Health inspection·February 15, 2023

F 0732 sheet for today. Level of Harm - Potential for minimal harm During an observation on 02/15/23 at 9:44 a.m., the staffing sheet posted was dated 02/15/23. Residents Affected - Many A record review of the facility's staffing sheets for February 2023 indicated there were no documented staffing sheets on 02/11/23, 02/12/23 and 02/14/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 2 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 13 of 15 residents reviewed for pharmacy services. (Residents #2, #12, #14, #18, #20, #24, #28, #29, #31, #38, #248, #249, #251). The facility did not administer all medications to Residents #2, #12, #14, #18, #20, #24, #28, #29, #31, #38, #248, #249, #251. These residents did not have some medications available for administration. This failure could place residents at risk of not receiving their medications as ordered. Findings included: Resident #2 A review of Resident #2's clinical record indicated the Resident was admitted to the facility on [DATE] with diagnoses including: chronic kidney disease, anxiety disorder, unspecified protein-calorie malnutrition, high blood pressure, type 2 diabetes, spinal stenosis, muscle wasting and atrophy, and schizoaffective disorder. A review of Resident #2's physician orders dated 12/23/22 indicated the Resident had orders for Carvedilol (hypertension)12.5 mg two times a day, Atorvastatin(cholesterol) 40 mg at bedtime, renal multivitamin tablet B complex and C folic acid one time a day, and tizanidine hydrochloride (muscle relaxer) 2 mg two times a day. A review of Resident #2's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Carvedilol on 01/13/23, she did not receive renal multivitamin on 01/31/23. Progress notes dated 01/13/23 and 01/31/23 indicated the medications were not available. A review of Resident #2's MAR dated 02/01/23 through 02/28/23, indicated she did not receive renal multivitamin on 02/02/23, 02/03/23 and 02/06/23, she did not receive tizanidine hydrochloride on 02/07/23 and 02/08/23 and she did not receive Atorvastatin on 02/10/23. Progress notes dated 02/02/23, 02/03/23, 02/06/23, 02/07/23, 02/08/23 and 02/10/23 indicated the medications were not available. Resident #12 A review of Resident #12's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: atrial fibrillation, high blood pressure, heart failure, dysphagia, alcohol use, dementia, anxiety, and major depressive disorder. A review of Resident #12's physician orders dated 02/15/23 indicated the resident had orders for Apixaban (anticoagulant used to prevent blood clots) 5 mg, two times a day; Famotidine (heart burn) 20 mg, one time a day and Spironolactone (for heart failure, high blood pressure and swelling) 50 mg, one time a day in the morning. A review of Resident #12's MAR dated 01/01/23 through 01/31/23, indicated he did not receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 3 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Spironolactone on 01/05/23, evening dose of Apixaban on 01/12/23 and morning dose of Apixaban 01/13/23. Progress notes dated 01/05/23, 01/12/23 and 01/13/23 indicated the medications were not available. A review of Resident #12's MAR dated 02/01/23 through 02/28/23, indicated he did not receive Famotidine on 02/07, 02/08, and 02/09. Progress notes dated 02/07/23, 02/08/23, and 02/09/23 indicated the medications were not available. Resident #14 A review of resident #14's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: psychotic disturbance, mood disturbance and anxiety, muscle wasting, major depressive disorder, history of urinary (tract) infections, hypothyroidism(lack of thyroid hormone), osteoarthritis(tissue that is worn down), and metabolic encephalopathy (delirium and acute confusional state). A review of Resident #14's physician orders dated 02/15/23 indicated the resident had orders for levothyroxine (lack of thyroid hormone) 50 mcg in the morning, meloxicam (for pain) tablet 15 mg in the morning, lidocaine external patch (for pain) 4% at bedtime, Macrobid (for UTI) 100 mg and cefuroxime axetil (antibiotic) 500 mg 2 times a day. A review of Resident #14's MAR dated 01/01/23 through 01/31/23, indicated she did not receive levothyroxine on 01/24/23, she did not receive meloxicam on 01/24/23, 01/25/23, 01/26/23, 01/27/23, 01/30/23 and 01/31/23. Progress notes dated 01/24/23 indicated the medications were not available. Progress notes dated 01/25/23, 01/26/23, 01/27/23, 01/30/23 and 01/31/23 indicated the medication was not available. A review of Resident #14's MAR dated 02/01/23 through 02/28/23, indicated she did not receive these medications on the following dates: *Lvothyroxine on 02/03/23, 02/07/23, 02/08/23 and 02/09/23, *Meloxicam on 02/01/23, 02/02/23, 02/03/23, 02/08/23, 02/09/23 and 02/10/23, *Cefuroxime axetil on 02/07/23 and 02/08/23, *Macrobid on 02/08/23, 02/09/23 02/10/23, and *Lidocaine patch on 02/13/23. Progress notes dated 02/01/23, 02/02/23, 02/03,23, 02/07/23, 02/08/23, 02/09/23, 02/10/23 and 02/13/23 indicated the medications were not available. Resident #18 A review of Resident #18's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes, atrial fibrillation, high blood pressure, indigestion, schizophreniform disorder (non-permanent psychotic disorder), stroke, anxiety, and depressive disorder. A review of Resident #18's physician orders dated 02/15/23 indicated the resident had orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 4 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some folic acid (vitamin supplement) 1 mg. one time a day, Lisinopril (blood pressure medication) 10 mg. every morning, potassium chloride (a supplement) 10 MEq. every morning, Seroquel (for schizophreniform disorder) 25 mg. a bedtime, and Zoloft (for depressive disorder) 50 mg. 1.5 tablets every morning. A review of Resident #18's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Zoloft on 01/03/23 and did not receive Lisinopril and potassium chloride on 01/09/23. Progress notes dated 01/03/23 and 01/13/23 indicated the medications were not available. A review of Resident #18's MAR dated 02/01/23 through 02/28/23, indicated she did not receive Lisinopril on 02/03/23, did not receive folic acid and Lisinopril on 02/08/23, did not receive Lisinopril on 02/10/23, did not receive folic acid and Seroquel on 02/13/23. Progress notes dated 02/03/23, 02/08/23, 02/10/23, and 02/13/23 indicated the medications were not available. Resident #20 A review of Resident #20's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: heart failure, high blood pressure, atrial fibrillation (irregular heart rate with reduced blood flow), mood disturbance and anxiety, delusional disorders, psychotic disturbance, and dementia without behavioral disturbance. A review of Resident #20's physician orders dated 01/01/23 indicated the resident had orders for colchicine(anti-inflammatory) 0.6 mg 1 tablet in the morning, Lasix (diuretic) 20 mg one time a day, sotalol (for irregular heartbeat) 80 mg one time a day, hydroxyzine (antihistamine) 50 mg two times a day and Lexapro (antidepressant) 0.5 mg in the morning. A review of Resident #20's MAR dated 01/01/23 through 01/31/23, indicated she did not receive colchicine 01/09/23 and 01/11/23. She did not receive Lasix on 01/08/23 and 01/10/23, she did not receive hydroxyzine on 01/09/23 and she did not receive Lexapro on 01/09/23 and 01/10/23. Progress notes dated 01/08/23, 01/09/23, 01/10/23 and 01/11/23 indicated the medications were not available. Resident #24 A review of Resident #24's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: post-traumatic stress disorder, diabetes, dementia, anxiety, sleeplessness, indigestion, and major depressive disorder. A review of Resident #24's physician orders dated 02/15/23 indicated the resident had orders for donepezil (for dementia) 10 mg. daily, furosemide (diuretic) 40 mg. one time a day, Linzess (for constipation) 145 mcg. one time a day, and Lisinopril (for blood pressure) 2.5 mg. one time a day. A review of Resident #24's MAR dated 01/01/23 through 01/31/23, indicated she did not receive furosemide on 01/11/23, 01/12/23, and 01/13/23 and did not receive Lisinopril on 01/23/23. Progress notes dated 01/11/23, 01/12/23, and 01/13/23 and 01/13/23 indicated the medications were not available. A review of Resident #24's Medication Administration Record (MAR) dated 02/01/23 through 02/28/23, indicated she did not receive Linzess on 02/09/23 and did not receive donepezil on 02/14/23. Progress notes dated 02/09/23 and 02/14/23 indicated the medications were not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 5 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Resident #28 Level of Harm - Minimal harm or potential for actual harm A review of Resident #28's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: peripheral vascular disease, high blood pressure, schizophrenia, insomnia, and muscle pain. Residents Affected - Some A review of Resident #28's physician orders dated 02/15/23 indicated the resident had orders for cyclobenzaprine (muscle relaxant) 5 mg three times a day, Cymbalta (for depression) 20 mg. in the morning every other day, Latuda (for schizophrenia) 80 mg one time a day A review of Resident #28's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Latuda on 01/03/23 and 01/03/23, did not receive Cymbalta on 01/11/23, and did not receive cyclobenzaprine on 01/30/23 and 01/31/23. Progress notes dated 01/03/23, 01/05/23, 01/11/23, 01/30/23 and 01/31/23 indicated the medications were not available. A review of Resident #28's MAR dated 02/01/23 through 02/28/23, indicated she did not receive cyclobenzaprine on 02/01/23, 02/02/23, and 02/03/23. Progress notes dated 02/01/23, 02/02/23 and 02/0323 indicated the medication was not available. Resident #29 A review of Resident #29's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: diabetes, multiple sclerosis (disease affecting the central nervous system causing muscle stiffness or spasms, paralysis typically in the legs), pressure ulcers (wounds that occur when the skin and tissue are damaged by prolonged pressure), high blood pressure, venous thrombosis and embolism (blood clot in a blood vessel), muscle wasting and atrophy (loss of muscle tissue). A review of Resident #29's physician orders dated 02/15/23 indicated the resident had orders for Alendronate Sodium (heart burn) 70 mg, one time in the morning every 7 days; Arginaid Packet (nutritional supplement for wound healing) 1 packet, two times a day; Baclofen (muscle spasms) 10 mg, four times a day; Metformin (diabetes) 500mg, two times a day; Rivaroxaban (anticoagulant used to prevent blood clots) 20 mg, one time a day, and Simvastatin (cholesterol) 10 mg, one time a day at bedtime. A review of Resident #29's MAR dated 01/01/23 through 01/31/23, indicated he did not receive the following medications: Alendronate Sodium (heart burn) on 01/05, 01/13; Arginaid Packet (nutritional supplement for wound healing) one dose on 01/02, 01/09, 01/10, 01/11, 01/12, 01/12 and 01/30; Baclofen (muscle spasms) four doses on 01/09, 01/25 and one dose on 01/24; Metformin (diabetes) one dose on 01/09 and two doses on 01/24; Rivaroxaban (anticoagulant used to prevent blood clots) on 01/09 01/10, 01/11, 01/12, 01/23, 01/24, 01/25 and 01/26. Progress notes dated 01/02, 01/06, 01/09, 01/10, 01/11, 01/,12, 01/13, 01/23, 01/24, 01/25, 01/26, and 01/30 indicated the medications were not available. A review of Resident #29's MAR dated 02/01/23 through 02/28/23, indicated he did not receive the following medications: Alendronate Sodium (heart burn) on 02/03; Baclofen (muscle spasms) two doses on 02/09; Metformin (diabetes) one dose on 02/07 and two doses on 02/08; Rivaroxaban (anticoagulant used to prevent blood clots) on 02/03; Simvastatin (cholesterol) on 02/06. Progress notes dated 02/03, 02/06, 02/07, 02/08, and 02/09 indicated the medications were not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 6 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Resident #31 Level of Harm - Minimal harm or potential for actual harm A review of Resident #31's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes, pain, high blood pressure, and depression. Residents Affected - Some A review of Resident #31's physician orders dated 02/15/23 indicated the resident had orders for metformin (for blood sugar) 500 mg. twice a day, trazadone (for depression or sleep) 50 mg. 0,5 tablet one time a day. A review of Resident #31's MAR dated 02/01/23 through 02/28/23, indicated she did not receive the metformin (for blood sugar) 500 mg. morning dose on 02/03/23 and did not receive trazadone on 02/09/23. Progress notes dated 02/03/23 and 02/08/23 indicated the medications were not available. Resident #38 A review of Resident #38's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: nontraumatic intracerebral hemorrhage (bleeding inside the brain from a ruptured blood vessel that may cause severe headache, tingling, or paralysis in face, arm, or leg, trouble swallowing), dysphagia (difficulty in swallowing), muscle weakness, coronary artery disease (narrowing of major blood vessels supplying blood to the heart that may cause chest pain and shortness of breath), high blood pressure, ischemic cardiomyopathy (weak heart muscles due to heart attack or coronary heart disease that may cause fatigue and shortness of breath), systolic and diastolic congestive heart failure (the heart cannot effectively contract with each heartbeat and relax in between), hemiplegia and hemiparesis following cerebral infarction affecting right side (right sided weakness and paralysis caused by a lack of blood and oxygen supply to the brain). A review of Resident #38's physician orders dated 02/15/23 indicated the resident had orders for Lisinopril (blood pressure) 20 mg, one time a day and Baclofen (muscle spasms) 10 mg, three times a day. A review of Resident #38's MAR dated 01/01/23 through 01/31/23, indicated he did not receive Baclofen (muscle spasms) one doses on 01/02. Progress notes dated 01/02 indicated the medication was not available. A review of Resident #38's MAR dated 02/01/23 through 02/28/23, indicated he did not receive Lisinopril on 02/03 and 02/07. Progress notes dated 02/03 and 02/07 indicated the medications were not available. Resident #248 A review of Resident # 248's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: partial intestine obstruction, low thyroid function, diabetes, Parkinson's (nerve cell damage of the brain), high blood pressure, congestive heart failure, arthritis, and chronic kidney disease. A review of Resident # 248's physician orders dated 02/07/23 indicated the resident had orders for Amlodipine 10 mg daily, Donepezil HCl 10 mg daily, Fluticasone Nasal Spray daily, Pantoprazole 40 mg daily, Vitamin C daily, Bumetanide 1 mg 2 (two) times a day, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 7 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Carbidopa-Levodopa ER (extended release) 50-200 mg 3(three) times a day, Metoprolol tartrate 12.5 mg 2(two) times a day, Mucinex DM Extended Release 12 Hour 30-600 mg 2 (two) times a day for 10 days, Gabapentin 300mg 3(three) times a day, Primidone 50 mg 3(three) times a day, and Trihexyphenidyl 2 mg 3 (three) times a day. A review of Resident # 248's MAR dated 02/01/2023 through 02/28/2023 indicated she did not receive these medications on the following dates: *Amlodipine (blood pressure) on 02/08/23, *Donepezil (dementia) on 02/07/23 and 02/08/23, *Fluticasone Nasal Spray (allergies) on 02/08/23, *Pantoprazole (stomach reflux) on 02/08/23, *Vitamin C (supplement) on 02/08/2023, *Bumetanide: (diuretic for congestive heart failure) 1 dose on 02/07/23, 2 doses on 02/08/23, 1 dose on 02/09/23, and 2 doses on 02/10/23 (total 6 doses) *Carbidopa-Levodopa (Parkinson's disease) 1 dose on 02/07/23, 2 doses on 02/08/23 and 1 dose on 02/10/2023 (total 4 doses) *Metoprolol tartrate(blood pressure) 2 doses on 02/08/23, *Mucinex DM (cough)on 02/08/23, *Gabapentin (seizures) 3 doses on 02/08/23 and 1 dose on 02/10/23 (total 4 doses) *Primidone (seizures) 2 doses on 02/07/23, 2 doses on 02/08/23 and 1 dose on 02/10/23 (total 5 doses), and *Trihexyphenidyl (Parkinson's disease) 2 doses on 02/08/23 and 1 dose on 02/10/23. A review of Resident #248's progress notes dated 02/08/23, 02/09, and 02/10/2023 indicated the medications were not available. Further review of the progress notes dated 02/08/23 through 02/11/2023 indicated neither the physician nor DON were notified of medications not being administered. Resident #249 A review of Resident #249's clinical records indicated the resident was admitted on [DATE] with diagnoses including: panic disorder, hypertension, hyperlipidemia, cerebral vascular accident (stroke), and chronic obstructive pulmonary disease. A review of Resident 249's physician orders dated 02/02/23 indicated the resident had orders for amlodipine 5mg daily, atorvastatin 20 mg daily, Climara Transdermal Patch 0.05 mg weekly, docusate sodium 100 mg two (2) times a day, donepezil 10 mg daily, duloxetine 30 mg daily, flaxseed oil 1000 mg daily, Flonase Allergy Relief Nasal Spray daily, meloxicam 7.5 mg daily, and polyethylene glycol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 8 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 powder 17 grams daily. Level of Harm - Minimal harm or potential for actual harm A review of Resident # 249's MAR dated 02/01/2023 through 02/28/2023 indicated she did not receive these medications on the following dates: Residents Affected - Some *Amlodipine (blood pressure) on 02/02/23 and 02/6/2023, *Atorvastatin (cholesterol) on 02/03/23 and 02/04/23, *Climara Transdermal patch (hormone) on 02/03/23 and 02/10/23, *Docusate sodium (stool softener) on 02/03/2023, *Donepezil (dementia)on 02/02/23, 02/04/23, and 02/05/23 *Duloxetine (anxiety, depression) 02/03/23, *Flaxseed oil (cholesterol) on 02/03/23 through 02/15/2023 (13 days), *Flonase Allergy Spray (allergies) on 02/03/23, 02/06/23, and 02/07/23, *Meloxicam (pain)02/03/2023, and *Polyethylene powder (laxative) on 02/03/23. A review of Resident #249's progress notes dated from 02/03/23 through 02/15/23 indicated medications were not available. Progress notes dated 02/03/23 and 02/04/23 indicated the charge nurse was made aware of some un-named medications not being available. No documentation was found to indicate the physician or DON were made aware of the medications being unavailable. Resident #251 A review of Resident #251's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: colon cancer, benign prostatic hyperplasia (enlarged prostate), elevated prostate specific antigen, and peripheral vascular disease. A review of Resident #251's physician orders dated 02/03/23 indicated the resident had an order for Tamsulosin HCL oral capsule 0.4 mg every day. A review of Resident # 251's MAR dated 02/01/23 through 02/28/23 indicated he did not receive Tamsulosin (enlarged prostate) on 02/08/23. A review of Resident #251's progress note dated 02/08/23 indicated Tamsulosin was not available. No documentation was found to indicate the physician, or the DON were notified. During an interview on 02/15/23 at 09:40 AM, LVN A stated that if a medication was not available, she would go to the medication room and see if it was available in the e-Safe (a pharmacy provided safe stocked with emergency and/or frequently ordered medications). She said if she could not get it from the safe, then she would call the pharmacy and if she could not get it in a timely manner, she said she would request the pharmacy to get it from a local pharmacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 9 of 10 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/15/23 at 09:53, MA C said if she did not have a medication available, she would tell the charge nurse. She said the charge nurse would check the e-Safe in the medication room and if not there, then the nurse would call the pharmacy. MA C also said that she re-ordered medications on Monday, Wednesday, and Friday for meds scheduled to be administered on the 6 -2 (Day) shift. She said the medication aide on the 2-10 (Evening) shift ordered medications for that shift. She also said the medication aide that worked on the weekends would re-order any medications if needed. During an interview on 02/15/23 at 10:01 AM, LVN B said if she needed a medication, she would attempt to get it from the e-Safe and if she could not, she would call the pharmacy. During an interview on 02/15/23 at 02:20 PM, MA D said she would tell the charge nurse if she did not have a needed medication in her cart. She said the nurses try to get it from the e-Safe first and if they can't, then they call the pharmacy. During an interview on 02/15/23 at 02:30 PM, the DON said she reviewed the orders for new admissions and checked the cart to ensure medications are available as ordered. She said she expected the medication aides to monitor for needed medications. An In-Service Report dated 01/13/2023 and signed by nurses and medication aides, contained the following instructions: If the medication is not available in the e-kit, the doctor needs to be notified. An in-service dated 01/24/2023 instructed the nurses and medications aides to request the Provider's pharmacy to obtain needed medications from a local pharmacy if the Provider's pharmacy could not deliver within 24 hours. The in-service also instructed the nurses and med aides to notify the DON/ADON if they had problems getting meds delivered. A review of the facility's policy PA 03-2.03 Ordering Medications provides the following information: Medications and related products are received from the pharmacy supplier on a timely basis. Section 3 under Procedures provides the following directions: If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery. Use the emergency kit when the resident needs a medication prior to pharmacy delivery. If not in the emergency kit, contact the pharmacy for possible local pharmacy to fill enough of the medication until the next scheduled delivery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675460 If continuation sheet Page 10 of 10