Health inspection·July 26, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Uropathy (conditions that affect the urinary tract due to blockage or backward flow of urine), and Neuromuscular Dysfunction of Bladder (conditions where the nerves or muscles don't work properly causing discomfort). She had a BIMS (assessment of cognitive status on a scale from 00 - 15) of 10 (indicating moderate impairment). Record Review of Resident #3's Care Plan revealed she was a moderate risk for falls related to confusion and deconditioning with interventions including ensuring the call light was within reach for assistance as needed. The record also reflected that she had an ADL Self Care Performance Deficit related to Dementia with interventions to encourage to use her call bell for assistance. Observation of Resident #3 on 07/26/23 at 9:20 AM revealed she was in a hospital bed. Items observed in her bed and in reach were a bowl of cereal and a cup of juice. Further observation revealed a call device was not in Resident #3's bed. The call device socket was observed in the wall of her room, behind her bed; the bed was approximately 1.5 feet from the wall. During an interview on 07/26/23 at 9:20 AM Resident #3 stated she had just returned from the hospital and was given a call button to press if she needed help. Resident #3 looked around her bed but was not able to locate the call button within reach . Interview with NA C on 07/26/23 at 1:02 PM revealed residents could use their call device if they need assistance or have an emergency when in their rooms. NA C stated call devices should be in reach , but did not state who was responsible for ensuring they were in reach. Observation of Resident #1's room on 07/26/23 at 1:02 PM with NA C revealed the call device sitting on top of her bed, positioned near the head of her bed; the dresser was now positioned away from the wall. Observation of Resident #3's room on 07/26/23 at 1:03 PM with NA C revealed the call device was not present in her bed. NA C was observed picking up the call light off the ground, which was behind Resident #2's bed, and hanging on the floor. NA C was observed placing the call device on the right side of Resident #3, attaching it to her bed. She confirmed with Resident #3 that she could reach her call device if placed in that spot. Interview with the LVN B on 07/26/23 at 1:12 PM revealed residents could use their call device for when they need help. She stated the device should be placed within arm's reach. She stated some residents use their call devices and some don't and those that don't will yell out if they need assistance. She stated for residents who are not as verbal as others, staff increase their checks on those residents . She stated in the past, Resident #1 has not used the call device, but recalled that Resident #3 has used the call device. Interview with the DON on 07/26/23 at 3:14 PM revealed residents were provided a call device to use when they have toileting needs, needing water or food or are in discomfort. She stated all residents should have a call device despite their level of mobility and care. She stated call devices should be within reach. She stated it is important that call devices are in reach for staff to be able to meet the needs of the resident. She stated from a medical standpoint, the risks of not having a call device in reach is that a resident may not get their food or water, get their comfort needs met, or be responded to timely during emergent situations like falls . She did not state who was responsible for ensuring call devices are within reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 2 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0558 During an interview with the ADM on 07/26/23 at 3:30 PM a policy and/or procedure was requested. The ADM stated the facility did not have any policies regarding call devices specifically. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 3 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 out of 1 resident (Residents #05) reviewed for respiratory care. The facility failed to change and/or label Resident # 05's oxygen equipment per the facility policy and procedure. This failure has the potential to affect residents by placing them at risk for infections and complications associated with respiratory equipment failure due to exposure to equipment that has been used for an amount of time beyond appropriate or intended use limits. Findings included: Record review of Resident #05's History and Physical revealed a [AGE] year-old male. His diagnoses included paranoid schizophrenia, extrapyramidal ( relating to movement of nerve cells in the spine) and movement disorder depressive disorder, gastroesophageal reflux disease, hepatomegaly ( enlarged liver), shortness of breath, dyspnea ( shortness of breath), hyperlipidemia (high fat in blood), peripheral vascular disease ( slow and progressive circulation disorder) , arteriosclerosis of coronary artery bypass ( heart surgery), acute on chronic obstructive pulmonary disease, general anxiety disorder, bi-polar disorder, essential hypertension( high blood pressure, insomnia( inability to sleep). Record review of Resident # 05's quarterly MDS , dated 07/06/2023 revealed a BIMS score of 14 out of 15 indicating no cognitive impairment. Record review of the care plan, dated 07/14/2023 revealed Resident 28 with a diagnosis of COPD requiring 02 therapy and also to be monitored for signs and symptoms of infection. Record review of Resident #05's physician's orders revealed the following orders: -May use oxygen @1-2 l/m via nasal canula as needed for shortness of breath. - Change oxygen tubing every Wednesday on night shift Observation on 07/24/23 at 12:04 PM, revealed Resident #05 was in the room walking around. The resident's oxygen concentrator was in the room and next to Resident #05's bed. The humidifier bottle on the concentrator was labeled with a last change date of 07/15/23. The oxygen tubing had no date on written. Interview on 07/24/23 at 12:04 PM, Resident #05 stated he has asthma so he uses oxygen on occasion. Resident stated staff usually changes tubing weekly. Observation on 07/26/23 at 12:04 PM, the humidifier bottle on the concentrator was still labeled with last change date of 07/15/23. The oxygen tube was undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 4 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/24/23 at 12:04 PM, LVN B stated Resident #05 is supposed to have his O2 equipment changed weekly every Wednesday . LVN B stated Resident #05 only uses the machine for panic attacks and should only be PRN. LVN B stated that by not changing the equipment last Wednesday, the facility policy has been violated. Interview on 07/24/23 at 12:04 PM, the DON stated that nursing staff should provide direct monitoring of the resident's oxygen therapy by doing rounds. The DON stated the charge nurse is responsible for changing the oxygen equipment per physician's order. The DON stated the facility's policy was to change 02 equipment weekly and/or as needed per physician's order. The DON stated it is deficient practice to not change resident # 05s oxygen equipment since 07/15/2023 . When asked if oxygen tubing should have been labeled she responded yes. The DON stated if oxygen equipment and tubing is not changed weekly per the doctor's order and labeled properly that it can cause resident have increased risk of acquiring an infection. Record review of facility policy for maintain oxygen equipment, not titled, or dated, revealed : Procedure: Change oxygen tubing, cannula/mask with date and initials weekly. Change humidifier bottle with date and time weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 5 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #02) of two residents reviewed for unnecessary medications. The facility failed to attempt a gradual dose reduction (GDR) for Resident #02's Clonazepam . These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included Record review of Resident #02's quarterly MDS assessment, dated 05/19/23, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 10. She had no signs and symptoms of delirium, no hallucinations or delusion, no physical behavioral symptoms and had not rejected care. She had diagnoses which included stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, other neurological conditions, amputation, hip and knee replacement, fractures and other multiple trauma, other orthopedic conditions, debility, cardiorespiratory conditions, and medically complex conditions. Record review of Resident #02's care plan, revised on 06/29/23, reflected: .Resident is on antianxiety medication (clonazepam) .Interventions .staff will monitor all the side effect signs, if any notify the resident's physician. Will have improved mood state happier, calmer appearance, no signs and symptoms of depression, anxiety or sadness) through the review date Record review of Resident #02's active physician's orders, dated 07/26/23, reflected, .clonazepam (anxiety) tablet 0.5 mg give 1 tablet by mouth twice daily . The start date was 06/04/21. Record review of Resident #02's Medication Administration Records, dated July 2023, reflected the resident received Clonazepam 0.5 mg bid daily. Record review of Resident #02's Nurses Notes, from 05/16/23 through 07/25/23, revealed the notes did not indicate any behaviors for Resident #02 including anxiety. Record review of Resident #02's last documented Psychiatrist report dated 06/07/23 reflected: Resident was seen today for follow-up for anxiety, delusions, depression/sadness, long-term memory problems, short-term memory problems and restlessness, Paranoid schizophrenia, schizoaffective disorder bipolar type. Assessment/Plan for anxiety revealed: *Clonazepam continued at current dose for anxiety-GDR future trial . Record review of the clinical physician's orders revealed from last attempt to lower dose of clonazepam 0.5 mg at bedtime was 05/18/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 6 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #02's Pharmacy Consultation report dated 09/13/22 reflected: .[Resident #02] receives clonazepam 0.5 mg at twice a day for anxiety Please attempt a gradual does reduction (GDR), annually/biannually in an effort to discontinue these drugs .Please provide short rationale describing why a GDR attempt is likely to support keeping dose at the current level . The physician responsed for the rationale for the decline in the GDR was last reduction was unsuccessful and was signed and dated by the MD on 10/05/22. Observation and interview on 07/26/23 at 01:04 PM revealed Resident # 02 getting out of bed, appearred tired. Resident #02 stated she had been feeling tired and confused for the past couple of years. Resident #02 stated she thinks it was because of her medication. Resident #02 said the doctor made changes to her medication but she still feels drowsy and would like a look into her medication regimen. Resident stated she spoken to the Psych Nurse regarding her medications and that the changes she made to the meds was not working. Interview with the LVN A on 07/26/23 at 01:12 PM revealed Resident #02 should not be on clonazepam for that long without lowering. She stated she doesn't know why Resident #02 medications haven't been lowered but that the psych nurse is responsible for looking into attempting a GDR. Interview with Pharmacist A on 07/26/23 at 01:12 PM revealed Resident #02 should have had an attempted reduction of clonazepam. Pharmacist A stated he requested a lowered dose to the doctor in September 2022 and another time this month . Pharmacist A stated that it is the responsibility of the psych nurse to decide if the resident needs to stay on the medication or not. Pharmacist A stated that by not attempting to GDR clonazepam Resident #02 can experience long term confusion and instability of gait (uncoordinated walking). Interview with Psych Nurse A on 01/19/23 at 10:11 AM she stated Resident #02 had not had a GDR this year due to failed attempts in the past. Psych Nurse A stated the previous clinician before her had documented issues with discontinuing clonazepam before, so she keeps Resident #02 on clonazepam to keep her stable. Psych Nurse A stated, I changed the Zyprexa and trazodone, the medications were adjusted by me since I noticed [Resident #02] sleeping a lot recently. Psych Nurse A also stated that Whenever there's an adjustment that needs to be made, the pharmacy gives me the recommendation and I make the adjustment. When asked what potential outcome could occur if Resident #02 does not have a GDR attempted, Psych Nurse A responded Heart attack, stroke, Extrapyramidal Syndrome (abnormal movement of body due to medication). Psych A stated she felt the benefits outweighed the risk for Resident # 02 to use the medication. Psych Nurse A stated, I have noticed she has slept often but [Resident #02] also hallucinated and had other psychiatric issues that is why I held off on decreasing the Clonazepam. When surveyor asked what clonazepam is used for Psych Nurse A responded anxiety. Psych A stated that she has noticed Resident #02 become more anxious in the facility over the past few weeks. Interview with the DON on 07/26/23 at 03:00 PM she stated the facility's policy regarding GDR on psychotropic medications are for the psych nurse to reduce medications based on her clinical judgement. The [NAME] stated If changes needed to be made to a residents medication regimen the Psych nurse will be responsible for ensuring that is done in accordance with CMS regulation and also patients preference. The DON stated pharmacy also makes recommendations. The DON stated that from a medical standpoint that psychotropic medication should have a GDR if agreed upon by physician . The DON stated the risk that could occur if Resident # 02 does not have a GDR is lethargy (low energy), constipation and addiction to the medication. Record Review of the undated Gradual Dose Reduction policy revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 7 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0758 After the first year a gradual dose reduction must be attempted annually unless clinically contraindicated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 8 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Many The facility failed to ensure injectable insulin of the staff was not stored with food items in the refrigerator. The facility failed to ensure food items in the refrigerator were not expired. These failures could place residents at risk for transmittable diseases, food-borne illness, and food contamination. Findings included: A.Observations and interview of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM revealed there was an insulin injection syringe in a plastic bag stored with other food products in the refrigerator. The insulin label reflected Toujeo (insulin glargine) injection 300 Units/mL (U-300). For subcutaneous use only. Do not remove insulin with syringe. Always use new needle. Do not mix with other insulins. Staff member DA A stated it was her insulin injection syringe. B.Observations of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM revealed the following items were not labelled and/or expired: 1. One plastic bag with 15 patties. There was no name and date written on it. The DM recognized it as sausage patties. 2.Three opened plastic containers of cheese spread. The date 6/15 was written on them. The DM stated the containers were opened on 6/15/23. During an interview on 07/24/23 at 10:30 AM DA A stated she usually kept her insulin syringe elsewhere. She stated that day she was in a hurry, and she kept the insulin syringe in the refrigerator situated in the kitchen. DA A stated storing personal belongings in kitchen refrigerator is risky as it could contaminate the food products in the refrigerator. During an interview on 07/24/23 at 10:00 AM the DM stated the refrigerator was exclusively for storing resident' food products and should not be used to store personal belongings of the staff members. She said there was a refrigerator in the staff room for employees. When the investigator asked about the risk of keeping an injection syringe with food products in the refrigerator, the DM stated the food products could get contaminated from the syringe. She added since it was an injection syringe, disease could be transmitted to the food through the blood from the needle. When asked about facility policy regarding safe storage of food products the DM stated it was facility policy that prepared food should not be stored in the refrigerator for more than 72 hours and food in containers once opened should be used within 7 days and labelling and dating also important to ensure food safety. During an interview on 07/26/23 at 3:00PM, the DON stated, storing personal belongings with food for residents was not acceptable. She stated by storing DA A's insulin syringe in the refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 9 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 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 0812 Level of Harm - Minimal harm or potential for actual harm with food products meant for residents, DA A breached the infection control protocols. The DON stated DA A was risking spreading blood and fluid borne and other diseases with her action. Review of facility in-service records revealed there were no in- services (training) on safe storage of food products since 01/01/2023. Residents Affected - Many Review of the facility's undated policy titled Dietary Services Policy & Procedure Manual 2012 reflected: All Storage Refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage . . Storage refrigerators shall be kept clean and organized. Spills are to be wiped up immediately . .Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately. Review of FDA food code 2022: Chapter 2 Management and Personnel on reflected: .2-103.11 person in charge.the person in charge shall ensure that: . (b)persons unnecessary to the food establishment operation are not allowed in the food preparation, food storage, or ware washing areas, except that brief visits and tours may be authorized by the person in charge if steps are taken to ensure that exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles are protected from contamination; pf . . (f)employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unadulterated, and accurately presented; pf . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 10 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 7 residents (Residents #39, #36, #15 and #17) reviewed for infection control in that: Residents Affected - Some a) LVN A and MA A did not clean and disinfect the wrist blood pressure monitor when it was used on Resident #39, Resident #36, and Resident #15. b) NA A and NA B used soiled gloves for handling clean gloves while providing incontinent care for Resident #17. These failures could place the residents at the facility at risk of transmission of diseases and infection. Findings included: Record review of Resident #36's face sheet dated 07/25/23 reflected Resident #36 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Heart Disease, Edema (swelling), Insomnia, Hypertension (High blood Pressure), Anxiety Disorder, Major Depressive Disorder, Pain, Chronic Kidney Disease, Hypothyroidism (Low level of thyroid hormone), and Alzheimer's disease with early onset. Record Review on 07/25/23 that of Resident #36's MDS assessment dated [DATE] revealed Resident #36's BIMS score was 3 indicating his cognition was severely impaired Review on 07/25/23 of Resident#36's care plan dated 08/01/23 reflected: [Resident #36] has hypertension noted. He is at risk for complications. The relevant intervention was, give anti-hypertensive medications as ordered and monitor for side effects such as give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (low blood pressure while standing up) and increased heart rate and effectiveness. An observation on 07/25/23 at 09:15 AM revealed, while taking the blood pressure of Resident #36 with a wrist blood pressure monitor, LVN A failed to sanitize it before and after use. LVN A opened the drawer of the medication cart and took out the box that contained the wrist blood pressure monitor. She then took out the monitor from the box and without sanitizing it, applied it on Resident #36. After the completion of measuring his blood pressure, she put the monitor back in the box, without sanitizing it. LVN A then placed the box back in the medication cart drawer. During an interview on 07/25/23 at 9:30 AM, LVN A stated she was aware of the importance of sanitizing the blood pressure monitor however forgot to do so as she was in a hurry. When the investigator asked her about the importance of sanitization of the monitor, she stated sanitization of medical equipment was necessary to minimize the spreading of contagious diseases. LVN A stated she practices as a nurse for about 8 years and worked at the facility for about a month. She said, she did not receive any training from the facility for disinfecting medical equipment however she had several in- services and trainings during her career as a nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 11 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39's face sheet dated 07/25/23 reflected Resident #39 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Anoxic Brain Damage (Damage due to the cessation of cerebral blood flow to brain tissue), Hypertension, and Senile Degeneration of Brain (a cause for dementia). Record Review on 07/25/23 that of Resident #39's MDS assessment dated [DATE] revealed Resident #36's BIMS score was 10 indicating his cognition was moderately impaired Review on 07/25/23 of Resident#39's MAR of July 2023 reflected: Lisinopril Tablet 2.5 MG Give 1 tablet by mouth one time a day related to Essential (primary) Hypertension. hold for SBP<90, DBP<50 or H R<60. Record review of Resident #15's face sheet dated 07/25/23 reflected Resident #15 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with schizoaffective disorder (A type of mental illness), Insomnia, Hypothyroidism (Low level of thyroid), Gastro-Esophageal Reflux Disease (Acid reflex of the stomach), anxiety disorder and Chronic Pain. Record Review on 07/25/23 that of Resident #15's MDS assessment dated [DATE] revealed Resident #15's BIMS score was 4 indicating his cognition was severely impaired. Review on 07/25/23 of Resident#15's MAR of July 2023 reflected: Propranolol HCl Tablet Give 10 mg by mouth two times a day for restlessness activation Hold if SBP is less than 90, DBP is less than 50. An observation on 07/25/23 at 10:00 AM revealed that while taking blood pressure using a wrist blood pressure monitor MA A failed to sanitize the wrist blood pressure monitor before and after using it on Resident #39 and Resident #15. MA A took the blood pressure of Resident #39 with the wrist blood pressure monitor. She did not sanitize the monitor prior to using it on Resident #15. After the completion of taking blood pressure without sanitizing, she kept the monitor in the drawer of the medication cart. During an interview on 07/25/23 at 10:45AM, MA A stated she was aware of the necessity of sanitizing the blood pressure wrist monitor every time after the use on residents. MA A said she practiced that in her whole career as a MA however forgot to do it that day most likely because she was nervous. When the investigator asked what the consequence of her action was, she stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. MA A stated she received trainings on infection control two months ago however no training was received on sanitization of medical equipment. Record review of Resident #17's face sheet dated 07/25/23 reflected Resident #17 was admitted to the facility on [DATE]. He was a [AGE] year-old female diagnosed with Hypothyroidism (low level of thyroid hormone), Type 2 Diabetes Mellitus, Hyperlipidemia (High level of fat in blood), Hypertension (High blood pressure), Major Depressive Disorder, Alzheimer's Disease, Gastro-Esophageal Reflux Disease, Insomnia, and Heart Failure. Record Review on 07/25/23 that of Resident #17's MDS assessment dated [DATE] revealed Resident #17's BIMS score was 5 indicating her cognition was severely impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 12 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review on 07/25/23 of Resident#17's care plan dated 08/01/23 reflected: Level of Harm - Minimal harm or potential for actual harm [Resident# 17] is at risk for skin breakdown related to her incontinence and related intervention was peri care per episode and document per protocol. Residents Affected - Some During an observation on 07/25/23 at 11:00 AM, NA A and NA B provided incontinent care to Resident # 17. NA A and NA B entered Resident #15's room and donned gloves after washing their hands. NA A pulled out some wet wipes from a packet and arranged them on the side table. Once the soiled brief was removed, NA A used the wipes passed on by NA B for cleaning Resident #17's perineal area. Once the cleaning was over, NA A removed her soiled gloves, handed over to NA B and requested her to discard them into a plastic bag that was closer to NA B. NA B after disposing NA A's soiled gloves, without changing her gloves, picked up new pair of gloves and handed them over to NA B. NA A used the gloves she was provided by NA A for handling new briefs. She used the same gloves for positioning the resident and adjusting the bed spread and blanket. During an interview on 07/25/23 at 11:00 AM, NA A stated she thought they (NA A and NA B) were doing the incontinent care correctly. When the investigator walked through the entire process of incontinent care, NA A, stated she understood where the mistake was. She said she should not have accepted the gloves that were passed on to her by NA B as NA B was wearing contaminated gloves. NA A stated compromise on infection control practices led to the possibility of spreading diseases. When asked about the training she had received, NA A stated she never received any training on peri care at the facility within the last 6 months. During an interview on 07/25/23 at 11:00 AM, NA B stated she should have changed gloves after handling the dirty gloves that were handed over by NA A. NA B stated not following infection control protocols was not good for the residents as there was a danger of spreading diseases through contamination. During an interview on 01/05/2023 at 2:00 PM the DON stated, NA A and NA B did not follow clean practices while providing peri care. The DON stated her expectation was that the nursing staff must follow facility policy/procedure for handwashing and sanitization of medical equipment. When the investigator asked about the risk of not following the infection control protocol like sanitizing medical equipment in between residents or changing gloves when required while providing care to residents, the DON stated there was a huge risk of the transmission of communicable diseases through contamination. The DON stated an in-service program for all the nursing staff members was initiated to address this issue. The DON said, she made regular rounds on the floor to identify deficient practices done by nursing staff. She stated any deficiency or unprofessional practices were addressed with remedial trainings or in extreme situations disciplinary measures. Review of the facility's policy infection control policy and procedure 2010 revised on 10/21/22: Gloving: Gloves are worn for three important reasons: To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . . To reduce the likelihood that microorganisms present on the hands of personnel will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 13 of 14 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 675388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillview Nursing & Rehabilitation 1110 Rice St Goldthwaite, TX 76844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident, or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed . . Failure to change gloves between resident contacts is an infection control hazard . . Routine cleaning and disinfection of resident care equipment . . 5. Any resident care equipment/article that is visibly contaminated with blood or body fluids will immediately be cleaned with an approved disinfectant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 14 of 14