Health inspection·October 13, 2022

F 0692 07/20/22 140.8 pounds DON Level of Harm - Minimal harm or potential for actual harm 08/04/22 141.7 pounds DON 08/10/22 136.6 pounds DON Residents Affected - Few 08/19/22 143.6 pounds DON 09/06/22 144.3 pounds DON 09/13/22 134.8 pounds DON 10/05/22 133.9 pounds RA 10/12/22 136.2 pounds RA During an interview on 10/12/22 at 02:25 PM DON was asked about Resident #19's weight loss of 7.21% over the last month. She said they keep track of that monthly. When asked if Resident #19's physician had been notified regarding her recent weight loss, DON said yes. When asked for proof of this notification, she said she would find it and submit the documentation. During an interview on 10/12/22 at 02:32 PM DON said she was looking into Resident #19's weights as the Hoyer lift often skews the weights and she usually has 'them' reweigh Resident #19. During an interview on 10/13/22 at 09:27 AM DC was asked if the facility notified her regarding Resident #19's weight loss from 09/06/22 to 09/13/22? She stated, You know what, they did. They did let me know. When asked if she did anything to address Resident #19's weight loss she replied, No ma'am I did not. When asked why not she stated, Straight up embarrassing human error. DC said typically when a resident loses more than 5% of their body weight in a month she would, .evaluate and look at intake and diet and see what might have caused that (the weight loss). With (Resident #19) in particular I would want to find out why? With tube feeding; was she sick; did she have an infection; did she refuse the bolus? And then I would adjust feeding accordingly. When asked why she made a new progress note for Resident #19 on 10/12/22, DM stated, I spoke to (DON) yesterday and she asked me about this, and I went back through my emails. I am so embarrassed I just flat, I missed it I sure didn't do it on purpose. When asked why the most recent note (dated 10/12/22) stated Resident #19 is within range for her weight at 133.9 pounds but a prior note by DC (dated 03/16/22) stated Resident #19 is within range from 145 to 136 pounds, DC stated, Well, um, I'd have to go back and look it up real quick. She had been, she had gotten, the family said they wanted her to lose some weight. I do agree that obviously, yes, she did have an important weight variance and weight loss within that month of September. She's (Resident #19) been there a long time she had gotten a little overweight so we kind of cut back on her feeding and stuff and I don't know what happened. In my mind, I think next time they weigh her we'll see if it is back up. Weights are a science. They really are. During an interview on 10/13/22 at 09:51 AM DON stated the facility's policy regarding weight loss was not followed with Resident #19. (The policy states that any Resident with a weight loss of 5% or more will be reweighed within 24 hours.) DON said she told the staff in charge of weighing residents to reweigh anyone who showed a large loss or gain just to be sure the first result was correct. She also mentioned issues around which Hoyer lift is used. When asked why, if the Hoyer lift was responsible for the discrepancy in Resident #19's weight, the policy was not followed to reweigh her, DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 2 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, We reweigh them that day. The restorative aids are the ones that do the weighing. I was doing all the weights because we didn't have an ADON and then (RA) picked up. She said of Resident #19, The main thing with her is she had Covid. It could be what caused it (Resident #19's weight change). Any little thing can trigger her to act up; her anxiety is so bad. DON was asked if the policy was followed in that the family, physician, and dietician were notified, and the notifications documented per facility protocol. She said, I send her (DC) the weights every time we get them. She said of the email from DC and the weekly weights sheet dated 09/18/22 through 09/24/22 which DON said was attached to the email, That's all I have because in 60 days everything falls off (speaking about her emails being automatically deleted). I enter (the weights) in computer, doctor comes once a week, and we tell him what we have. We let the PA or NP and food service manager know what's going on verbally and doctor gets what is documented in the chart. DON was asked for documentation showing DC, family, and doctor were notified but she could not provide documentation. When DON was asked what is typically done when a resident has a significant weight loss, she stated, We call her (DC) immediately and let her know and she addresses it. She can put orders in. Of Resident #19, DON said, She is usually a reweigh every time and it (Resident #19's weight) is usually back to the normal spot. DON said Resident #19's care plan was not updated per facility policy because of the change over from one person to another doing the weighing. During an interview on 10/13/22 at 10:17 AM DON looked at the weights in Resident #19's EHR and compared them to the documentation she submitted. She said it looks like the last two weights for September were not entered into the EHR. When asked how the doctor would know about the last two weights for September if they are not entered into the EHR, she said he would not know about them. Record review of Resident #19's dietary progress notes revealed an entry from 03/16/22 by DC. In this entry DC noted Resident #19's usual body weight range is between 136-145lbs. In another entry by DC dated 10/12/22 she noted Resident #19's preferred range of 133 lbs. Record review of Resident #19's progress notes indicated the following: On 08/18/22 02:04 AM feeding running well On 08/19/22 at 02:12 AM continuous feeding running well On 08/20/22 at 11:43 AM PEG tube per orders, flowed and tolerated well On 08/21/22 at 04:56 PM Mrs. (Resident #19) continues on isolation in Covid unit due to positive covid results, Mrs. (Resident #19) remains asymptomatic. On 08/22/22 07:10 PM PEG tube is patent and flowing via gravity, Bolus feedings given this shift per orders resident tolerated well. On 08/23/22 at 03:06 AM Resident has no signs or symptoms of COVID at this time .feeding running without complications at this time. On 08/24/22 at 05:31 AM Resident has no signs or symptoms of COVID at this time .Resident's PEG tube patent; flushing well, feeding running without complications at this time. On 08/25/22 at 07:00 PM resident tolerated bolus feedings well (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 3 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0692 On 08/26/22 at 06:04 PM resident tolerated boults [sic] feedings well. Level of Harm - Minimal harm or potential for actual harm On 08/29/22 at 12:21 PM voicemail left informing family of room change Record review revealed no progress notes for Resident #19 in the month of September. Residents Affected - Few Record review of Resident #19's physician order report revealed the following: On 01/23/20 an order for tube feeding On 10/12/22 an order to monitor weights x 4 weeks for evaluation of stable weight . Record review of paperwork submitted by DON as documentation of notification of DC regarding Resident #19's weight loss revealed an email exchange between DON and DC as well as a single sheet of paper DON stated was an attachment to said email. This sheet of paper was titled Weekly Weights [DATE]th thru 24th. No where in the submitted paperwork was there proof the facility notified DC of Resident #19's weight loss from 09/13/22 as had been requested. Record review of facility policy titled Nursing Policies and Procedures Preventing or Mitigating Undesirable Weight Loss and dated 07/01/16 revealed the following: POLICY: The Registered Dietician Nutritionist/Designee will review the patient/resident's nutritional status to prevent and control undesirable weight loss . 8. Address significant weight loss or gain in the dietary progress notes and by developing and/or updating the plan of care. Record review of facility policy titled Nutrition Policies and Procedures Weighing the Resident and dated 08/01/20 revealed the following: 2. If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed within 24 hours. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Nutrition Services Director. Document this notification via facility protocol. 5. The facility dietician review the patient's/resident's nutritional status and makes recommendations for intervention int eh nutritional progress notes if significant weight change is noted. 6. Review significant, unplanned changes and insidious gradual weight loss or gain trends in weights at the Quality of Care Committee meeting. 7. Update the plan of care with goals and approaches/interventions listed. 8. Percent body weight (wt) change is calculated using the following formula: Note: usual weight refers to the weight over a period of months or years while actual weight refers to the accurately recorded weight of the past several days or weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 4 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0692 % body wt. change = usual wt - actual wt x 100 Level of Harm - Minimal harm or potential for actual harm usual wt Residents Affected - Few 9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week 5% in 30 days 7.5 % in 90 days 10% in 180 days FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 5 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; it was determined the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 3 medication carts and 1 of 1 medication rooms reviewed for medication storage for Resident's #8, #62. Two insulin medications in the 300-Hall medication cart were not marked with the date they were opened and accessed LVN B did not administer or store a medication properly. Review of the facility's medication room revealed 5 OTC medications that were expired. The facility's failure could place residents receiving medication at risk for administration of medication incorrectly or that are ineffective resulting in exacerbation of the disease being treated or the introduction of infection from contamination. Findings include: Record review of Resident #8's face sheet dated 10/13/22 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it), dysarthria (weakness in the muscles used for speech), aphasia (loss of ability to understand or express speech), memory deficit, muscle wasting (a decrease in size and wasting of muscle tissue), and type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #8's last MDS completed 7/13/22 was a quarterly listing him with a BIMS of 9 indicating he was moderately cognitively impaired and that he had a functionality of set-up to one-person to two-person assistance with activities of daily living. Record review of Resident #8 care plan with an admit date of 12/16/20 revealed he was care planed for diabetes to include hyper-hypoglycemic episodes. During an observation and interview completed on 10/11/22 at 11:45 of the 300 Hall medication cart with LVN B the following was noted: Resident #8's Novolog pen was not dated on the pen of when it was opened/accessed. The pen had a sticker that read as follows: Discard 28 days after opening-with a section to mark the date of when the pen was opened that was not marked. LVN B assessed the insulin pen and when asked to verify the amount of insulin left in the pen stated, It's getting close to empty. Resident #8's Lantus insulin pen had no date on the pen of when it was opened/accessed. This insulin pen also had a sticker that read as follows: Discard 28 days after opening-with a section to mark the date of when the pen was opened that was not marked. When questioned LVN B confirmed that she had given insulin from this Lantus insulin pen this AM and stated, there is barely any insulin left in this insulin pen. When questioned if either insulin pen was marked with a date of when they were opened/accessed LVN B stated, I do not see them. There is not a date on them. LVN B confirmed that the insulin pens were supposed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 6 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0761 Level of Harm - Minimal harm or potential for actual harm have a date of when they are accessed/opened so that staff will know when the insulin will expire. When asked what could happen if the insulin is not marked correctly with the access/open date LVN B stated, It would not be good. The resident could receive a medication that could not be affective. When asked to verify the stickers on both insulin LVN B looked and stated, it says to discard after 28 days. I will throw both away immediately and replace them. Residents Affected - Some Record review of Resident #62's face sheet dated 10/12/22 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] for diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), repeated falls, acute sinusitis (a condition in which the cavities around the nasal passages become inflamed), constipation (when a person passes less than three bowel movements a week, or has difficult bowel movements), muscle weakness, urinary tract infections, hypertension (a condition in which the force of blood against the artery wall is to high), and heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #62's last MDS completed 9/15/22 was a quarterly listing her with a BIMS of 14 indicating she was cognitively intact, and she had a functionality of requiring set-up assistance with most activities of daily living. Record review of Resident #62's care plan with an admit date of 2/7/21 revealed she was care planned to be a long-term resident with diagnoses of COPD with an approach to administer medication per physician orders. Resident #62 had no care plans for self-administration of medications. During an observation on 10/12/22 at 09:17 AM Resident #62 exited her room with an Advair Disc (a bronchodilator (a drug that causes widening of the bronchi) used to treat symptoms of asthma and chronic obstructive pulmonary disease) and lay the disc on the treatment/medication nurses' cart in the 300 Hallway. This surveyor observed 4 different residents in the hallway near this treatment/medication cart to include two self-propelling in their wheelchairs past the treatment/medication cart that had access to the Advair Disc. Also observed the medication aide pulling medications across the hall from the treatment/medication cart. Noted 3 staff member to include therapy and 2 aides walk past the cart with the Advair Disc still placed on top of the cart and in plain view. During an interview on 10/12/22 at 09:29 AM Resident #62 was in her room sitting on her bed wearing her O2. Resident #62 reported that LVN B brought the Advair Disc to her before she went to breakfast to keep in Resident #62's room so she could take the medication immediately after breakfast. Resident #62 confirmed that she had the Advair Disc in her room since before breakfast. Resident #62 reported that this happens regularly, that she will return from breakfast, immediately use the Advair Disc, then return/place it on top of the medication cart in the hallway for the nurse to put back in the cart. During an interview on a10/12/22 at 09:31 AM LVN B returned to the 300 Hall Treatment/Medication cart and began to set up for treatments. LV B noticed the Advair Disc and removed it from the top of the cart and placed it in one of the drawers. When asked if the Advair Disc was supposed to be left out, LVN B stated, Yes. This is for Resident #62, and I had dining room duty this morning. Resident #62 likes to get it at a certain time, so I gave it to her early and she leaves it in her room and takes it after breakfast. When asked again if she left the medication with the resident LVN B stated, Yes I left it in her room. I handed it to her, and she brought it to me when she was done. During an interview on 10/12/22 at 10:23 AM the administrator entered the conference room and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 7 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated to this surveyor, Just to let you know we are starting an in-service on Medication Management, and we are sending that nurse (LVN B) home and we are not sure we are going to let her come back. During an interview on 10/13/22 at 08:52 AM when questioned if a resident's insulin should be labeled with the open/access date the DON (with the administrator present) reported that she felt the insulins in questioned were accessed by agency staff and that it was at that time that they were accessed and not marked. When asked if facility staff should monitor medication and ensure that it is properly labeled such as the insulin the DON stated, Yes they should be checked. The administrator agreed. The DON verified that they put the dispose of in 28 days on the insulin pens to ensure that they are removed before the medications become ineffective. The administrator agreed with the DON's statements and stated, Its regulation that we do this. When asked what the consequences of not marking the insulins correctly could be both the DON and Administrator reported the medication would not be as effective. When questioned if a medication should be left with a resident to administer and the resident later return the medication to the nurse resulting in the medication being left in the hallway the DON stated, That nurse knew better than to do that. I don't know why she did that. We can't do that. When asked what the results of this practice could be the administrator stated, Any resident could get that medication, that could be a danger to any of them. The DON agreed. During an observation on 10/13/22 at 08:37 AM of the medication storage room with RN C the following was noted: OTC storage drawer contained the following: 3 containers of Aspirin 325 mg 100 tablet unopened with the expiration dated 9/1/22 1 container of Rena Vite 100 tablet unopened labeled expiration date 9/1/22 Storage Bin with Patient specific medications contained the following: 1 bottle of Lactulose 16 fl oz not opened with the discard date of 6/6/22. During an interview on 10/13/22 at 08:38 AM RN C reported that all containers of Aspirin were expired as of 9/1/22, the container of Rena Vite was expired as of 9/1/22 and the 1 bottle of Lactulose was expired 6/6/22. RN C reported that if the medications had been given it would have been a medication error and the medications wouldn't be as effective. RN C reported that she does not know who comes in to check if medications are expired but someone checks them weekly. During an interview on 10/13/22 at 08:54 AM the DON (with the administrator present) stated normally we go in and check the medication room. Pharmacy comes in monthly to discard expired medications and Stat Safe comes quarterly to go through everything in the medication room. The DON stated she believed the reason for expired medications could be due to either a nurse or C/S lady stocking medications that were already expired. The DON stated if the residents received expired medications, it could be ineffective, and it wouldn't have the amount of strength it should have. The DON stated the policy is to rotate and pull the older medications first. Record review of the facility provided training titled Medication Labeling and Dates initiated 10/11/22 revealed the following: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 8 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0761 You must date medication when you open it. Date opened/Start Date. All meds are dated. Level of Harm - Minimal harm or potential for actual harm 2. All medications require a label. Residents Affected - Some The policy attached to this training was titled Pharmacy Services Policies and Procedures dated 11/1/17, revealed the following: Subject: Medication Labeling: 1. Ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates . Record review of the facility provided training titled Medication Management initiated 10/11/22 revealed the following: 1. Authorized staff to administer medications -keep medications secured. Carts to be locked. Nothing dangerous or medications to be left on cart. The policy attached to this training was titled Medication Management Program revised 4/21/21, revealed the following: Subject: Medication Management Program Procedures-Guidelines for Implementing and Efficient Medication Pass Security and Safety Guidelines: 5. No medications, chemicals, or other dangerous articles are left on top of the cart. 16. Medications are dispensed at the time of administration. Pre-pouring or dispensing for a later administration time is not permitted. 11. The authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave a medication in a resident rom without order to do so. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 9 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview and record review, the facility failed to ensure the menu was followed for 2 of 2 lunch meals reviewed for menus and nutritional adequacy on 10/11/2022 and 10/12/2022 for 9 of 18 residents reviewed (Resident #s 6,11,44,46,61,63, 64, 65 and 134) in that: A. Dietary staff did not serve brownies to all residents who were served a regular diet on 10/11/2022 (Residents # 6,11,61,64, 65 and 134) and did not puree brownies for residents (Resident #s 44,46 and 63) who received pureed diets. B. Dietary staff did not serve pureed bread during the noon meal on 10/12/2022 for 3 residents reviewed for pureed diets (Resident #s 44,46 and 63). These failures could place residents who eat regular foods and residents who eat pureed foods at risk of not having their nutritional needs met. Findings included: Record Review for the week of 10/11/2022 through 10/13/2022 revealed the planned menu dated 10/11/2022 for the noon meal was Apple Baked Pork Chop, Fresh Baked Roll, Creamed Spinach, Escalloped Potatoes and Brownies for dessert. The planned menu for 10/12/2022 revealed the noon meal was: Chicken Parmesan, Bread Stick, Seasoned Summer Squash, Buttered Noodles and Peaches. The diet spreadsheet for the noon meal on 10/11/2022 indicated residents on pureed diets received a pureed brownie and residents with a regular diet received a regular brownie. During an observation and interview on 10/11/2022 at 11:00 AM, [NAME] D was preparing pureed foods for the noon meal. [NAME] D stated there were 5 residents on pureed meals. [NAME] D completed pureeing the noon meal foods and had not pureed the brownies. When asked about the brownies she stated residents with a pureed diet were served pudding. When asked if she had asked those residents if they wanted pudding instead of brownies, she said she had not asked them. When asked why she was not serving brownies to all residents she stated the speech therapist said residents on puree could not have brownies. In an interview and an observation on 10/11/2022 at 12:17 PM, Resident # 64 's regular meal tray did not have a brownie. Resident # 64 stated he wanted a brownie. He said his tablemate got a brownie and he got fruit. He stated no one had asked him if he wanted fruit instead of a brownie. During an observation on 10/11/2022 at 12:30 PM, Resident #134's meal tray did not have a regular brownie. He stated he loves brownies and anything chocolate. He stated he did not know why he did not get a brownie for lunch. He stated he wanted a brownie. In an interview and observation on 10/11/2022 at 12:31 PM, Resident #61's family member stated she did not know why Resident #61 got fruit instead of a brownie. She stated she thought it bothered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 10 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #61 because she did not get a brownie. She stated Resident #61 was looking for the brownie when she got her tray. She further stated Resident #61 loves brownies and has been losing weight. She further stated Resident #61's trays rarely ever have what she was supposed to have. In an interview and observation on 10/11/2022 at 12:37 PM, Resident #6's meal tray did not have a regular brownie. Resident # 6 was served fruit cocktail instead. Resident # 6 said she would like a brownie and did not know why she did not get one. In an interview and an observation on 10/11/2022 at 12:40 PM, Resident #63's meal tray did not have a pureed brownie. Resident #63 received fruit. Resident #63 stated she wanted a brownie. She stated no one had asked her if she wanted fruit instead of a brownie. She said everyone else had a brownie. She stated it made her feel left out. She said Everyone at my table got a brownie except me. In an interview and observation on 10/11/2022 at 12:22 PM, Resident #44's pureed meal tray did not have a pureed brownie. She stated she did not know why she did not have a brownie. She stated she would like a brownie. During an observation on 10/11/2022 at 12:34 PM, Resident #11's meal tray did not have a regular brownie. During an observation on 10/11/2022 at 12:34 PM, Resident #65's meal tray did not have a regular brownie. During an observation of the noon meal on 10/12/2022 the following was observed: During an observation on 10/12/2022 at 12:21 PM, Resident #44's meal tray did not have any pureed bread. During an observation on10/12/2022 at 12:23 PM, Resident #46's meal tray did not have any pureed bread. During an observation on 10/12/2022 at 12:26 PM, Resident #63's meal tray did not have any pureed bread. In an interview on 10/13/2022 at 10:10 AM the ST was asked about diets for residents on puree. She stated she had not told anyone in the kitchen, that residents on puree could not have brownies. When asked if a resident on puree could choke on a brownie, she said brownies do not usually get stuck in someone's throat and would not cause choking. She stated as long as the brownies were pureed correctly the residents could have brownies. She further stated there was only one resident (Resident #44) on her treatment that could not have pureed bread at this time. In an interview on 10/13/2022 at 9:15 AM the RD stated all residents are on a liberalized diet and diabetics can have everything residents on a regular diet could have. She stated the regular diet meets the criteria of the American Heart Association. Diabetic residents have a liberalized diet as well. The RD stated all residents should have been served what was on the menu. The RD stated the corporate office calculated all foods listed on each menu to make sure all residents have the correct diet and balanced nutrients. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 11 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 10/13/2022 at 1:30 PM, the DM stated she was aware brownies were not served to all residents for the lunch meal on 10/11/2022. The DM stated first the dietician told her residents on a pureed diet could not have brownies. The DM stated she thought brownies were bread. She stated she did not ask residents what they wanted. She stated the residents with a pureed diet were served pudding or fruit. When asked why pureed bread was not served at the noon meal on 10/12/2022 she called [NAME] D over and asked [NAME] D if she made the pureed bread. [NAME] D stated she had not made pureed bread for the lunch meal on 10/12/2022. [NAME] D stated she forgot to make the bread. When the DM and [NAME] D were asked what the consequences of not serving the menu as written both had to be prompted for an answer. Both the DM and [NAME] D agreed weight loss could be a big consequence of not getting all the foods served on the menu. The DM stated she had received training from the dietician. The DM stated she had been doing training in the kitchen as well. Record Review of the facility policy titled, Menus dated 08/01/2020 revealed: Policy: Menus will be planned to meet the nutritional needs and preferences of the residents and are in accordance with the recommended daily allowances of the food and Nutritional Board of the National Research Council, National Academy of Sciences. Procedures: 1. Utilize facility menu to best fit the preferences of the resident. Record Review of the policy titled, Meal Service dated 08/01/2020 revealed the food and nutrition dept will check trays for accuracy to ensure the diet order and tray ticket was followed, serve foods that meet the resident's preferences, serve foods in a form designed to meet individual consistency needs, e.g., chopped ground, pureed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 12 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 2 of 13 residents (Resident #55 and #56) reviewed for hospice care. Resident #55 had no information in the facility provided by the treating hospice. Resident #56 had no information in the facility provided by the treating hospice. The deficient practice could affect residents currently residing in the facility receiving hospice care resulting in not receiving the needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident #55's clinical record face sheet dated 10/11/22 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroy memory and other important mental functions), pain, chronic ulcer (underlying tissue damage or trauma has caused skin loss), hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a chronic condition in which the hear doesn't pump blood as well as it should), osteomyelitis (inflammation of bone caused by infection, generally in the legs, arms, or spine), dysphagia (difficulty swallowing foods or liquids), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record Review of Resident #55's last MDS was a quarterly completed on 8/24/22 listed her with a BIMS of 3 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with most activities of daily living. Section O Special Treatments, Procedures, and Programs, Resident #55 was listed as Hospice Care while a resident. Record review of Resident #55's clinical record revealed a physicians order with a start date of 2/14/22 that read admit to the facility for hospice care. End Date: Open Ended. Record review of Resident #55's clinical record revealed a care plan with the following: Start Date: 5/22/22 Pressure Ulcer-Wound Team/Hospice Team to evaluate wounds Start Date: 2/24/22 ADL Function-Assist with bathing when hospice in unavailable. Start Date: 2/24/22 Resident is under hospice care. During an interview on 10/11/22 at 03:43 PM when asked to find the hospice coordination book to determine Resident #55's DNR status, the DON looked in both cabinets behind the nurse's station and stated, It's supposed to be here, but I can't find it. It's not in the bookcases where we keep them. I guess it's not here. The ADON stated she was on the phone with the hospice for Resident #55 and they told her they were currently working on this residents care coordination book and that is the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 13 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0849 reason why the care coordination book is not in the building. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/22 at 03:56 PM the ADON stated, I just talked with Resident #55's hospice and they told me they don't do the notebooks now. Resident #55's hospice told me they are going to bring use a plan of care, so we have that information. When asked if the facility had any information from Resident #55's hospice the ADON stated, No we don't have any information from that hospice right now. Residents Affected - Few During an interview on 10/11/22 at 04:26 PM the ADON stated, Resident #55's hospice brought us all new books with all the required resident information just now, so we do have what we need at this time. Record review of Resident #56 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #56's face sheet listed the following diagnoses: respiratory disease (a type of disease that affects the lungs and other parts of the respiratory system), obstructed urine flow (a blockage in one or both of the ureter tubes that carry urine form the kidneys to the bladder), depressive episodes (a period when a person will experience a low or depressed mood), dysphagia(difficulty swallowing foods or liquids), panic disorder (an anxiety disorder where you regularly have sudden attacks of panic or fear), personal history of intestinal cancer (a cancer of the colon or rectum, located at the digestive tract lower end), repeated falls, and vertebral bone infection (an infection involving the spine). Record review of Resident #56's last MDS was an annual MDS, dated [DATE] listing her with a BIMS of 10 indicating she was moderately cognitively impaired, and she has a functionality of requiring 2-person extensive assist with all ADLs except for eating, which requires only 1-person supervision. Record review of Resident #56's clinical record revealed a physicians order with a start date of 8-19-2020 that reads admit to hospice care. End Date: Open Ended. Record review of Resident #56's clinical record revealed a care plan with the following: Start Date: 8/20/20 Resident #56 is on hospice. During an interview on 10/13/22 at 10:45 AM when asked for the hospice book for Resident #56, the ADON reported she could not find one and that she would look and call Resident #56's hospice During an interview on 10/13/22 11:25 AM the ADON said there was not a hospice book in the building for Resident #56 but that Resident #56's hospice nurse was here today to furnish the book. During an interview on 10/13/22 at 11:28 AM HN A verified that they did not currently have a coordination of care book in the facility that they kept documentation in for the Resident #56. HN A reported that they kept all documentation in their electronic record and if the facility needed the information they were just an email away. When asked how they coordinate a hospice residents care between her hospice and the facility HN A stated, I have several residents and am in here almost daily. Most of our coordination is verbal. I also try to attend the care plan meetings, but I can't always make it. When asked if the hospice provided the facility with a copy of their care plan, visit notes, orders, or physician certification HN A stated, No but as I said before all that information is just an email away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 14 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/13/22 at 09:11 AM with the DON and Administrator when asked for the person responsible in the facility for coordination with the hospice for care both reported that it was the nursing departments responsibility for ensuring that hospice coordination of care was completed, that no one person was currently assigned that duty. When asked if hospice should be providing documentation to the facility of the care, they are providing the DON stated, Yes, they (the hospice) should be charting and keeping a chart on each resident they have. The administrator agreed. When asked if she felt there should be coordination of care between the hospice and the facility the DON stated, Oh yes. The administrator agreed. When questioned if not having information provided from the hospice could cause any issues with resident care the administrator stated, The resident could have the wrong information or code status, but we have all that information updated in our computerize chart. The DON agreed and stated, Typically we have all the information in the hospice book that is supposed to be provided but we keep in in the computer too. When asked if they keep the hospice care plan in the facility computer chart both reported that we have hospice at out care plan meetings, so our care plan is updated with their information. When asked if the hospice physician certification was in the facility computer chart they stated, No. When asked if the hospice visit notes/information was in the resident chart they the DON stated, I don't know on that, I'm not sure. The administrator reported that she was not sure either. Record review of the facility provided policy titled Hospice Care dated 8/29/17, revealed the following: Procedures: 4. To provide continuity of care, the hospice, nursing home, and resident /representative must collaborate in the development of a coordinated care plan . 8. The facility and hospice provider will have ongoing collaborative communication. 10. To address communication regarding the resident care between the nursing home and the hospice the nursing facility will designate a staff person to participate in the congoing communication . Record review of the facility provided contract signed 2/12/20 for the hospice providing care for Resident #55 revealed the following: 2.14 Providing information -Hospice shall promote open and frequent communication with facility and shall provide facility with sufficient information to ensure that provision of services under this agreement is in accordance with the hospice plans of care, assessment, treatment, planning, and care coordination. In addition, at minimum, hospice shall provide the following information to facility for each hospice patient: a-Hospice Plan of Care, Medication, and Orders b-Election Form c-Certification d-Contact information e-On Call Information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 15 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility provided contract signed 2/12/18 for the hospice providing care for Resident #56 revealed the following: 4.3 Hospice shall provide the following information to Nursing Facility for each hospice patient: The most recent hospice plan of care specific to each hospice patient, Hospice election form and any advance directive specific to each hospice patient, Physician certification and recertification of the terminal illness specific to each hospice patient, Names and contact information for hospice personnel involved in hospice care for each hospice patient, Instructions on how to access the hospice 24-hour-on-call system. Hospice medication information specified to each hospice patient. Hospice physician and attending physicians (if any) orders specific to each hospice patient. Event ID: Facility ID: 675498 If continuation sheet Page 16 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. This failure affected the physical, mental, and emotional comfort of 8 of 88 residents. Residents Affected - Some Residents #56, #53, and six residents who wished to remain anonymous expresssed annoyance with the number of flies in the facility. Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Record review of Resident #56's admission Record revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included respiratory disease, obstructed urine flow, depressive episodes, dysphagia, panic disorder, personal history of intestinal cancer, repeated falls, and a vertebral bone infection. Record review of the most recent Care Plan, dated,08/17/22 indicated Resident #56 was bedfast and receiving Hospice care. The Care Plan noted Resident #56's need for assistance with all ADL's. The annual MDS, dated [DATE], revealed a BIMS of 10 (indicating mildly impaired cognition) and a need for 2-person extensive assist with all ADL's except for eating which required only 1-person supervision. Record review of Resident #53's admission Record revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included after effects of stroke, lack of coordination, reflux disease, cognitive communication deficit, opioid dependence in remission, stimulant dependence in remission, schizophrenia, schizoaffective disorder, bipolar disorder, and seizures. Resident #53's most recent Care Plan was dated 08/05/22. An annual MDS, dated [DATE], revealed a BIMS of 13 (indicating intact cognition) and a need for 1 to 2-person assist with all ADL's. During an observation and interview on 10/11/22 at 08:39 AM Resident #56 was lying in bed with her breakfast tray on the over bed table. There were 4 flies on her blankets and her breakfast tray and one fly on the wall near the head of her bed. When asked if the flies bother her, she stated, Oh, well, yes. They clean me and it don't seem to make much difference. I guess with my condition, needing to be cleaned, they are always here. I've heard some of the others talk about them too. During an observation on 10/11/22 at 10:26 AM Resident #56 was asleep leaning slightly to her left. The head of her bed was raised and there were two flies on her blanket. During an observation and interview on 10/11/22 at 11:12 AM Resident #53 was sitting in his wheelchair in his room. He said of flies in the facility, They are all over the damn place. I can pick up my phone and order fly swatters. But (LVN F) who works here said I can't have them because they are bad in the dining room. She said that I can't have the swatters because it is nasty and unsanitary to kill them (flies). But do you know what a fly does when it lands on something? It vomits and it shits! Which do you think is more unsanitary? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 17 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/11/22 at 12:09 PM Resident #56 was awake in bed with the head of the bed raised. There were 3 flies on her blanket and one landed on her face and one landed in her hair. She shooed the flies away with her right hand and said, These flies are about to get me! I guess they smell the BM (bowel movement) or the food. The people next door have talked about them too. During an observation on 10/11/22 at 12:28 PM 5 flies observed in the dining room, 4 on tables where residents were eating and 1 on the shoulder of a resident who was eating. During an anonymous interview on 10/12/22 at 10:47 AM several residents were asked about flies in the facility. Anonymous Resident #1 stated, Oh boy! Now that's a deal! Anonymous Resident #2 stated, I handed out fly swatters the other day, I had my daughter buy them for me. Anonymous Resident #3 stated, But then if you miss them (flies with the fly swatter) it just makes them mad. Anonymous Resident #4 stated, They just come right back and sit on your face! Anonymous Resident #5 stated, There is an overabundance of flies this year. I mean, we always have them, but this year is bad! Anonymous Resident #6 stated, They are everywhere! During an interview on 10/12/22 at 11:32 AM ADM, said she thinks MS called pest control and had them make a special trip because the last week or so the flies have been pretty bad. She said pest control comes on a regular monthly schedule, but she thinks they came an extra time at the end of last week. She said, I've been thinking I might need to go buy some flyswatters. During an observation and interview on 10/12/22 at 12:13 PM Resident #56 was in bed with the head of the bed raised to a sitting position and pureed lunch on the over bed table. There were two flies in her room that kept flying back and forth and landing on the bedding, lunch plate, tea glass, and Resident #56's hair. Resident #56 shooed a fly with her hand and said, We have ants and bugs all over the place. No matter what you pick up, there they are. During an observation on 10/12/22 at 12:20 PM two flies were observed in the dining room on two different tables with residents sitting and eating at both tables. During an interview on 10/12/22 at 12:23 PM MS said he does think pest control came out an extra time recently to spray the room of a particular resident. He said the need for it was mentioned in morning meeting and he called pest control. He retrieved the (name of pest control) book and displayed receipts for monthly visits from July through October. He said pest control comes once a month unless they are called to do an extra spraying. During an interview on 10/13/22 at 10:27 AM RN E said she is an agency nurse. She said she remembers Resident #53 being very upset about the flies and about LVN F telling him he would need permission from ADM before he can have his family bring 50 fly swatters to the facility. RN E said Resident #53 was cursing and talking to her while she was doing med pass and was really upset, saying flies are nasty, and things like that. Record Review of Resident #53's progress notes revealed the following: On 10/02/22 at 12:46 PM LVN F noted, Res came up to nurses station stating 'I'm going to have my mom bring me 50 flyswatters and give them to all the residents to kill flies in the dining room' this nurse stated to him 'I don't think you can do that you'll have to ask the administrator, it would be unsanitary to kill flies on the tables' res became angry and self propelled behind the nurse station beside my chair where I was working on charting and stated 'So it's sanitary for flies to vomit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 18 of 19 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 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and shit on my plate? I'm going to send my plate back every time fly lands on my plate' stated to res 'do what you need to do' he became angrier and started cussing this nurse turned back to the computer and continued to chart, res finally self propelled away, informed res nurse of incident. On 10/02/22 at 02:28 PM RN E noted, This resident came up to skilled hallway and started telling CNA and I .'I hate my mother and this nurse up at the nurses desk will not let me bring any flyswatters to kill all these flys.' Attempted to calm resident, not easily redirected at this time. Informed his charge nurse of situation. Record review of the facility's pest control book contained only one receipt for the month of October for 10/07/22. Record review of the facility's pest control policy dated 08/01/20 revealed: (MS) is the designated Integrated Pest Management (IPM) Coordinator for Facility. This person will act as a liaison between Facility and the pest management professional . 2. Facility staff will: A. Note and report any evidence of pest activity (i.e. rodent droppings). All documentation/reports shall be as detailed as possible. B. Report sighting of live pests immediately to the Integrated Pest Management Coordinator to request emergency service to provide additional, unscheduled treatment, as necessary. C. Make note of the exact location of where the pest sighting occurred and inform the Integrated Pest Management Coordinator immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 19 of 19