. Resident #7's MDS Assessment reflected that he had active diagnoses of anxiety, psychotic disorder, and schizophrenia. Resident #7 was prescribed narcotic medications for antipsychotic (type of drug used to treat symptoms of psychosis), antidepressant (prescription medicines to treat depression), and anticonvulsant (medication used to prevent or control seizures). Record review of Resident #7's Care Plan dated 03/26/2025 reflected, Focus:[Resident #7] has ID and is PASRR positive.Date Initiated: 04/08/2021Revision on: 07/17/2025Focus:[Resident #7] has episodes of delirium where he believes the FBI, space crafts, or other bizarre things are happening to him.Date Initiated: 04/15/2021Revision on: 04/01/2024Focus:[Resident #7] often believes that the state will take him away, that the facility management are wanting to get rid of him, or that workers here at the facility no longer like him. At times he is easily redirected with positive redirection but there's times that this belief is firmly held until resident has forgotten the subject.Date Initiated: 06/29/2022Revision on: 07/05/2022Focus:[Resident #7] has a dx of intellectual disability.Date Initiated: 09/09/2022Revision on: 09/09/2022Focus: [Resident #7] has impaired visual function d/t cataracts.Date Initiated: 03/02/2022Revision on: 09/09/2022Focus:[Resident #7] has mood problem r/t Disease Process schizophrenia.Date Initiated: 07/15/2025Revision on: 07/15/2025Focus:[Resident #7] has a dx of depression.Date Initiated: 09/09/2022Revision on: 04/23/2024Focus:[Resident #7] wanders aimlessly. Does not attempt or want to leave facility. [Resident #7] likes to sit in chairs in front of the facility outdoors, will walk to side of building where he keeps cans. [Resident #7] educated that if he does choose to leave the property to notify nurses.Date Initiated: 06/03/2021Revision on: 04/19/2023Focus:[Resident #7] is resistive to care r/t psych dx.Date Initiated: 06/04/2021Revision on: 07/26/2022 Focus:[Resident #7] is making verbal threats. Claims to take a roll of quarters and hit Someone.Date Initiated: 11/22/2022Revision on: 11/22/2022Focus:[Resident #7] needs out of room social, spiritual, and stimulus activities and mentalstimulation. [Resident #7] enjoys have small, odd jobs around the facility, such as helping clean, putting supplies away, ETC.Date Initiated: 04/22/2022Revision on: 04/27/2023Focus:[Resident #7] requires anti-psychotic medications for dx of paranoid schizophrenia.Date Initiated: 03/02/2021?Revision on: 04/23/2024Focus:[Resident #7] requires antidepressant medication.Date Initiated: 675105 Page 9 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11/03/2023Revision on: 11/03/2023Observation in the facility's Secured Unit on 08/12/25 at 10:50 AM, revealed the exterior door of the Shower Room was ajar and was unlocked and unsecured. The exterior door to the Shower Room had a touch pad lock. Upon entry into the Shower Room, there was a wooden cabinet with a Master Lock for a lock, but the lock was unsecured on the wooden cabinet. There was a key hanging from a chain beside the wooden cabinet that can be used to unlock the Master Lock on the wooden cabinet. Inside of the wooden cabinet were the following items: 1 open bottle of cleanser, one 128 fl. oz. container labeled, Spray Cleanser, 1 container of deodorant, 2 bottles of mouthwash, 1 unsealed package of twin-size razors, and 1 roll of toilet paper. On the top of the wooden cabinet, there was 1 gallon container labeled, Shampoo & Body Wash. On the floor there was 1 - 1 gallon container labeled, Shampoo & Body Wash. The storage rack contained several undergarments, towels, 2 bottles of mouthwash (1 bottle was open), 1 deodorant, 1 opened container of shaving cream, and 1 container of barrier cream.Observation on 08/12/25 at 11:15 AM revealed CNA M was playing bouncing ball with the residents in the Dining Hall. Observation in the facility's Secured Unit on 08/12/25 at 4:17 PM, revealed that the exterior door of the Shower Room was ajar, unlocked, and unsecured. The wooden cabinet inside of the Shower Room was unlocked and unsecured. On 08/12/25 at 11:36 AM attempts were made to interview the 6 residents in the Secured Unit but they were non-interviewable.Observation on 08/14/25 at 6:50 AM, 2 Surveyors arrived at the facility. There was no one observed at the Nurses Station and Resident #7 entered the Nurses Station and pressed the red button and the front door of the facility opened. Observation on 08/14/25 at 7:54 AM, 2 more Surveyors arrived at the facility. There was no one observed at the Nurses Station and Resident #7 entered the Nurses Station and pressed the red button and the front door of the facility opened. The Activities Director was observed in the Lobby of the facility doing activities with residents.Observation on 08/14/25 at 7:56 AM, revealed that there was no at the Nurses Station. There was a red button observed underneath a piece of paper. The red button was observed being used to open the front exterior doors at the facility. There was also a visitor standing outside of the facility with the surveyors and all parties entered the facility at the same time. In an interview with Resident #7 on 08/14/25 at 8:01 AM, revealed that he had been a resident at the facility for several years. Resident #7 said that he likes to help the staff at the facility by doing chores. Resident #7 said that his chores include picking up trash and emptying trash cans in the facility, which helps him stay busy. Resident #7 said that he had opened the front door for people several times and that staff told him that he was not supposed to enter the Nurses Station to press the button to open the door. Resident #7 said that he did not know why he opened the door for the surveyors earlier, he just wanted to make sure that the surveyors did not wait outside too long because the staff were busy. Resident #7 stated that he never opened the door to anyone dangerous.In an interview with the Social Worker on 08/14/25 at 8:15 AM, she stated that she had been employed at the facility for 1 year. The Social Worker stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and unsecured during the surveyors observation. The Social Worker stated that during her walkthroughs and visits in the Secured Unit, the exterior door to the Shower Room was closed. The Social Worker stated that there was a risk for any resident that can gain access to the items in the Shower Room to ingest the fluids, and/or cut or harm themselves or others with the razors. She stated that she was aware that Resident #7 had opened the front door for staff/guests/visitors on a about 2-3 occasions. She stated that in the past when she observed Resident #7 walk behind the Nurses Station to open the front door, she would redirect him and tell him that he was not supposed to be the desk in the Nurses Station and press the red button to open the front door. She 675105 Page 10 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that she would tell [Resident #7] that only staff were permitted to behind the desk of the Nurses Station and told him that if anyone was outside and needed to be let inside, he should let staff know and someone would open the door for the visitors/guests. The Social Worker stated that she did not inform the Administrator or the DON about Resident #7 entering the Nurses Station and pressing the red button to open the front door for anyone standing outside the front door awaiting to enter the facility. She stated that she did not know why she did not notify the Administrator and DON about Resident #7 opening the front doors at the facility. She stated that Resident #7 liked to assist and help staff and he thought that him opening the front door for anyone at the front door was helping the staff. The Social Worker stated that there was a possible risk for danger to anyone inside of the building, if Resident #7 opens the front door to anyone who was not supposed to be in the building. In an interview with the Activities Director on 08/14/25 at 8:39 AM, she stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and secured during the surveyors observation. The Activities Director stated that during her visits to the Secured Unit, the exterior door to the Shower Room was closed. She stated that she if she observed the exterior door to the Shower Room unlocked, open or unsecured she would close the door, notify the staff in the Secured Unit that the door was open and then she would notify the Administrator and DON. The Activities Director stated that if any residents have access to the Shower Room area, there are cleansers, shampoo and liquids in there that can be accidently ingested and could cause a resident to have stomach issues if that drank it. She stated that the razors in the Shower Room could be used by anyone to cut themselves, other residents or staff. The Activities Director stated that she was unaware that Resident #7 had opened the front door for 4 surveyors, and a visitor on 2 different times on 08/14/25. She stated that she was aware that Resident #7 had opened the front door for people in the past. She stated that she had told Resident #7 on a few occasions not to enter the Nurses Station and press the red button to open the front door for people awaiting to enter the building . She stated that in the past, she would redirect Resident #7 and educate him on not opening the door for people outside. The Activities Director stated that she did not inform other staff, including the DON and Administrator that Resident #7 had entered the Nurses Station and pressed the red button to open the front door for visitors. The Activities Director stated that she did not know why she did not inform her management team about Resident #7's behaviors. She stated that when Resident #7 opened the door for everyone awaiting to enter the building, there was a risk and a potential that he could let the wrong person or people in the building that could hurt or harm everyone in the building, which could cause people to be injured. In an interview with CNA S on 08/14/25 at 6:47 PM, revealed that she had been employed at the facility for 2 years. CNA S stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and secured during the surveyors observation. CNA S stated that she had never observed both areas in the Secured Unit unlocked. CNA S stated that if she observed both areas unlocked and unsecured , she would immediately lock both areas and notify the DON about what she saw in both areas. CNA S stated that if the exterior door to the Shower Room was unlocked and unsecured, a resident or visitor could enter the area and have access to the restricted area, which was supposed to be locked. CNA S stated that if anyone had access to the unlocked Shower Room and the wooden cabinet inside of the Shower Room, they could accidently ingest some poisonous liquids, burn themselves with the liquid, and cut themselves with the razors. CNA S stated that if anyone ingests the hazardous liquids, such as the cleanser, it will cause them to have some health issues like stomach aches, injuries and damage to their bodies. In an interview 675105 Page 11 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with LVN T on 08/14/25 at 7:05 PM, revealed that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and unsecured during the surveyors observation. LVN T stated that she had never observed both areas in the Secured Unit unlocked. LVN T stated that if she observed both areas unlocked and unsecured, she immediately would lock both areas and notify the DON and the Administrator about what she saw in both areas. LVN T stated that she would speak with staff that worked in the Secured Unit and inform them that everyone needed to keep both areas locked and unsecured at all times. LVN T stated that if the exterior door to the Shower Room was not secured and locked, anyone could have access to everything in the Shower Room. LVN T stated that the Shower Room area has cleansers, soaps, mouthwash and razors and there was a potential for anyone to hurt or harm themselves if they ingest the fluids and they can become sick. LVN T stated that which access to razors, someone could hurt or harm themselves or others. LVN T stated that she was unaware that Resident #7 entered the Nurses Station and opened the front door for the surveyors and the visitor. She stated that Resident #7 had been a resident at the facility for over 10 years. She stated that she did not think that he would open the front door to anyone he did not recognize to enter the facility. LVN T stated that Resident #7 gets bored and he collects soda cans and crushes them and keeps them in a bag to collect them. LVN T stated that Resident #7 is alert and had never observed him opening the front door for anyone to enter the facility. LVN T stated that there was security risk if Resident #7 opened the front door to the facility to allow anyone to enter the facility. LVN T stated that harm could be could if Resident #7 allows anyone into the facility. She stated that harm could be caused, but it was difficult to answer the question because Resident #7 is high functioning. LVN T stated that Resident #7 did not know the code at the front door to exit the facility. In an interview with the DON on 08/15/25 at 3:11 PM, she stated that she had been employed at the facility for 1 year. The DON stated that there are currently 6 residents in the Secured Unit. She stated that the facility recently opened the Secured Unit in July 2025. She stated that due to there being only 6 residents currently in the Secured Unit, there was only 1 CNA on duty every shift . The DON was advised of the surveyors observations in the Secured Unit. She stated that she was unaware that the exterior door to the Shower Room in the Secured Unit was unlocked and unsecured during the surveyors observation. She stated that her expectation for staff were to keep the exterior door to the Shower Room always closed due to there being shampoos, conditioners, cleansers, mouthwash, cleaning supplies and razors inside the Shower Room. The DON stated that she was unaware that the door to the wooden cabinet inside the Shower Room was also unlocked and unsecured during the surveyors observation. She stated that her expectation was the same as the exterior door to the Shower Room, both areas are to always be locked at always secured. She stated that both areas contained the same items and if a resident in the Secured Unit accidently wandered into the Shower Room, there was a risk for them to accidently ingest hazardous chemicals and could get sick. The DON stated that if a resident ingested any hazardous chemicals, they could become nauseated, have horrible vomiting episodes which could lead to potential harm. The DON stated that if a resident were to find some razors in the Shower Room and the wooden cabinet inside of the Shower Room, there was a potential for them to cut themselves, other residents, visitors, staff or anyone in the facility's Secured Unit which could be harmful. The DON stated that a resident in the Secured Unit were to touch some of the hazardous chemicals in the Shower Room, there was a potential for them to have a chemical burn or be allergic to the hazardous chemicals inside of the containers. The DON revealed that razors were to be kept in a secured area, which means they are to be always locked and never to be kept in an unlocked compartment. The DON stated that all staff are responsible for ensuring 675105 Page 12 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that doors and areas that are supposed to be locked at secured always. The DON stated that if staff observe a door that is unlocked and unsecured, her expectation is for her staff to immediately lock and secure the door and notify herself and the Administrator of their findings. The DON stated that she would immediately reeducate all staff on the dangers of leaving the exterior door and the wooden cabinet inside of the Secured Unit's Shower Room and all Shower Rooms locked and always secured. The DON stated that she was unaware that Resident #7 was observed by state surveyors on 2 separate times on 08/15/25 walking behind the Nurses Station and pressing the red button to open the front exterior doors of the facility to allow visitors/guests into the facility. The DON stated that Resident #7 likes to assist staff with tasks within the facility, but she did not know that he was opening the front doors of the facility for visitors/guests to enter the facility. The DON was advised that according to the Activities Director and the Social Worker, both have observed Resident #7 enter the Nurses Station and open the door for guests/visitors on several occasions but would redirect him not to open the doors front door for guests/visitors. The DON stated that both staff members have never notified her or the Administrator that Resident #7 had entered the Nurses Station to open the door for guests/visitors on several occasions. The DON stated that she would speak all staff in all departments and provide them with some In-Service Trainings on ensuring the safety of the residents and not allowing Resident #7 to have access to the Nurses Station and the red button to open the front door for guests/visitors. The DON stated that when Resident #7 opened the door to visitors/guests, there was a risk for someone to enter the facility that should not be in the facility to hurt and harm everyone in the facility. On 08/15/25 at 3:26 PM, an email was sent to the Administrator and DON requesting the facility's policies related to securing doors, locks, razor blade storage, cleaning supplies storage and accidents and hazards. In an interview with the DON on 08/15/2024 at 3:28 PM, the DON stated that the facility did not have any of the requested policies related to securing doors, locks, razor blade storage, cleaning supplies storage and accidents and hazards. In an interview with the Administrator on 08/15/2024 at 4:20 PM, he stated that he had been employed at the facility for 1 year. The Administrator was advised of the surveyors observations in the Secured Unit. He stated that he was unaware that the exterior door to the Shower Room in the Secured Unit was unlocked and secured during the surveyors observation. The Administrator stated that the exterior door to the Shower Room in the Secured Unit should always be locked and secured due to the items inside of the Shower Room, such as shampoos and cleansers. He stated that he was unaware that the wooden cabinet inside the Shower Room was also unlocked and secured and should be locked and secured always. The Administrator stated that he was unsure what items were inside of the wooden cabinet inside of the Shower Room. He stated that after the DON notified him about the exterior door to the Shower Room, he notified Maintenance and they would be repairing the door and the lock on the wooden cabinet inside of the shower room would be replaced. He stated that staff advised him that the door to the Shower Room is hard to close and he would be repairing both areas. The Administrator stated that there was a risk to anyone who has access to the items in the Shower Room area to ingest the chemicals. He stated that anyone who ingests chemicals and/or had access to razors, there was a potential that they can hurt or harm themselves. The Administrator stated that he was unaware that Resident #7 was observed by state surveyors on 2 separate times on 08/15/25 walking behind the Nurses Station and pressing the red button to open the front exterior doors of the facility to allow visitors/guests into the facility. The Administrator was advised that according to the Activities Director and the Social Worker, both have observed Resident #7 enter the Nurses Station and open the door for guests/visitors on several occasions but would redirect him not to open the doors front door for guests/visitors. The 675105 Page 13 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administrator stated that both staff members had have never notified the DON or himself that Resident #7 had entered the Nurses Station to open the door for guests/visitors on several occasions. The DON stated that she would speak with staff and provide all staff with In-Service Trainings on safety, locks, securing door and not allowing Resident #7 to have access to the Nurses Station and the red button to open the front door for guests/visitors. The Administrator stated that the red button at the Nurses Station is no longer operable. He stated that all staff had been In-Serviced and were given directives to use the on the interior front door when allowing any and everyone into the building. The Administrator stated that when Resident #7 opened the door to visitors/guests, there was a risk for someone to enter the facility that he did not know. The Administrator stated that Resident #7 was good with face recognition and did not think that he would open the door to anyone he did not recognize. On 08/15/25 at 4:41 PM, an attempted telephone call to CNA M was unsuccessful .Record review of the maintenance logbook at the nurses' station, reflected no documentation of the repairs to the door or the broken lock on the wooden cabinet inside the Shower Room in the facility's Secured Unit.The facility did not provide any requested policies related to securing doors, razor blade storage, locks, cleaning supplies storage and accidents and hazards prior to the Survey Team exiting the facility on 08/15/25. 675105 Page 14 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one (Resident #2) of four residents reviewed for medication administration.The facility failed to ensure LVN A administered each medication separately via Resident #2's g-tube per physician's orderThis failure could place residents at risk for potential significant medication interactions such as medication-medication or medication-food interactions.Findings included:Record review of Resident #2's Quarterly MDS Assessment, dated 07/19/25, reflected the Resident was a [AGE] year-old male, had a BIMs score of 8 indicating he was moderately cognitively impaired. The Resident had diagnoses which included dysphagia (difficulty swallowing foods and liquids), Cerebrovascular accident (a disruption of blood flow to the brain, leading to brain cell damage).Record review of Resident #2's Comprehensive Care Plan, revised 07/16/25, reflected [Resident# 2] requires tube feeding swallowing difficulty r/t CVA. Facility interventions included: The Resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Monitor/document/report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration.Record review of Resident #2's physician orders reflected: Enteral Feed Order every shift check G/T placement prior to administration of meds and hanging enteral feedings Verbal Active 04/11/2025 04/12/2025. Enteral Feed Order every shift Check gastric residual volume. Hold feeding for 1 hour____ and notify physician for residual greater than ____60ml_. Verbal Active 04/11/2025 04/12/2025 Enteral Feed Order every shift Flush enteral tube with 30ml water pre/post medication administration and 10 ml water between each medication Verbal Active 04/15/2025 04/15/2025.An observation on 08/13/25 at 8:46 AM revealed Resident #2 had enteral feeding Isosource 1.5 Cal infusing via G tube at 75ml/hr. LVN L performed hand hygiene and donned clean gloves. LVN L verified and pulled Resident #2's medications per MAR. The medications included: Eliquis 5mg 1 tablet, Folic Acid 1mg 1 tablet, Multivitamin with minerals 1 tablet, Chewable aspirin 81mg 1 tablet, Baclofen 10MG 1 tablet, Thiamin 100mg 1 tablet. LVN L put all the tablets in one pill pouch and crushed all the medications together, then she put the crushed medication in an 8-ounce cup and filled the cup with water. LVN L removed gloves, sanitized her hands, donned clean gloves, and went into the Resident's room. LVN L stopped the G Tube feeding. LVN L checked for G Tube placement, and then she checked for residual with none noted. LVN L did not flush the G Tube before administering the medication. LVN L administered the medication using a syringe then after administering the medication LVN L flushed the G Tube with 60 cc of water. In interview on 08/13/25 at 8:56 AM revealed LVN L knew that G tube medication was not supposed to be crushed and given together, but she stated that she crushed them together because the medications were mostly vitamins and that she had spoken to NP Q and NP Q was okay with her crushing the medication. LVN L stated that she was aware that she was supposed to flush the G Tube before administering medication, but she did not because there was no residual. She stated that flushing the G Tube before administering medication was important to get food out of the way and to prevent medication food interaction. She stated that cocktailing medication can result in medication interaction that can harm the resident or be ineffective. She stated she had been in-serviced on medication administration to include G tube administration a few weeks ago.An interview on 08/13/25 at 1:41 PM, the DON revealed all G- tube medications were not to be cocktailed unless there was a physician's order. The DON stated that before administering 675105 Page 15 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, nurses should check and follow the physician orders. The DON stated the policy was to check for placement, check for residual, flush before medication administration, and flush after medication administration. The DON stated staff had been in-serviced on G tube medication and management. The inservice was done 8/13/2025. The DON stated the risk to the resident was interaction of medication that might not be safe to administer at the same time. The Resident could experience side effects such and nausea, vomiting, and diarrhea. In an interview on 08/14/2025 at 10:28AM, NP Q revealed that G tube medication should not be cocktailed unless there was a physician order. She stated she had not given an order to cocktail Resident #2's medication. She stated the policy was to check for placement, check for residual the flush before administering medication. NP Q stated the nurse should flush with water between medications then flush after completing medication administration. NP Q stated that cocktailing medications together could lead to medication-to-medication interaction. The risk to the patient was side effects of medication interactions that can make the resident sick.Review of the facility's policy Medication Administration Procedures reflected the following: Defining the schedules for administering medications to: Maximize the effectiveness (optimal therapeutic effect) of the medication Prevent potential significant medication interactions such as medication-medication or medication-food interactions. 675105 Page 16 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one medication cart (600 hall) of the facility's two medication carts reviewed for medication storage. The facility failed to ensure that opened insulin pens,1) Lantus 100 unit/ml and 2) Insulin pro 100units/ml were properly labeled and dated before storing in the 600-hall medication cart. This failure could place resident at risk by diminishing the effectiveness, and therapeutic benefits of the medications and/or result in medication error by giving the wrong resident the wrong insulin.The findings included:Observation on [DATE] at 11:03 AM with LVN B on the 600-hallway's medication cart revealed opened insulin pens: 1. Lantus 100 unit/ml and 2. Insulin pro 100 units/ml that had no patients' labels, and no dates indicating when the insulins were open.In an interview on [DATE] at 11:05 AM with LVN B he stated the nurses were responsible for checking all insulin pens and vials had patient labels and open dates. LVN B stated he did not realize the opened insulin pens Lantus 100 unit/ml and insulin pro 100 units/ml did not have labels and open dates. He stated that it was important to date opened insulins because opened insulins expire after 28 days. LVN B stated that the risk to the resident was receiving expired insulin that could cause negative drug effects that could harm the resident. He stated that having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in hospitalization. He stated that he knew that he was supposed to check and ensure all medications were within date before administering to the residents. LVN B stated that he had been in-serviced on medication storage and dating all opened insulins by online training and the administration. He stated that he would remove the unlabeled and undated insulin from the cart immediately.An interview on [DATE] at 1:47 PM with the DON, revealed that all insulin pens and vials should be labeled, and they should have an open date. She stated that it was the responsibility of every nurse to check the label and open date before administering insulin to a resident. The DON stated insulin was supposed to be dated because it expired 28 days after opening. She stated that failure to have open dates on insulin could result in administrating medication that was expired and could not be effective or that could have negative side effects to the resident. He stated the ADON audited the medication carts as needed, but there was not a set schedule. She stated that the pharmacist audited the medication carts monthly.Review of the facility policy PCU027 - Medication Storage in the Facility Policy reflected that: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication. 675105 Page 17 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure that 1 of 1 dented can was removed from the rack in the dry pantry areaThe facility failed to ensure that Dietary X properly used hair restraints during food preparation. This failure could place residents at risk for food exposed to adulteration or potential contaminants.Findings Included:Observation and interview on 08/12/25 at 9:15 AM, the Dietary Manager stated she had been employed at the facility for four years. The initial tour of the kitchen revealed that in the dry storage area 1 of 1 dented can on the rack with the other canned items, instead of in the area labeled as Dented Cans Only, do not use. Dietary Manager indicated the dented cans were used first. The Dietary Manager repeated a second time what was said about the use of the dented cans. During interview with the Dietary Manager on 08/15/2025 at 2:51pm in the dining room she stated she moved the dented can to a separate location away from the other cans for to be returned to the distributor. Dietary X had been observed on 8/15/25 at 2:57pm not properly using the hair restraint to cover all hair during food preparation. Dietary Manager stated on 8/15/25 at 2:57pm if someone ingested food that had been contaminated, there was a risk they could get an airborne illness and potentially cause harm and sickness. Interview with the Dietary [NAME] on 08/15/2025 at 3:00pm revealed dented food cans had a specific place in the corner and cannot be used but would be returned to the distributer. The Dietary [NAME] revealed dented food cans were not used due to cracks, leaking food, air or insects entering the can, possibly causing harm due to ingesting metal from the can, increase medical issues, possible internal micro cuts, and food poisoning. The Dietary [NAME] stated without the proper use of hair restraints, risks of biological contaminants (the presence of harmful biological agents, such as bacteria, viruses, fungi, parasites, or animal dander, in food, water, air, or on surfaces, which can cause disease, allergic reactions, or pose a risk to health and safety) with the harm of making a resident sick, especially if they already had a compromised immune system along with the overall decline of the quality of the food. Record review of the facilities policy titled Food Storage and Supplies, dated 2012 does not revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.Review on 8/15/25 at 3:55pm of the U.S. Public Health Service Food Code dated 2017 reflected: .3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under S 6-404.11; . 675105 Page 18 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and 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 1 (Resident #2) of 6 residents reviewed for infection control. 1.LVN L failed to don (to put on) PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution.This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included:Record review of Resident #2's Quarterly MDS Assessment, dated 07/19/25, reflected the resident was a [AGE] year-old male, had a BIMs score of 8 indicating he was moderately cognitively impaired. The resident had diagnoses which included dysphagia (difficulty swallowing foods and liquids), Cerebrovascular accident (a disruption of blood flow to the brain, leading to brain cell damage).Record review of Resident #2's Comprehensive Care Plan, dated 07/16/25, reflected (Residents name) requires tube feeding swallowing difficulty r/t CVA. Facility interventions included: Monitor/document/report to MD PRN: aspiration - fever, SOB, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.Record review of Resident #2's Comprehensive Care Plan, dated 04/25/25, reflected (Residents name) was on enhanced barrier precautions. Facility interventions included: Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.An observation on 08/13/25 at 8:46 AM, revealed Resident #2's room had an Enhance Barrier Precaution signage outside his room and cart set up with PPE. LVN L performed hand hygiene with sanitizer and entered Resident #2s' room, stopped the G tube feeding, administered medication via feeding tube and restarted the tube feeding Isosource 1.5 Cal . LVN L did not don PPE. An interview on 08/13/25 at 8:56 AM, revealed LVN L knew that Resident #2 was on enhanced barrier precaution, and she should have donned PPE before accessing the resident's (Resident#2) feeding tube. She stated that failure to use PPE could put the resident at risk for infection. She stated that she had been in-serviced on enhanced barrier precautions a few weeks ago.An interview on 08/13/25 at 1:41 PM with the DON revealed that her expectation was the staff should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated that risk to the patient was MDRO infection. She stated that the staff had been in-serviced on infection control and enhance barrier precautions. The facility policy titled Enhanced Barrier Precautions reflected: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and Residents Affected - Few 675105 Page 19 of 20 675105 08/15/2025 Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160

F 0880 tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675105 Page 20 of 20