Health inspection·July 16, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few possible. She said a medication count was conducted at the end of every shift and anytime they pass the medication cart off to another employee. Interview on 7/16/2024 at 2:48pm with LVN, employed for approximately 10 days, she stated she received training on misappropriation during her initial training and with her previous employer previously. She stated an understanding of misappropriation and said she has never taken a medication from the medication cart, nor has she seen anyone else take medication. Interview on 7/16/2024 at 3:04pm with DON, employed with the facility for 18 years, stated she in-serviced staff on 6/29/2024 following the incident with CMA-A. She identified accountability measures currently in place at the facility as cameras were located throughout the building, carts were kept locked, a medication count was conducted at beginning and end of each shift, the building was locked and secured, and the ADM reviewed camera footage after any incident. She said she feels the incident with CMA-A was an isolated incident and the disciplinary action was appropriate. Interview on 7/16/2024 at 3:20pm with ADM reflected accountability measures include medication count at the beginning and end of each shift and that CMA's must document each time a PRN medication is given to a resident. She stated that the disciplinary action against CMA-A was appropriate as she had been an employee in good standing for over 6-years and feels like it was an isolated incident. She said CMA-A is supervised by a nurse on the night shift and there is another CNA working nights as well. She said there are no routine medications given to residents during the night shift, so the medication cart is rarely opened. Review of the most recent Criminal History Conviction search dated 1/19/2024 for CMA-A, reflected no search results found. Review of Notice to Employee Receiving This Employee Disciplinary Report dated 7/1/2024 was signed by CMA-A and ADM. The document stated, Your failure to accomplish the corrective plan of action, including any specified deadlines, may result in further disciplinary action up to and including discharge. Discharge will automatically accompany third written counseling in a 12-month period, or any infraction of a serious nature that would warrant immediate discharge. Review of Employee Disciplinary Report dated 7/1/2024 was completed by ADM. The document stated, CMA-A will not be allowed to work as a medication aide. She will not have access to medications, medication cart, medication room, and medication keys. CMA-A received a demotion to CNA and took a pay in accordance. Review of Attendance Form dated 6/29/2024, for in-service titled Abuse, Neglect, Residents Rights, Exploitation Misappropriation was signed by 30 employees from various departments. Review of facility policy titled Resident Rights, revised 2/2021 stated: Policy Statement - Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation Section 1 - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: Section C - be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022 stated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 2 of 3 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 07/16/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 3 of 3