Health inspection·September 26, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Body (which was a disease having affected the brain having caused problems with thinking, movement, behavior, and mood,) and hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls). Record review of Resident #26's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. Record review of Resident #26's census date reflected a payer source change from Texas Medicaid to Medicare Part A on 2/7/2024. Medicare Part A, as a payer source, terminated on 5/1/2024. The resident stayed at the facility . Interview on 9/25/24 at 3:00 PM with the BOM revealed she oversaw the issue of the SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055) to those residents who exhausted Medicare Part A days of coverage who remained in the facility (not electing hospice.) She stated she was provided with a blank copy of the SNF ABN when she started working at the facility, but she was not provided with any more charts, documentation, or the Processing Manual Chapter 30 to calculate exactly when a resident was supposed to be given an SNF ABN. The intent of the SNF ABN was it was supposed to let the residents know they were reaching their 100 days of Medicare Part A coverage. Then, given the opportunity to accept fiscal responsibility or appeal the decision. When a resident was not provided with the SNF ABN, they risked being charged for skilled nursing services and the opportunity to the decision to Medicare. Neither Resident #26, nor Resident #27 had a reduction in their quality of care. Their 60-day waiting period to have their Medicare Part A had started, per Medicare rules. The failure rested upon training. Interview on 9/26/2024 at 1:58 PM with the ADMIN revealed she expected the BOM already knew the parameters for having issued Residents a SNF ABN, if they met criteria. The ADMIN stated that she, and corporate offices, should have made sure she was trained, but the ADMIN took the responsibility for the failure. There were no safeguards in place to identify the need for proper SNF ABN disbursement. SNF ABNs were given to residents to know if they might have endured a cost associated with received services previously covered by Medicare Part A. Neither Resident #27, nor Resident #28, lost any Medicare Part A days, leading up to their 100. Both residents were in the position to meet Medicare Part A requirements in and receive services in the future. Neither resident experienced any harm. Upon request, the ADMIN stated the facility utilized the Medicare Claims Processing Manual, dated 12-20-2023, as a guideline to disperse the SNF ABN. Record review of the facility's Resident Rights Policy, dated 2003, reflected the facility was supposed to inform each resident upon admission, and periodically during the residents' stay, if there are any changes of services available in the facility and of charges for those services, including any charges for services not covered under Medicare. Record review of the Medicare Claims Processing Manual (Section 70.2), dated 12-20-2023, reflected an SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items, or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 2 of 24 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 09/26/2024 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 0582 EVENT Level of Harm - Minimal harm or potential for actual harm DESCRIPTION Initiation Residents Affected - Few In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary. Reduction In the situation in which a SNF proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary. Termination In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 3 of 24 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 09/26/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 27 residents, in the memory care unit, reviewed for a safe, clean, comfortable, and homelike environment The facility failed to report maintenance issues to the MNTD and make repairs to a loose hand railing, in the memory care unit community bathroom . This failure could have placed the residents in the memory care unit to falls. Findings included: Observation on 9/24/2024 at 11:38 AM revealed a handrail, inside the community bathroom on the facility's memory care unit, was loose. The handrail was still attached firmly to the wall in the bathroom but had 1 to 2 inches of vertical movement. There were no sharp edges. Interview on 09/24/24 at 11:41 AM with CNA A revealed the handrail was loose. She stated she was trained to report maintenance issues to the MNTD by writing the area of concern in the facility's maintenance book and telling the MNTD. She stated the book was in the main room, at the front of the facility, near the nurse's station . Interview and observation on 09/26/24 at 8:42 AM with the ADM revealed the handrail in the memory care unit's community bathroom was loose. The ADM was unaware the handrail was loose; she had not received any reports for the need of maintenance. The ADM was observed having closed the restroom, having pended repairs . Observation on 09/26/24 at 9:37 AM revealed the ADM and the MNTD having begun to repair the handrail in the memory care unit's community restroom. Interview, observation, and record review on 09/26/24 at 11:56 AM with MNTD revealed the handrail in the memory care unit's community bathroom was tightly secured to the wall. The MNTD stated the process to report maintenance concerns was to write the issue on the maintenance book. He checked the book daily and made repairs as they were raised. CNA A had informed him yesterday, 9/25/2024, that the handrail was loose. He looked at it yesterday, but was unable to secure it, so he had planned to fix it today, 9/26/2024. He received a text message from the ADM today, at 8:50 AM, having instructed him to fix the handrail. The loose handrail could have caused a resident to lose their balance or have had an actual fall. Record review of the facility's maintenance book revealed no maintenance requests having pertained to the bathroom's handrail. Interview on 09/26/24 at 2:07 PM with the ADM revealed she expected her staff to utilize the maintenance book and report maintenance issues to the MNTD. Issues that were a hazard, or posed risk to resident safety, were supposed to be reported and fixed immediately. A safeguard in place to identify maintenance issues consisted of a check list called Angel Rounds. The failure to repair the handrail timely was the failure of staff to use the Angel Round checklist and the maintenance book per policy. There had been no accidents in the memory care unit's community bathroom. Record review of the maintenance log, located on the desk next to the nurse's station, reflected a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 4 of 24 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 09/26/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm chronological order of maintenance requests. There was no request made for the handrail in the memory care unit's community bathroom. Record review of the facility Angel Round's Checklist, undated, reflected no line item to check the memory care unit's community bathroom. Residents Affected - Some Record review of the facility's Preventative Maintenance Policy, dated 2003, reflected the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance. The facility will maintain all preventive maintenance logs in a notebook binder. The book will be maintained in a neat and organized manner and will be easily accessible at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 5 of 24 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 09/26/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 23, Resident # 29, and Resident #104) reviewed quality of life. Residents Affected - Some The facility failed to ensure Resident #23's, Resident #29's, and Resident #104's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. 1. Record review of Resident # 23's Face Sheet dated, 09/25/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of other frontotemporal neurocognitive disorder (a rare brain disease that causes gradual damage to the frontal and temporal lobes of the brain), dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance ( a medical condition that refers to a moderate stage of dementia- decline with thinking, remembering, and reasoning, to the point that it interferes with a person's daily life- in patients with other diseases that cause cognitive decline), and impulse disorder ( difficult to control you actions or reactions). Record review of Resident #23's Quarterly MDS Assessment, dated 08/30/2024, reflected the resident had a BIMS score of 8 which reflected her cognition was moderately impaired. Resident #23 required supervision with showers. She was independent with personal hygiene. Resident #23 required supervision with eating. Record review of Resident #23's Comprehensive Care Plan, 09/03/2024 reflected Resident #23 had an ADL self-care performance deficit related to dementia. Intervention: Resident #23 required limited to extensive assistance with dressing, personal hygiene, and bathing. Resident #23 resided on the secured unit related to wandering into unsafe areas. She was at risk for complication. Intervention: monitor for discomfort and exit seeking. Resident #23 had impaired vision. She was at risk for complications. She had glasses, however, did not wear them all the time. Intervention: Monitor, document, and report to MD the following signs and symptoms of acute eye problems. Observation on 09/24/2024 at 9:46 AM revealed Resident #23 was lying in bed. Resident # 23 had blackish/ brownish substance underneath the forefinger, ring finger, and middle fingernails on her right hand. In an interview on 09/24/2024 at 9:48 AM revealed Resident #23 stated her nails looked bad. Resident #23 did not respond to any other questions such as: if she reported her dirty nails to staff, how long the blackish substance had been on her nails, and why she thought her nails looked bad. 2. Record review of Resident # 29's Face Sheet, dated 09/25/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebella stroke syndrome ( a type of stroke that occurs when blood flow to the part of the brain is disrupted), visual agnosia ( a condition that affects how your brain processes what you see), and tremor ( involuntary shaking can affect hands, arms, or head, and usually happens when trying to hold a position). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 6 of 24 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 09/26/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #29's Quarterly MDS Assessment, dated 08/09/2024, reflected Resident #29 had a BIMS score of 4 which reflected his cognitive status was severely impaired. Resident #29's vision was severely impaired (no vision or sees only light, color or shapes; eyes do not appear to follow objects). He was dependent on staff for personal hygiene, dressing, showers, toileting hygiene, and transfers. Record review of Resident #29's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #29 had an ADL self-care performance deficit related to dementia (the loss of thinking, remembering, and reasoning. To the extent that it interferes with a person's daily life and activity). Intervention: Resident #29 required extensive to total assistance with personal hygiene. Observation on 09/25/2024 at 10:30 AM revealed Resident # 29 was in the dining area sitting at a table. Resident #29 had blackish/ brownish substance underneath the middle, and ring fingernails on his right hand. There was a hard blackish/brownish substance on the tip of his middle finger. An attempted interview on 09/25/2024 at 10:34 AM with Resident #29 revealed he was not interview able. 3. Record review of Resident #104's Face Sheet, dated 09/25/2024, reflected an [AGE] year-old female was admitted on [DATE] with diagnoses of parkinsonism, unspecified ( a progressive brain disorder that causes movement problems, mental health issues, and other health issues), anxiety disorder (excessive worry, and feelings of fear, dread, and uneasiness), and essential hypertension ( a type of high blood pressure that develops gradually over time and was not caused by another medical condition). Record review of Resident #104's Quarterly MDS Assessment, dated 06/14/2024, reflected the resident had a BIMS score of 5 which indicated her cognition status was severely impaired. Resident #104 was assessed to require partial/moderate assistance (helper does more than half the effort) with the following: personal hygiene, eating, oral hygiene, showers, dressing, and transfers. Record review of Resident 104's Comprehensive Care Plan, revised on 09/13/2024, reflected Resident #104 had an ADL self-care performance deficit related to dementia. Intervention: Resident #104 required one to two staff participation with personal hygiene. Resident #104 had impaired cognitive function related to dementia (the loss of thinking, remembering, and reasoning and interferes with a person's daily life and activities), and Parkinson's disease. Observation on 09/25/2024 at 2:00 PM Resident #104 was in her room lying in bed. Resident #104 had blackish/brownish substance underneath her middle and ring fingernails on her right hand. An attempted interview on 09/25/2024 at 2:04 PM with Resident #104 revealed she was not interview able. Record review of Resident #23, Resident # 29, and Resident #104's electronic medical record reflected there was no documentation of when fingernail care was provided, name of person that administered nail care, and the condition of the nails. In an interview on 09/26/2024 at 8:45 AM the Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may. She stated there was a possibility a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 7 of 24 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 09/26/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident may develop vomiting or diarrhea. She stated all residents were expected to receive nail care during showers and as needed. The Director of Nurses stated the CNAs completed nail care on all residents except for the residents with a diagnosis of diabetes (a disease when your blood sugar was too high). She stated it was the nurse's supervisor responsibility to monitor residents nail care. In an interview on 09/26/2024 at 08:52 AM, CNA A stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA A stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA A stated there were also a possibility a resident may become severely dehydrated and may need to be transferred to emergency room to determine what type of bacteria was underneath the residents' fingernails. CNA A stated she had been in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated the only residents she knew that refused nail care was Resident #10. In an interview on 09/26/24 at 08:56 AM, LVN C stated the nurses, and the CNAs were responsible for nail care. He stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNAs responsibility to clean and trim all other residents' nails during showers or as needed. He stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria . He also stated if a resident swallowed the bacteria there was a possibility a resident may become ill with diarrhea. He stated she was only aware of Resident # 10 that refused nail care. LVN C stated the nurse supervisor was responsible for monitoring nail care. In an interview on 09/26/2024 at 9:02 AM, LVN A stated the nurses was responsible for diabetic nail care such as trimming, filing, and cleaning. She stated the CNAs were responsible for all other resident's nail care. LVN A stated if a blackish/brownish substance was underneath the resident's nails, there was a possibility it could be some type of bacteria. LVN A stated if a resident ingested the blackish substance and it was bacteria, a resident may become ill with vomiting, diarrhea, and possibly E. coli (a type of bacteria that is commonly found in the intestines). She stated Resident #10 refused nail care and she was not aware of any other resident that refused any type of nail care. LVN A stated she had been in-serviced on nail care but did not recall the date or time of the in-service. In an interview on 09/26/2024 at 9:08 AM, CNA D stated the nurses completed all diabetic fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA D stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. She stated if a resident had a blackish substance underneath their nails, it was probably some type of bacteria. She stated if a resident swallowed bacteria it was had potential that the resident may develop major stomach problems such as diarrhea. CNA D stated if a resident became severely ill the resident may need to be transferred to an emergency room for more care. She stated all residents except Resident #10 agreed to staff completing nail care. She stated she had been in-serviced on nail care but did not remember the date of the in-service. She stated it had been about a year. 1. Record review of the facility's Policy on ADLs revised February 2018 reflected The purpose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 8 of 24 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 09/26/2024 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 0677 this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Level of Harm - Minimal harm or potential for actual harm 2. Nail care includes daily cleaning and regular trimming. 3. Proper nail care can aid in the prevention of skin problems around the nail bed. Residents Affected - Some 4. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 3. The condition of the resident's nails and nail bed, including: 1. Redness or irritation of skin of hands and feet. 2. Bluish or dark color of nail beds. 3. Corns or calluses. 4. Ingrown nails. 5. Bleeding; and/or 6. Pain. 4. Any difficulties in cutting the resident's nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 9 of 24 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 09/26/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 3 of 13 residents (Resident #18, Resident #26, and Resident 30) reviewed for dietary services. The facility failed to ensure Resident #18, Resident #26, and Resident #30 received their prescribed diet for 09/24/2024 lunch. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food,) and diminished quality of life. Resident #18 Record review or Resident #18's AR, dated 09/24/2024, reflected an [AGE] year-old man, born on 7/11/1942, who admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (which was a progressive disease having caused mild memory loss, inability to execute conversations, and the inability to respond to the environment) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review of Resident #18's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 3. A BIMS Score of 3 indicated the resident had severe cognitive impairment. Resident was prescribed a mechanically altered diet, while a resident. Resident required supervision or touching assistance with eating, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Record review of Resident #18's CP reflected an area of Focus for potential weight loss, revised on 7/10/2024, evidenced by illness. The Goal, revised on 7/2/2024, indicated the resident was supposed to maintain weight. The Intervention, revised on 7/10/2024, was a delegated dietary staff to provide a mechanical soft diet. Record review of Resident #18's Order Summary Report reflected an order, started 4/7/2022, for a regular diet with mechanical soft texture. Record review of Resident #18's weights, located in PCC, reflected no weight loss/gain in the last 30 days; 1.59% of body weight gain in the last 90 days; and a 1.54% of body weight loss in the last 180 days. Interview, observations, and record review on 09/24/24 at 12:18 PM with Resident #18 revealed him sitting at the lunch table. His meal ticket, located on the table next to him, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of his entrée for lunch revealed the roasted new potatoes on his plate had the skin in place. Interview revealed the peels were hard to eat because he did not have enough teeth. He was observed sticking out his tongue having displayed a quarter sized piece of roasted new potato skin. He took it from his tongue with his fingers. He was not observed having choked or aspirated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 10 of 24 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 09/26/2024 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 0808 Resident #26 Level of Harm - Minimal harm or potential for actual harm Record review or Resident #26's AR, dated 09/24/2024, reflected a [AGE] year-old man, born on 1/18/2027, who admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (which was a progressive disease having caused mild memory loss, inability to execute conversations, and the inability to respond to the environment) and heart disease (which occurred when the heart muscle did not perform efficiently). Residents Affected - Some Record review of Resident #26's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 4. A BIMS Score of 4 indicated the resident had severe cognitive impairment. The resident was prescribed a mechanically altered diet, while a resident. Resident required supervision or touching assistance with eating, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Record review of Resident #26's CP reflected an area of Focus for weight loss and nutrition, initiated on 9/29/2022, evidenced by mental status. The Goal, revised on 5/8/2024, indicated the resident was supposed to maintain weight and receive proper nutrition. The Intervention, revised on 8/22/24, delegated dietary staff to provide a mechanically altered diet. Record review of Resident #26's Order Summary Report reflected an order, started 7/10/2024, for a regular diet with mechanical soft texture. Interview and observation on 09/24/24 at 10:33 AM with Resident #26 revealed him, with his RP, in the common room on the memory care unit. Interview with the RP revealed his dad received excellent care at the facility. He did not have any issues or concerns. Record review of Resident #26's weights, located in PCC, reflected no weight loss/gain in the last 30 days; 1.49% of body weight loss in the last 90 days; and a 6.38% of body weight loss in the last 180 days. Interview, observation, and record review on 09/24/24 at 12:30 PM with Resident #26 revealed him sitting at the lunch table being assisted with his meal by CNA A. His meal ticket, located on the table next to him, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of his entrée for lunch revealed the roasted new potatoes on his plate had the skin in place. Resident #26 was non-interviewable. Interview with CNA A revealed she was helping him eat his lunch. She was observed having cut his roasted new potatoes, with skin, into small bite size pieces. CNA A stated she did not remember if Resident #26 displayed difficulty eating the roasted new potatoes, with skin. He was not observed having choked or aspirated. Resident #30 Record review or Resident #30's AR, dated 09/24/2024, reflected a [AGE] year-old woman, born on [DATE], who admitted to the facility on [DATE]. She was diagnosed chronic obstructive pulmonary disease (COPD) (which was a respiratory condition characterized by persistent breathlessness and cough) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review of Resident #30's Quarterly MDS, dated [DATE], reflected the resident had a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 11 of 24 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 09/26/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Score of 3. A BIMS Score of 3 indicated the resident had severe cognitive impairment. Resident was prescribed a mechanically altered diet, while a resident. Resident required set up or clean up assistance with eating, which meant the helper provided set up prior, and cleaned up after, while the resident completed the activity. Record review of Resident #30's CP reflected an area of Focus for unplanned weight loss/gain, initiated on 6/14/2024, evidenced by COPD. The Goal, revised on 6/14/2024, indicated the resident was supposed to maintain weight and proper nutrition. The Intervention, initiated on 6/14/2024, delegated dietary staff to provide a mechanical soft diet. Record review of Resident #30's Order Summary Report reflected an order, started 3/22/2022, for a regular diet with mechanical soft texture. Record review of Resident #30's weights, located in PCC, reflected a .70% body weight loss in the last 30 days; .71% of body weight gain in the last 90 days; and a 2.90% of body weight gain in the last 180 days. Interview, observation, and record review on 09/24/24 at 12:41 PM with Resident #30 revealed her sitting at the lunch table. Her meal ticket, located on the table next to her, designated the resident to receive a Mechanical Soft Diet. The ticket indicated the resident was supposed to have received [peeled] roasted new potatoes. Observation of her entrée for lunch revealed the roasted new potatoes peels on her plate. She had removed the skin with her knife and fork. Interview revealed she removed the potato skins because she had difficulty chewing and swallowing them. She was not observed having choked or aspirated. Interview on 09/24/2024 at 12:20 PM LVN D revealed she did not compare the meal tickets to the meal trays for any of the residents in the main dining room, residents in the memory care unit, or the residents in their rooms. She stated she was expected to ensure each meal tray matched what was on the meal slip. LVN D stated a resident, who received the wrong texture diet, may have choked or aspirated. She had been in-serviced (trained) on meal service; the nurses were required to compare each resident's meal ticket to match residents' meal tray prior to the meal tray being served to the resident. Interview on 09/24/24 at 12:37 PM with LVN A revealed the kitchen was supposed to check each meal tray as it left the kitchen to make sure the meal matched the specifics of the residents' meal ticket and prescribed diets. Again, staff in memory care unit dining room were supposed to check the meals and tickets prior to having served the residents. She stated that neither she, nor other nursing staff in the memory care unit, checked the meal tickets for today's lunch meal. Interview on 09/24/24 at 2:10 PM with the dietary manager revealed the process of the facility for having plated and delivered the residents' meals. The dietary cooks were supposed to check the resident's meal ticket and plate the food accordingly. The kitchen aids, who added beverages and desserts, were supposed to double check the meal tickets. The dietary manager was supposed to oversee the meal process to make sure all the meal trays matched the meal tickets and prescribed diets. Any failures, having related to discrepancies related to texture or therapeutic diets, fell upon the whole team in the kitchen. The failure rested upon the dietary cooks, kitchen aids, and the dietary manager. Once the trays left the kitchen, any discrepancies related to texture, or therapeutic diets, fell upon the nursing staff. The dietary manager stated a resident who was supposed to get a mechanical soft diet required potatoes to be peeled. The skins, on the roasted new potatoes, were a hazard, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 12 of 24 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 09/26/2024 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 0808 because the residents could not chew, or swallow them. Level of Harm - Minimal harm or potential for actual harm Interview on 09/26/24 at 12:00 PM with the DOT revealed residents, who were prescribed mechanical soft diets, were residents who displayed difficulty chewing and swallowing in the resident assessment. A resident who required mechanical soft diets, who received regular texture meals, risked having choked, aspirated, or difficulty eating. Nursing staff were required to check the residents' meals against the resident specific meal ticket for accuracy. Residents Affected - Some Interview on 09/26/24 at 12:35 PM with the DON revealed staff, who were passing out the meal trays, were supposed to make sure the food tray matched the resident's meal ticket. Residents who received a different texture meal, such as regular texture instead of mechanical soft, would have had difficulty chewing and swallowing and risked aspiration or choking. A mechanism in place, to make sure residents received the correct diet, was initial staff training and periodic spot checks by upper management. Staff were trained to know the difference between regular texture, mechanical soft texture, and a pureed texture. The failure for the residents to receive the correct texture fell upon dining staff misreading, or not identifying discrepancies, with the resident 's specific meal ticket. The DON had not received complaints from residents about texture differences; there had not been any resident to suffer adverse health effects from texture discrepancies. Interview on 09/26/24 at 02:31 PM with the ADM revealed alternate textured diets were ordered for residents, per their attending physician or provider, based on resident assessments. She expected her staff to make sure prescribed textures were congruent with the resident's specific meal ticket. Residents who consumed different textures could aspirate, choke, or consume fewer calories. Practices in place, to avoid texture inconsistent meal service, consisted of spot checks and table visits from nursing and administrative staff. The failure for the staff to ensure plates were provided with the correct texture fell upon misreading the resident 's meal ticket. Record review of the facility's Therapeutic Diet Policy, dated October 2017, reflected a mechanically altered diet was ordered, the provider was supposed to specify the texture modification. The facility was supposed to have sufficient staff, with the appropriate training set, to carry out the functions of meal service, including validation of tray card diet type and texture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 13 of 24 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 09/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 2. The facility failed to seal, label, and date tortillas and failed to label and date two large bags of ice-covered chicken in one of one freezer located in the dry storage area. These failures could place residents at risks for health complications and foodborne illnesses. Findings included: 1. Observation on 09/24/2024 at 9:15 AM Dietary [NAME] was not wearing gloves. She touched her shirt and touched a cleaning towel. She did not wash or sanitize her hands prior to touching the fourchettes of the gloves when she was placing the gloves on her hands. She touched clean plates and inside of a scoop. In an interview on 09/24/2024 at 9:19 AM the Dietary [NAME] stated she did touch her shirt and touched the cleanser towel to clean different surfaces. She stated she did pick up the gloves where the fingers go inside the gloves, and she did not wash or sanitize her hands. The Dietary [NAME] stated she did touch clean plates and inside of the scoop she was going to use to begin cooking lunch. She stated she had been in-serviced on washing hands prior to wearing gloves and in between tasks. She did not recall the date of the in-service. Observation on 09/24/2024 at 12:15 PM the Dietary Aide was placing desserts, utensils inside of napkin, plate of the lunch meal and drink, and carrying the tray outside of the kitchen (approximately 4 feet) where the meal tray cart was located. There was not enough room in the kitchen for the covered meal cart. The Dietary Aide was not wearing gloves. She touched the right side of her pants and shirt four times. She did not wash her hands after touching her clothes. The Dietary Aide touched six residents' napkins holding residents' silverware. The Dietary Aide touched inside the dessert plate and touched inside of the cups of tea. In an interview on 09/24/2024 at 1:15 PM the Dietary Aide stated she did touch her pants and shirt and did not wash her hands. She stated she was expected to wash her hands anytime she touched anything that may be contaminated. The Dietary Aide stated her clothes were considered contaminated. She stated she did touch napkins and she may have touched inside the cups of tea. The Dietary Aide stated she did touch inside the dessert plate. She stated there was a possibility there was bacteria on her hands and she could have cross contaminated the napkins, inside of cups, and plates. The Dietary Aide stated if there were bacteria on her hands and it was on a resident's napkin, plate, or inside of the cup, it was possible a resident may become ill with stomach problems from the bacteria. She stated she had been in-serviced on hand hygiene when serving food. Observation on 09/25/2024 at 8:25 AM the Dietary Dishwasher Aide was in the dishwasher room. She was not wearing gloves. The Dietary Dishwasher Aide picked up her cellphone with her fingers and the palm of her right hand. She placed the cellphone with her fingers on her right hand inside of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 14 of 24 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 09/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many right-side pants pocket. She did not wash or sanitize her hands. The Dietary Dishwasher Aide picked up clean plates and the fingers on her right hand touched inside of six clean plates. She also touched the tines (sharp pointed parts of a fork) of approximately 4 forks. In an interview on 09/25/2024 at 8:30 AM the Dietary Dishwasher Aide stated she did place her cell phone in her pants pocket. She stated cell phones and clothes were considered dirty. She stated she was to wash her hands after touching her cell phone and her pants. The Dietary Dishwasher Aide stated she did touch several plates and the tips of some forks. She stated if bacteria transferred from her fingers and hand onto plates and forks there was a possibility if a resident ate out of the plate or used the fork a resident may become sick such problems with their stomach and may become ill with diarrhea. 2. Observation on 09/24/2024 between 9:10 AM and 9:30 AM on the food prep area in the kitchen, tortillas were in a non-sealed clear plastic bag without a label or date. The facility failed to seal, label, and date tortillas and failed to label and date four of ten pounds of hamburger meat not in the original package. Observation on 09/24/2024 between 9:10 AM and 9:30 AM revealed there were approximately one inch of ice-covered chicken in two clear bags without a label or date. The two clear bags of chicken were not in the original package. In an interview 09/26/24 at 08:06 AM the Dietary Manager stated any time dietary staff placed gloves on their hands the staff were expected to wash their hands. The Dietary Manger stated if any staff touched the outside of gloves with soiled hands there was a possibility the bacteria may transfer from the gloves onto the clean dishes or food. The Dietary Manger stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. The Dietary Manger stated if any dietary staff touched their clothes/ cell phone or anything not considered clean, the dietary staff were expected to wash their hands immediately. She stated the Dietary Aide touched the napkins, inside of dessert plates, and inside of the cups of tea, she was expected to wash her hands immediately after she touched her clothes. She stated the Dietary Aide may have contaminated the napkins, plates of food, and the cups of tea. She stated all foods were to be labeled, dated, and sealed. The Dietary Manager stated all food products should be dated as soon as they were received. The Dietary Manager stated any food in the freezer with ice covering the food may affect the quality of food and taste. She stated all staff should be checking for quality and expiration dates but ultimately the responsibility falls on her to ensure that nothing was out of date or stored improperly. In an interview on 09/26/2024 at 10:50 AM the Administrator stated her expectations were all staff in the kitchen to wash their hands when visibly soiled and between tasks. She stated if dietary staff touched their cell phone, their clothes, or cleaning dish towel, their hands would be considered soiled. The staff would need to wash their hands immediately before they touched clean dishes, clean napkins, cups . etc. She stated the dietary staff were to wash their hands if they touched their clothes or cell phone. The Administrator stated the Dietary Manager was responsible for the operation of the kitchen. She stated the policy on refrigerators was the same they would use on freezers related to label and dating. Record review of the Facility's Policy on Dietary Food Service Personnel Policy and Procedure, dated 2012, reflected sanitation and food handling: wash your hands (with soap and hot water) before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 15 of 24 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 09/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning. Handle all utensils and dishes so the food or customer contact surfaces are not touched. Record review of the Facility's Policy on Storage Refrigerators, dated 2012, reflected food must be covered when stored, with a date label identifying what is in the container. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 16 of 24 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 09/26/2024 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 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 transmission of communicable diseases and infections for 5 of 5 resident (Resident #20, #22, #32, #33, and #42) reviewed for infection control. Residents Affected - Some The facility failed to ensure MA performed proper hand hygiene when passing medications on Residents #20, #32, and # 33. The facility failed to ensure CNA-A and CNA-B sanitized equipment between residents. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident 22's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Parkinsonism, Anxiety, Depression, HTN, and Hyperlipidemia. Record review of Resident 22's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 22's Care Plan, reflected a Focus area was initiated for resident requiring a full body sling lift for transfers on 7/30/24 with a goal for the resident to sit out of bed daily. Record review of Resident 32's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), HTN, Macular degeneration (eye deterioration), Depression, Seizures, and Atrial Fibrillation. Record review of Resident 32's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated the resident's cognitive ability was not impaired. Record review of Resident 32's Care Plan, reflected a Focus area was initiated for impaired cognitive function on 6/11/2024 with a goal to maintain current level of cognitive function. Record review of Resident42's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Peripheral Vascular Disease (Blood vessel disease), Anxiety, Hypomagnesemia, Hypokalemia (low potassium), and Opioid -Induced Disorder. Record review of Resident 42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident 42's Care Plan, reflected a Focus area was initiated for pain management on 8/23/2024 with a goal for resident to verbalize adequate relief of pain. Record review of Resident 20's undated face sheet, revealed she was an [AGE] year-old female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 17 of 24 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 09/26/2024 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 0880 admitted [DATE] with diagnoses of Alzheimer's, Depression, HTN, and Hypothyroidism. Level of Harm - Minimal harm or potential for actual harm Record review of Resident 20's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Residents Affected - Some Record review of Resident 20's Care Plan, reflected a Focus area was initiated for impaired cognitive function/dementia related to dementia on 6/14/2024 with a goal for resident to maintain current level of cognitive function. Record review of Resident 33's undated face sheet, revealed he was an [AGE] year-old male admitted [DATE] with diagnoses of neurocognitive disorder, Tremor, Anxiety, Muscle Wasting, and History of Falling. Record review of Resident 33's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive ability could not be accurately assessed. Record review of Resident 33's Care Plan, reflected a Focus area was initiated for requiring use of full body lift-med sling on 6/21/2024 with a goal for resident to be out of bed daily. Observation on 9/25/24 at 8:53 am revealed the MA removed her gloves after applying gel to Resident 20's knee. She then picked up the cup the resident had been holding and put gloves in the cup to discard. MA discarded the cup, wiped down the measuring tool, and then touched the mouse and cart to start new med's on other residents with no hand hygiene done prior to touching the cart. Observation on 9/25/24 at 9:10 am revealed the MA had gloves on to apply eye drops to Resident 32. She took the Kleenex box into the room to hand the resident a Kleenex to dry her eyes. Eye drops administered with gloves on, and Kleenex box picked up and then taken out to the medication cart while wearing the same gloves. She touched items on the med cart before removing the gloves. No hand hygiene seen/no hand rubbing seen after gloves removed. Observation on 9/25/24 at 9:18 am revealed the MA gave Resident #42 her pain med's (no gloves) and touched the used medication cup to discard it. She then returned to the medication cart without applying hand hygiene prior to touching the cart. Observation on 9/25/24 at 1:39 PM revealed CNA-A and CNA-B placed Resident #22 in the Hoyer sling. As they were hooking the Hoyer straps, the resident was touching multiple areas on the Hoyer bars. The Hoyer was then removed from the resident's room without sanitizing the contaminated areas of the equipment. Hand Hygiene was observed for both staff. Observation on 9/25/24 at 2:04 PM revealed CNA-A and CNA-B moved the Hoyer Lift from Resident #22's room to Resident #33's room without sanitizing the equipment. They then proceeded to place Resident #33 in the Hoyer sling and move him to the bed. Hand hygiene was performed. In an Interview with the MA on 9/25/24 at 9:20 am regarding lack of hand hygiene seen during the medication pass, she stated that she reached into drawer 3 to do hand hygiene (out of the state surveyors viewing area). She has a bottle of alcohol gel in the left corner of drawer 3. She stated she stored it there instead of on the top of the medication cart to keep residents from picking up the alcohol gel. The MA agreed she may have not done that between touching resident 20's med cup and touching the medication cart and the measuring tool which could have contaminated those items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 18 of 24 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 09/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 9/26/24 at 1:29 PM with LVN-A she stated, the policy on hand hygiene after contacting resident items was to sanitize hands after touching patient items. She stated this was important, so you don't spread anything. LVN-A stated the negative outcome to residents if this was not done was that the residents could get sick from infections. LVN-A also stated the policy on cleaning Hoyer's was that they were to be cleaned every time it was used before going to the next resident. She stated the Hoyer should be wiped down with wipes between rooms and if residents touch the equipment. She said it should be wiped down because residents can touch the equipment, touch themselves, and spread disease and infection to themselves and other residents which could make them sick. In an interview on 9/26/24 at 1:36 PM with LVN-B she stated, the policy on hand hygiene after contacting resident items was to clean with alcohol gel or soap and water. She stated this was important to prevent spread of infections and for resident rights. LVN-B stated if this was not done the residents could get infected or contaminated. She stated the policy on cleaning Hoyer lifts was to clean with manufacture guidelines between residents as it could come in contact with residents when in use. LVN-B also stated this was important to prevent spread of infection and if not done then resident could get infections. In an interview on 9/26/24 at 1:40 PM with CNA-C she stated, the policy on hand hygiene after contacting resident items was to wash hands or use hand sanitizer and it was important for infection control. She stated not doing it could cause residents infections and transmit disease. She stated reusable equipment should be wiped off with alcohol wipes between residents. CNA-C also stated the policy on cleaning a Hoyer Lift between rooms was to clean and sanitize with wipes to prevent spreading bacteria and disease. In an interview on 9/26/24 at 1:55 PM with the DON she stated, the policy on hand hygiene after contacting resident items was to wash your hands between patients and equipment. She stated this was important to reduce infections. She stated not doing it could cause infections. She stated the policy on cleaning equipment that was re-usable on multiple residents was to clean between rooms. She stated the Hoyer lift should be cleaned between rooms and residents. If they touch the equipment, it should be cleaned. She stated this was important to prevent transmission of disease and to prevent infections for residents. In an interview on 9/26/24 at 1:45 PM with the ADMIN she stated, the policy on hand hygiene after contacting resident items was to wash your hands. She stated this was important so germs were not spread to other items or residents which could cause illnesses. The ADMIN stated the policy on cleaning equipment that was re-usable on multiple residents was to wipe equipment clean. She stated the policy on cleaning the Hoyer lifts as it goes from room-to-room, was to clean if soiled and routine cleaning weekly. She stated if residents touch Hoyer's they should be cleaned so germs were not spread from 1 resident to another and not cleaning it could pass illness or germs. A record review of the facility policy titled, Handwashing/Hand Hygiene Version 3.0 in the 2001 Med-Pass, Inc with a last revision date of 2023 reflected the following: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated immediately before and after touching a resident or their environment. Hand Hygiene is indicated immediately after glove removal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 19 of 24 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 09/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2023 reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Residents Affected - Some Durable medical equipment is cleaned and disinfected before reuse by another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 20 of 24 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 09/26/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 adequately equipp residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 2 of 8 Residents (Resident #4 and Resident #50) who were reviewed for resident call systems. Residents Affected - Few The facility failed to ensure Resident #4 and Resident #50's shared bathroom had a pull string attached to the call light switch making the call light button accessible if the resident were lying on the floor. This failure could place residents at risk of harm by not being able to call for help when needed. Findings included: Resident #4 Record review of Resident #4's AR, dated 9/24/2024 reflected a [AGE] year-old man, born on [DATE], who admitted to the facility on [DATE]. He was diagnosed with Schizophrenia (which was a severe mental disorder having caused hallucination, delusions, and disorganized speech,) hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls,) and an anxiety disorder (which was a mental heal condition marked by heightened responses, or worry, to certain situations and stimuli.) Record review of Resident #4's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. Resident had no impairment in either upper or lower extremity (shoulder, elbow, wrist, and hand, hip, knee, ankle, or foot.) Resident did not utilize a device for mobility. Resident was independent with toileting hygiene, toilet transfer, sit to standing, and walking 150 feet (which meant the resident completed the activity without assistance.) Resident was always continent of bladder and bowel. Record review of Resident #4's CCP reflected an area of Focus for fall risk, revised on 1/31/2024, evidenced by confusion. The Goal, revised on 5/3/2024, indicated the resident would not sustain serious injury. The Intervention, initiated on 7/24/2023, delegated nursing home staff to ensure the resident's call light was within reach and encourage resident to use it; an area of Focus for ADL self-care, revised on 5/24/2023, evidenced by self-care performance. The Goal, revised on 5/3/2024, indicated resident would maintain current level of function in transfers and toilet use. The Intervention, initiated on 5/23/2023, delegated nursing home staff to encourage resident to use bell to call for assistance. Observation and interview on 9/24/2024 at 10:56 AM revealed Resident #4 lying in his bed under the covers watching television. Resident was soft spoken and slightly difficult to engage; however, the resident was able to verbalize, by speech, and demonstrated, with body language, he was not in any distress. Observations of the resident's bathroom, shared with the adjoining room (Resident #50's room,) reflected a call light switch on the wall next to the commode. The call light switch was approximately 2.5 feet from the floor. The call light switch was angled upwards, having indicated the switch needed to be pulled downwards to be activated. The call light switch did not have an attached string extending to the floor. He correctly demonstrated the use of his call light button affixed to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 21 of 24 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 09/26/2024 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 0919 bed. Level of Harm - Minimal harm or potential for actual harm Observation on 9/26/2024 at 8:32 AM of Resident #4's shared bathroom reflected the call light switch did not have a string having extended to the floor. Residents Affected - Few Interview on 9/26/2024 at 8:33 AM with Resident #4 revealed he was capable of ambulating to the restroom to utilize the commode. He was not aware there was supposed to be a string on the call light switch in the bathroom. Having then known there was supposed to be a string attached to the call light switch, he stated he would have wanted to reach it if he fell. If he had fallen in the bathroom and could not reach the switch 2.5 feet up the wall to call for help, he would have felt helpless and angry. Resident #50 Record review or Resident #50's AR, dated 9/24/2024, reflected a [AGE] year-old man, born on 2/24/1986, who admitted to the facility on [DATE]. He was diagnosed with unspecified focal traumatic brain injury (which was a traumatic brain injury,) hypertension (which was a disease having reduced blood pressure having inhibited blood flow to certain parts of the body,) and depression (which was a mental disorder having resulted in sadness and diminished interest in normal day-to-day activities.) Record review of Resident #50's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 11. A BIMS Score of 11 indicated the resident had moderate cognitive impairment. Resident had no impairment in either upper or lower extremity (shoulder, elbow, wrist, and hand, hip, knee, ankle, or foot). Resident utilized a wheelchair for mobility. Resident required set up or clean up assistance with toileting hygiene, which meant the helper provided set up prior, and cleaned up after, while the resident completed the activity. Resident required supervision or touching assistance with sitting to standing and toilet transfer, which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity. Resident was occasionally incontinent of bladder and bowel. Record review of Resident #50's CP reflected an area of Focus for moderate fall risk, revised on 5/2/2024, evidenced by confusion, physical function decline, gait, and balance problems. The Goal, revised on 7/30/2024 indicated the resident would not sustain serious injury. The Intervention, initiated on, 5/1/2024, delegated nursing home staff to ensure resident's call light was within reach and encouraged resident to use it: an area of Focus for pain, revised on 5/2/2024, evidenced by fractures and trauma. The Goal revised on 7/30/2024, indicated the resident would not have discomfort. The Intervention, revised on 5/2/2024, delegated nursing home staff to call for assistance when in pain; an area of Focus for communication problems, revised 6/14/2024, evidenced by garbled communication. The Goal, revised on 7/30/2024, indicated the resident would maintain current level of communication (having responded to yes or no questions.) The Intervention, initiated on 6/14/2024, delegated nursing home staff to ensure a safe environment with call light in reach; and, an area of Focus for ADL self-care performance, initiated on 5/1/2024, evidenced by physical function decline R/T confusion. The Goal, revised on 7/30/2024, indicated the resident will keep his current level of function in toilet use. The Intervention, initiated on 5/1/2024, delegated nursing home staff to encourage to resident to use bell to call for assistance. Observations and interview on 9/24/2024 at 11:12 PM with Resident #50 revealed him lying in his bed watching television. Resident #50 was afflicted with communication problems. Having knelt to his level and having utilized yes or no questions, the resident was able to verbalize, with speech, that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 22 of 24 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 09/26/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm he was not in distress or in any pain. Observations of the resident's bathroom, shared with the adjoining room (Resident #4's room,) reflected a call light switch on the wall next to the commode. The call light switch was approximately 2.5 feet from the floor. The call light switch was angled upwards, having indicated the switch needed to be pulled downwards to be activated. The call light switch did not have an attached string extending to the floor. He correctly demonstrated the use of his call light button located on his bed. Residents Affected - Few Observation on 9/26/2024 at 8:51 AM of Resident #50's shared bathroom reflected the call light switch did not have a string having extended to the floor. Interview on 9/26/2024 at 8:52 AM with Resident #50, having used yes or no questions, revealed he had used the commode in his room. He was able to get from the bed to his wheelchair, get to the bathroom with the use of his wheelchair; get from his wheelchair to the commode (he stated he had held on,) get from the commode to his wheelchair; and get back to his bed with his wheelchair. His communication problems inhibited him from having elaborated. Interview on 9/26/2024 at 9:01 AM with CNA C revealed residents have call light buttons in their rooms to call for assistance from staff. The call light buttons were supposed to be in arm's reach of the resident at all times. In addition to the call light button in each resident's room, there was also a call light switch located in each resident's bathroom. The call light switch was located on the wall next to the commode at the same level as the commode's seat. The call light switch had a string attached that extended to the floor. CNA C explained a resident might use the switch to call for help while on the commode but did not know why there was a string attached. She stated she had not received any instruction or training to have ensured the string was attached and hung towards the level of the floor. Having then known the string was a requirement for the resident to use if they were lying on the floor, she stated a resident's inability to call for help could have caused extended periods of pain, sadness, or feelings of neglect. CNA C stated the facility staff performed room checks, called Angel Rounds, to make sure the residents' call light systems were in proper working condition but was unaware if the string on the call light switch in the bathroom was one of the checks on the Angel Round list. Interview on 9/26/2024 at 11:56 AM with the MNTD revealed the bathrooms in the resident's rooms required not only a call light switch, but also required a string, or a cord, which hung in the direction of the floor. The string, or cord, hung in the direction of the floor to make the call light switch accessible if the resident were laying on the floor. The call light switch string in the shared bathroom of Resident #4 and Resident #50 was not present. Interview on 9-26-2024 at 12:20 PM with the MNTD revealed he went to the shared bathroom of Resident #4 and Resident #50 and replaced the string on the call light switch. Interview on 09/26/24 as 12:55 PM with the DON revealed staff were trained to make sure the call light switches in the residents' bathrooms were functioning properly, but not trained to have ensued a string was present, or a string had stretched to the floor. A safeguard in place to address call light switches in the resident's bathrooms, was a checklist and visual inspection called Angel Rounds. The checklist suggested having ensured the call light switch in the bathroom was working properly, but the check list did not annotate the call light switch had to have a string that stretched to the floor. Residents, who had fallen to the floor in the bathroom, who were unable to use the call light switch, because there was no string, risked exposure to prolonged pain, risked further injury, and risked feelings of helplessness. The failure for the call light switch not having a string, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 23 of 24 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 09/26/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extended to the floor, fell upon awareness and staff training. The DON reported there have been no occurrences of residents falling in the bathrooms and not having been able to receive assistance through the call light switch system. Interview on 9/26/2024 at 2:59 PM with the ADMIN revealed she expected staff to follow policy and to have ensured the call light switch string, in the bathroom, was in the most accessible spot for the resident. The most accessible spot for the call light switch string was attached to the switch and having extended to the floor. A safeguard in place to check for functional call light switches in the bathroom was the use of a visual inspections, with a checklist, called Angel Rounds. The Angel Round's checklist directed the inspector to make sure the call light switch, in the bathroom, was working correctly, but did not annotate the requirement to check for the string. The ADMIN, herself, performed the Angel Round check for the bathroom in Resident #50's room yesterday, 9/25/2024, for cleanliness, but did not notice the string missing. She performed another Angel Round check, today 9-26-2024, where she only looked at the room for cleanliness. Upon request, the ADMIN was unable to produce the checklist she used for Resident #50's room. The failure to identify, and correct, the missing string on the call light switch fell upon nursing staff, maintenance, and the use of the Angel Rounds checklist., and oversite. Neither Resident #4, nor Resident #50, experienced and falls in the shared bathroom. Observation on 9-26-2024 at 4:00 PM in Resident #4 and Resident #50's shared bathroom reflected the string on the call light switch had been replaced and extended to the floor. Record review of the facility Angel Round's Checklist, page 1, undated, reflected a line item, called [Is the call light in the bathroom in working order?] Record review of the facility's Preventative Maintenance Policy, dated 2003, reflected the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance. The facility will maintain all preventive maintenance logs in a notebook binder. The book will be maintained in a neat and organized manner and will be easily accessible at all times. Record review of the maintenance log, located on the desk next to the nurse's station, reflected a chronological order of maintenance requests. There was no request made for (Resident #4) or (Resident #50) requesting repair of the bathroom call light switch string. Record review of the facility's Resident Call System, dated September 2022, reflected each resident was provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675388 If continuation sheet Page 24 of 24