Health inspection·February 16, 2024

F 0678 compressions, artificial ventilation and defibrillation and is referred to as CPR.). Level of Harm - Immediate jeopardy to resident health or safety Record review of MDS assessment dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Residents Affected - Few Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the physician order summary report dated [DATE] stated Resident #1 was a full code. Record review of MDS dated [DATE] indicated Resident #1 had clear speech, understood others and made herself understood. The MDS indicated Resident #1 had moderately impaired cognitive function (BIMS of 10). The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised on [DATE] indicated Resident #1 was a full code. Record review of the nursing note dated [DATE] at 6:19 a.m. stated nurse aide called for nurses. Upon entering room resident had no rise or fall of chest. Nurse called for code status. Resident being a full code CPR was initiated. This nurse called 911 at 0621 (6:21 a.m.). This nurse along with fellow coworkers performed CPR taking turns with compressions. This writer was the last nurse to speak to resident at 0510 (5:10 a.m.) while administering morning medication . The nursing note was not signed. Record review of the nursing note dated [DATE] as a late entry at 6:19 a.m. stated, This nurse was called to room by CNA, that resident was not breathing- upon exam there were no resp (respirations) immediately called code status .911 called - all measures taking with CPR administered and continued until EMS arrived at 6:35 a.m. Res (resident) was given 3 rounds of epi (epinephrine) with fluids. Res (resident) was intubated. CPR continued until 6:55 a.m. without success The nursing note was signed by ADON B. During an interview on [DATE] at 1:52 p.m., ADON B said on [DATE] she worked the floor and was assigned Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. ADON B said that morning ([DATE]) she immediately responded when the CNA yelled out that Resident #1 was not breathing. ADON B said Resident #1 was a full code and CPR was started immediately. ADON B said the night shift nurses, LVN A and LVN C were still in the facility and also responded. ADON B said the crash cart was brought in immediately but the AED pads for the AED machine could not be located. ADON B said nurses continued CPR as she attempted to locate the AED pads. ADON B said she could not locate the pads and called the DON for assistance. ADON B said she was told by the DON that extra AED pads were located in one of the cabinets in the medication room. ADON B said she could not find the AED pads in the medication room. ADON B said she never found the AED pads. ADON B said AED pads were not placed on Resident #1 until EMS arrived and placed their AED (the AED brought by EMS) on Resident #1. ADON B said there was no way to know if Resident #1 had a shockable rhythm prior to EMS arrival. ADON B said the AED pads were not located until after the code. The ADON said the DON found the AED pads upon his arrival to the facility. ADON B said she did not know why the AED pads were not on the crash cart on [DATE]. ADON B said the crash cart was checked daily. She said part of those checks were to ensure the AED machine was ready for use and AED pads were attached to the machine. ADON B said a green indicator light flashes on the AED signaling the pads were connected and the AED was ready for use. ADON B said she assumed whoever had performed the daily check on crash cart before the code event had not ensured the green (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 2 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few light was flashing /AED pads were connected. While viewing the Crash Cart Checklist from [DATE] to [DATE] ADON B identified all of the signatures on the checklist as herself, LVN C, and LVN E. Record review of the Crash Cart Checklist from [DATE] to [DATE] indicated the crash cart had been checked daily. The checklist contained a check box labeled AED. The crash cart checklist did not specify the crash cart was checked for AED pads or the blinking green indicator light. The Crash Cart Checklist documented the following nurses' signatures on the following specified dates leading up to Resident #1's death; *[DATE]- signed by ADON B; *[DATE]- signed by ADON B; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN C; *[DATE]- signed by LVN E; *[DATE]- signed by LVN E; *[DATE]- signed by LVN C; and *[DATE]- signed by LVN C. During an interview on [DATE] at 2:15 p.m., LVN A said she had worked [DATE] from 6:00 p.m. to [DATE] to 6:00 a.m. and was the nurse assigned to Resident #1. LVN A said she was still in the facility completing her charting when Resident #1 was found not breathing by the day shift CNA. LVN A said ADON B was her relief that morning and ran to check Resident #1. LVN A said ADON B yelled out for the Resident #1's code status. LVN A said she checked Resident #1's code status and found she was full code and immediately yelled out to ADON B that Resident #1 was a full code. LVN A said LVN C and LVN D immediately grabbed the crash cart and went to Resident #1's room. LVN #1 said she immediately called 911 and went to the room. LVN A said the AED pads could not immediately be located on the crash cart and there was a delay applying the AED pads to Resident #1 because the pads were not on the crash cart as they should have been. LVN A said she believed the AED pads were located and applied to Resident #1 before the arrival of EMS. Resident #1 said the delay in applying the AED pads was more than one minute but could not have been longer than 5 minutes. LVN A said she was not in the room the entire time the code was in process before the arrival of EMS because she stepped out of the room while on the phone with 911 in order to provide more detailed information regarding Resident #1. During an interview on [DATE] at 2:20 p.m., LVN C said he immediately responded when Resident #1 was found not breathing. LVN C said he initiated chest compressions and was the primary nurse that delivered compressions until EMS arrival. LVN C said he was in the room the entire time the code was in process prior to the arrival of EMS. LVN C said the AED was not used prior to the arrival of EMS because the AED pads could not be located. LVN C said there was no way to know if Resident #1 had a shockable rhythm until EMS arrived because the AED pads could not be found. LVN C said on [DATE]-[DATE] and [DATE]-[DATE], he had just signed the crash cart check list because he trusted the nurses that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 3 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 had signed before him but did not verify the AED had pads connected/green indicator light was flashing. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 2:40 p.m., LVN D said she was working the morning of [DATE] when Resident #1 was found unresponsive. LVN D said she ran and got the crash cart and by the time she arrived in Resident #1's room with the crash cart, CPR had already been started. LVN D said she remained in Resident #1's room the entire time the code was underway until the arrival of EMS. LVN D said the AED pads could not be found and so the AED was not utilized. LVN D said she heard someone say Resident #1 had an ICD (implantable cardioverter-defibrillator a small battery-powered device placed in the chest. It detects and stops irregular heartbeats, also called arrhythmias. An ICD continuously checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heart rhythm. ICDs require regular checks to ensure they are operational.) LVN D said when EMS arrived, they used their AED machine on Resident #1. LVN D said she was not sure a shock was delivered because she left the room shortly after EMS arrived. LVN D said the facility AED pads were not found until after the code. Residents Affected - Few During an interview on [DATE] at 3:05 p.m., the Medical Director said Resident #1 had a history of cardiac arrest. The Medical Director said if an ICD is functioning properly an AED would not be needed. The Medical Director said he believed Resident #1 had an ICD but could not say when she (Resident #1) last saw her cardiologist or had the device checked. During an interview at [DATE] at 3:10 p.m., the DON said the AED pads were to be with the AED at all times. The DON said the AED was supposed to checked daily as part of the crash cart daily checks. He explained, there was green indicator light that flashed on the AED indicating the AED was ready for use. The DON said the indicator light would not flash if the AED pads were not connected. The DON said he expected nurses to ensure the AED pads were connected and the AED was ready for use when daily crash cart checks were performed. The DON said ADON B had called him when the AED pads were not with the AED and could not be located on [DATE]. The DON said he tried to instruct ADON B on where to find the replacement AED pads. The DON said he found the AED pads when he arrived to the facility in one of the medication room cabinets. The DON said Resident #1 had an ICD but could not say when the device was last checked. The DON said there was no way to know for sure if Resident #1 had a shockable rhythm before the arrival of EMS as an AED was not utilized prior to their (EMS) arrival. The DON said he ensured after the incident that AED pads were connected to the AED and an extra set of AED pads were placed within the back zipper pocket of the AED case. The DON said other than word of mouth there had been no in-services for staff related to the incident. The DON said he was not sure he had notified the Administrator regarding the incident. During an interview at [DATE] at 3:39 p.m., the Administrator said he had not been notified by anyone that staff could not locate AED pads on the morning of [DATE] when Resident #1 coded. The Administrator said he had not been notified that there had been no use of an AED until the arrival of EMS as a result of staff not having been unable to locate the AED pads. The Administrator said the AED pads should be with the AED at all times and nurses should be checking that the pads are there during daily crash cart checks. Record review of the EMS report dated [DATE] reflected Resident #1's ECG (electrocardiogram, a recording of the heart's electrical activity) displayed a rhythm of asystole (the heart's electrical system fails entirely, which causes the heart to stop pumping. It is also known as flat-line. Asystole is a non-shockable rhythm). The EMS record indicated EMS arrived at approximately 6:30 a.m. and continued resuscitation efforts until 6:52 a.m., at which time efforts were discontinued and Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 4 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 was pronounced dead. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility policy and procedure titled Automatic External Defibrillator, Use and Care of, revised March of 2015 found the policy and procedure stated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac arrest. Policy Interpretation and Implementation (1) During a sudden cardiac arrest event, follow guidelines outlined in the procedure for Cardiopulmonary Resuscitation and Basic life Support . (3) The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AED) is part of the CPR/BLS training. (4) In general, SCA [sudden cardia arrest] should be suspected if: (a)The victim's symptoms appeared very suddenly; (b) He or she is unresponsive; and (c)His or her breathing has stopped. (5) If an individual is found unconscious and SCA is suspected, begin the AED Protocol below. Initial Assessment and Safety Precautions . (3) Assess the victim: (a)Responsiveness - if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring it to the victim .Applying Pads to the Victim .(6) Attach two AED pads to the victim's bare chest (one on the upper right , one on the left) .Defibrillation. (1) After applying pads .The AED will analyze the heart rhythm and indicate whether a shock is needed . (5) Follow the AED prompts until the emergency medical service arrives . Residents Affected - Few The facility policy and procedure titled Emergency procedure- Cardiopulmonary Resuscitation, revised [DATE] found the policy and procedure stated, Policy Statement-Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines . (4) The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. (5) Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival . Preparation for Cardiopulmonary Resuscitation . (6) Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Emergency Procedures- Cardiopulmonary Resuscitation- . (7) When the AED arrives, assess for need and follow AED protocol as indicated. (8) Continue with CPR/BLS until emergency medical personnel arrive. The Administrator was notified on [DATE] at 4:42 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:57 p.m. The facility's plan of removal was requested on [DATE] at 4:57 p.m. The facility's Plan of Removal was accepted on [DATE] at 12:58 p.m. and included: Regional nurse provided in-service to the director of nursing and administrator on regulations of CPR and AED. Topics of in-service included, AED must be checked daily to ensure it is functioning properly and ready to go. Education also provided that the facility must identify a storage area for emergency supplies and ensure staff know the location. Initiated: [DATE] completed: [DATE] 5:25 p.m. In-services on the CPR policy including the use of AED, daily checks verifying pads are connected and ready to use. Location of replacement pads in the facility and importance of replacing immediately if used. daily check sheet updated with checks to include battery connected and replacement pads, in-services were started on [DATE] at 5:45pm by DON for all licensed nursing staff. All licensed nurses will be in-serviced prior to their next shift. No nurse will be allowed to work until in-service is completed. Initiated [DATE] to be completed on [DATE] 1:00 p.m. Administrator and DON verified that the AED is functioning as manufacturer intended, with pads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 5 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 connected. replacement pads added to AED storage compartment. completed on [DATE] 5:30 p.m. Level of Harm - Immediate jeopardy to resident health or safety An audit of all employees for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. facility audited the last 90days of resident discharges to ensure no other full code residents were affected. no other residents required CPR inside the facility. Initiated: [DATE] completed: [DATE] 7:00 p.m. Residents Affected - Few Facility scheduled a QA with medical director to be held on [DATE] at 8:00 a.m. Initiated: [DATE] completed: [DATE] at 8:30 a.m. Facilities policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation was reviewed and updated by administrator and regional nurse on [DATE] to ensure that current policy meets the standards of practice and regulatory requirements on properly trained staff are in the building 24/7. Initiated: [DATE] completed: [DATE] 5:00 p.m. Ongoing systematic change to ensure CPR trained staff are knowledgeable on AED and location of all emergency supplies and equipment on all shifts is that all licensed personnel will receive training at the time of hire. Storage area for AED pads has been identified with a large red sign AED pads here- initiated: [DATE] completed [DATE] 7:30 p.m. The QAPI team, led by the administrator, will meet weekly for 3 weeks to discuss coordination of completion of all in-services, assessments, and interventions are utilized and completed. The medical director was notified on [DATE] of the immediate jeopardy called on facility. Initiated: [DATE] completed: [DATE] 8:00 p.m. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the signed statement dated [DATE] at 5:30 p.m., verified the crash cart was checked by both the Administrator and DON for AED pads were connected to the AED, the green indicator light was observed flashing, an extra set of AED pads were in place. The expiration dates of the pads were checked and the AED powered on and prompts began without error codes. Record review of the undated facility document titled Future QAPI Dates QAPI plan to meet weekly for 3 weeks ([DATE] at 10:00 a.m., [DATE] at 10:00 a.m., and [DATE] at 10:00 a.m.). Record review of the undated new Crash Cart Checklist displayed the following added check off items: *AED pads connected; *Extra AED pads in bag; and *Expiration date on AED pads checked. The new Crash Cart Checklist had been completed with the new items checked off and signed. Record review of the CPR Certification Audit document reflected AUDIT OF all nurses for CPR certification and training was completed by the administrator on [DATE] for CPR compliance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 6 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the in-service training report dated [DATE], Topic: Potential for Clause reflected the DON and Administrator had received in-service over the importance of actual failures or potential for failures must be reported, investigated, staff in-serviced as necessary to ensure no other residents would be affected, all corrective actions taken and monitored. Record review of the in-service training report dated [DATE], Topic: Importance of Regulation 678 reflected the DON and Administrator and received in-service/instruction that the AED must be checked daily to ensure it is functioning properly and ready to go and that the facility must identify a storage area for emergency supplies /ensure staff know the location. Record review of the in-service training report and accompanied sign in sheet dated [DATE], Topic: Checking the AED and AED pads reflected nurse in-services over; the updated Emergency Procedure -CPR policy; on the use of AED; on daily checks- verifying pads were connected and ready to use; on the location of replacement pads in the facility; and importance of replacing the pads immediately after use; and the updated crash cart check off list had been initiated. Record review of the audit document of deceased residents since [DATE] verified in the last 90 days no additional discharged /deceased residents had required full code interventions. Record review of the facility QA agenda and sign in sheet dated [DATE] reflected a QA meeting with the Medical Director was held on [DATE] at 8:00 a.m. and agenda outline included Medical Director notification of identified system failure and identification of Immediate Jeopardy on [DATE] and corrective actions taken as of [DATE] at 8:00 a.m. The document was signed by the Medical Director. Record review of the updated policy and procedure titled Emergency Procedure- Cardiopulmonary Resuscitation found the policy and procedure had been reviewed and revised and ensured maintain equipment and supplies necessary for CPR/BLS in the facility at all times remained in the policy and procedure. Record review of the undated, AED acknowledgment form found that the new applicants would sign acknowledgement form which stated, The AED must be checked every day. Nurses must ensure the green light is flashing verifying the pads and batteries are connected. Nurses must check to ensure replacement pads are in the storage compartment. Replacement pads are also located in the Med Room in a cabinet with a red sign alerting to the location. If at any time the AED is not functioning properly, the DON and Administrator must be notified immediately. During an observation on [DATE] at 12:40 p.m., a large red sign taped to a cabinet door in medication room alerted the viewer of the location of extra AED pads. Three additional boxes of AED pads were labeled and in place. During an observation on [DATE] at 12:45 p.m., the facility crash cart was found with the AED in place, the green indicator light was flashing on the AED, AED pads were connected to the AED, an additional set of AED pads were found in the attached zipper compartment, and the expiration date checked on both set of pads. The placement and use of the new Crash Cart Checklist was also observed. Staff interviewed on [DATE] between 1:00 p.m. and 3:00 p.m. (LVN F, LVN, G, LVN H, LVN C, RN I, RN J, LVN K, LVN L, LVN M, ADON N, ADON B, ADON, O, LVN P and LVN Q [ these nurses comprise 6 of 7 of the facilities staff day shift nurses, 3 of 7 staff night nurses plus 4 nurses with other primary roles- 3 of which regularly work the floor]), said crash cart checks were to be performed daily and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 7 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few those checks must include ensuring AED pads were connected to the AED machine, the flashing green indicator light was observed, extra pads were in the attached zipper pocket of the AED case and the expiration dates on both sets of the AED pads were checked. The nurses also said in addition to the extra set of AED pads a spare battery was located in the attached zipper pocket. The nurses said that after a code the AED pads were to be replaced immediately after the code. The nurses said the replacement pads could be found in the medication room behind the cabinet labeled with a red sign indicating the location of the AED pads. The nurses said if they went to replace the pads and they were not in those locations they would immediately notify the DON. The nurses correctly identified the changes made to the crash cart checklist as, AED pads connected; Extra AED pads in bag; and Expiration date on AED pads checked. The nurses also said that checking the box marked AED meant the AED was on the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light indicated pads were connected and the AED was ready for use. The nurses also stated if any issues or obstacles were encountered during the course of care for residents that resulted in a bad outcome or potentially could result in a bad outcome, they would notify the DON and Administrator in order for administration and QAPI team to review the situation take any corrective actions and ensure no additional residents were affected. During an interview on [DATE] at 3:06 p.m., the DON said he should have notified the Administrator of the failure to have the AED pads readily available on [DATE] (which resulted in Resident #1 not receiving AED intervention until arrival of EMS). The DON said he should have ensured the notification so that the situation could have been reviewed, all failures identified and all corrective actions put in place, including staff in-services. The DON said going forward the facility would implement a system to ensure DON was notified any time the crash cart was pulled for use, even if after pulling the cart it was discovered/determined the resident was a DNR and the cart was not used. The DON said perhaps this was the situation that resulted in the AED pads not being in place when Resident #1 coded on [DATE] as the facility audit for the past 90 days discovered no other resident that been administered a full code. The DON said anytime the cart is pulled the entire crash cart would be audited to ensure all essential equipment (including AED pads) were replaced. He said in addition spots checks would be initiated to ensure nurses completed crash cart checks appropriately. The DON said all new staff hired would read and sign the AED acknowledgement form and in addition, all staff would have to sign the acknowledgement annually. The DON said there had also been discussion of mounting the AED machine, making it visible from the nursing station to ensure the green indicator light could be easily and readily viewed. The DON said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to return to work until in-services were completed. During an interview on [DATE] at 3:13 p.m., the Administrator said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to work until in-services were completed. While the IJ was removed on [DATE] at 3:22 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 8 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 2 Residents (Resident #2) reviewed for PRN (as needed) pain medication administration. The facility failed to ensure the documentation of Resident #2's prn (as needed) pain medications were documented in the MAR. This failure could place residents at risk of delayed pain medication administration, or over medication. Findings included: Record review of the face sheet for Resident #2 dated 2/16/24 indicated she was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including dementia, breast cancer, heart failure, type 2 diabetes, and pain. Record review of the MDS assessment dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated she had severe cognitive impairment (BIMS score of 7). The MDS indicated Resident #2 frequently had pain during the 5-day look back period. The MDS indicated Resident #2's pain frequently made it hard for her to sleep at night. The MDS indicated Resident #2's pain frequently limited her day-to-day activities. The MDS indicated Resident #2 rated her worst pain at a 8 on the 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine). The MDS indicated Resident #2 had received or declined prn pain medication. Record review of the care plan revised on 2/1/24 indicated Resident #2 had pain related to cancer of the left breast. The care plan interventions included administer medications as ordered and evaluate/ record/ report effectiveness of pain medication. Record review of the active physician order dated 3/25/17 indicated Resident #2 was to be administered acetaminophen-codeine (Tylenol # 3) 300mg/30mg 1 tablet twice a day as needed for pain. Record review of the active physician order dated 5/18/17 indicated Resident #2 was to be administered Hydrocodone -Acetaminophen (Norco) 10mg/325mg 1 tablet every 6 hours as needed for pain. Record review of the facility controlled drug record for acetaminophen-codeine (Tylenol #3) 300mg/30mg for Resident # 2 from 2/1/24 to 2/15/24 indicated 1 tablet had been administered on the following dates and times; *2/1/24 at 11:00 am - signed by LVN K; *2/3/24 at 5:45 a.m.- signed by LVN A; *2/3/24 at 2:35 p.m.- signed by LVN F; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 9 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 *2/4/24 at 2:30 a.m.- signed by LVN A; Level of Harm - Minimal harm or potential for actual harm *2/4/24 at 11:35 a.m.- signed by RN T; *2/5/24 at 0420 a.m.- signed by LVN A; Residents Affected - Few *2/5/24 at 12:15 p.m.- signed by LVN K; *2/7/24 at 8:10 a.m.- signed by LVN F; *2/7/24 at 11:45 p.m.- signed by LVN A; *2/8/24 at 8:10 a.m.- signed by LVN F; *2/8/24 at 4:30 p.m.- signed by LVN F; *2/10/24 at 0120 a.m.- signed by LVN S; *2/11/24 at 12:00 p.m.- signed by LVN R; *2/12/24 at 1:50 a.m.- signed by LVN S; *2/12/24 at 10:35 a.m.- signed by LVN F; *2/12/24 at 8:27 p.m.- signed by LVN A; *2/13/24 at 2:55 p.m.- signed by LVN F; *2/13/24 at 11:45 p.m.- signed by LVN A; *2/14/24 at 3:01 p.m. - signed by LVN K; *2/15/24 at 3:30 am - signed by LVN S; and *2/15/24 at 8:00 am - signed by LVN K. Record review of Resident #2's MAR for February 2024 did not record any administration of acetaminophen-codeine (Tylenol # 3) 300mg/30mg 1 tablet on the following dates and times; *2/1/24 at 11:00 a.m.; *2/3/24 at 5:45 a.m.; *2/3/24 at 2:35 p.m.; *2/4/24 at 11:35 a.m.; *2/5/24 at 4:20 a.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 10 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 *2/5/24 at 12:15 p.m.; Level of Harm - Minimal harm or potential for actual harm *2/7/24 at 11:45 p.m.; *2/10/24 at 1:20 a.m.; Residents Affected - Few *2/11/24 at 12:00 p.m.; *2/12/24 at 1:50 a.m.; *2/12/24 at 8:27 p.m.; *2/13/24 at 11:45 p.m.; *2/14/24 at 3:01 p.m.; *2/15/24 at 3:30 a.m.; and *2/15/24 at 8:00 a.m. Record review of the facility-controlled drug record for Hydrocodone -Acetaminophen (Norco) 10mg/325mg for Resident #2 from 2/1/24 to 2/15/24 indicated 1 tablet had been administered on the following dates and times; *2/1/24 at 8:30 p.m.- signed by ADON B; *2/2/24 at 8:20 p.m.- signed by LVN A; *2/3/24 at 7:30 a.m.- signed by LVN F; *2/3/24 at 7:55 p.m.- signed by LVN A; *2/4/24 at 7:20 a.m.- signed by RN T; *2/4/24 at 7:50 p.m.- signed by LVN A; *2/5/24 at 3:50 p.m.- signed by LVN K; *2/5/24 at 9:50 p.m.- signed by LVN S; *2/7/24 at 12:00 a.m.- signed by LVN S ; *2/7/24 at 5:50 p.m.- signed by LVN F; *2/9/24 at 12:42 a.m.- signed by LVN A; *2/9/24 at 6:35 p.m.- signed by LVN S; *2/10/24 at 3:00 p.m.- signed by LVN K; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 11 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 *2/10/24 at 7:30 p.m.- signed by LVN S; Level of Harm - Minimal harm or potential for actual harm *2/11/24 at 9:45 p.m.- signed by LVN S; *2/12/24 at 6:10 p.m.- signed by LVN F; Residents Affected - Few *2/13/24 at 7:20 a.m.- signed by LVN F; *2/13/24 at 7:36 p.m.- signed by LVN A; *2/14/24 at 8:40 a.m. - signed by LVN K; *2/15/24 at 4:30 a.m. - signed by LVN S; and *2/15/24 at 3:00 p.m. - signed by LVN K; and *2/15/24 at 10:00 p.m. - signed by LVN S. Record review of Resident #2's MAR for February 2024 did not record any administration of Hydrocodone -Acetaminophen (Norco) 10mg/325mg 1 tablet on the following dates and times; *2/2/24 at 8:20 p.m.; *2/3/24 at 7:55 p.m.; *2/4/24 at 7:50 p.m.; *2/7/24 at 12:00 a.m.; *2/7/24 at 5:50 p.m.; *2/9/24 at 6:35 p.m.; *2/10/24 at 3:00 p.m.; *2/10/24 at 7:30 p.m.; *2/11/24 at 9:45 p.m.; *2/13/24 at 7:36 p.m.; *2/14/24 at 8:40 a.m.; *2/15/24 at 4:30 a.m.; *2/15/24 at 3:00 p.m.; and *2/15/24 at 10:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 12 of 13 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 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 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 - Few During an interview on 2/14/24 at 12:12 a.m., LVN K said she regularly administered Resident #2 her PRN Tylenol #3 and Norco. LVN K said she always signed the narcotic out of the facility-controlled drug records but could not say for sure she always documented the administrations on Resident #2's MAR. LVN K said she should have ensured the medications were both signed out on the controlled drug record and documented on the MAR. LVN K said she usually referred to the controlled drug records to see if the drugs could be administered because she knew she was not the only nurse one forgetting to document medication administration on the MAR. During an interview and observation on 2/16/24 at 2:00 p.m., Resident #2 laid in her bed. Resident #2 said she was always administered her pain medications when she asked for them and said her pain medications relieved her pain. Resident #2 said she was not in any pain at that moment. During an interview on 2/16/24 at 3:00 p.m., LVN F said she regularly administered Resident #2 her PRN Tylenol #3 and Norco. LVN F said it was not acceptable to sign a medication out on the controlled drug records and not document the administration on the MAR. LVN F said the signing out a drug on the controlled drug records indicated the time and date the medication was pulled and documented the new count the count (amount remaining of the medication after 1 dose was pulled for the resident). of the medication. LVN F said the MAR was to be the record of the administration to the Resident. LVN F said regarding signing out on the controlled drug records on 2/3/24 and 2/7/24, she must had forgotten to document on the MAR. During an interview on 2/16/24 at 3:15 p.m., LVN R said she did not regularly administer PRN pain medications to Resident #2 but had done so occasionally. LVN R said PRN pain medications that were controlled substances should be signed out on the controlled drug records. LVN R said the administration of those PRN pain medications should be documented on the resident's MAR. LVN R said she must have forgotten to document her the administration of Tylenol #3 to Resident #2 on 2/11/24. An interview with LVN S regarding incomplete documentation of medications was attempted on 2/14/24 and 2/16/24 but was not completed. An interview with LVN A regarding incomplete documentation of medications was attempted on 2/14/24 and 2/16/24 but was not completed. During an interview on 2/16/24 at 4:00 p.m. the DON said it was not acceptable that nurses had not documented Resident #2's PRN medications on the MAR. The DON said the nurses' documentation on the controlled drug records indicated time and date the medication was pulled and the count of the controlled medication after the medication was signed out. The DON said it (the controlled drug record) was not intended to be the administration record. The DON said there had not been any system in place to ensure nurses were documenting prn pain medications on the MAR but would ensure one was put in place and would start in-services right away. During an interview on 02/16/24 at 4:05 p.m., the Administrator said he expected nurses to document pain medication administration on the MAR and ensure accuracy of the medical record. Record review of the facility's policy and procedure titled Charting and Documentation, revised April 2008, stated Policy Statement- All services provided to the resident, .shall be documented in the medical record. Policy Interpretation and Implementation - (1) All observations, medications administered, services performed, etc., must be documented in the resident's clinical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 13 of 13