Health inspection·April 27, 2023

F 0578 Record review of the clinical record for Resident #1 revealed an Order Summary with the following order: Level of Harm - Minimal harm or potential for actual harm Code Status: DNR (with a start date of 6-10-2022) Residents Affected - Few Record review of the clinical record for Resident #1 revealed a DNR dated 6-10-2022 (by Resident #1's legal guardian) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no information in the Directive by Two Physicians section. Resident #2 Record review of the face sheet dated 4-27-2023 in the clinical record for Resident #2 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow, and malnutrition (lack of proper nutrition). Under the section Advanced Directives Resident #2 was listed as a DNR. Record review of the clinical record for Resident #2 revealed the last MDS completed was a quarterly dated 4-17-2023 with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring one to two-person assistance with activities. Record review of the clinical record for Resident #2 revealed a care plan with problem start date 1-13-2023 with the following: Code Status: DNR Record review of the clinical record for Resident #2 revealed an Order Summary with the following order: Code Status: DNR (with a start date of 1-13-2023) Record review of the clinical record for Resident #2 revealed a DNR dated 12-22--2022 (by Resident #2) with the following: Section-Physician Statement-there was no date of when the physician signed the DNR form. Section-All person who have signed about must sign below, acknowledging that this document has been properly completed-there were no secondary signature in this section for Resident #2. Resident #3 Record review of the face sheet dated 4-27-2023 in the clinical record for Resident #3 revealed a [AGE] year-old male resident admitted to the facility originally on 2-10-2023 and readmitted on [DATE], discharged [DATE] with status listed as expired. Resident #3 had diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 2 of 7 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 04/27/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vessels that supply it), pneumonia (lung inflammation caused by a bacterial or viral infection), seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), alcoholic cirrhosis of the liver (an advanced sage of alcoholic liver disease that cause your liver to become stiff, swollen, and barely able to do its job). Under the section Advanced Directives Resident #3 was listed as a DNR. Record review of the clinical record for Resident #3 revealed the last MDS completed was a quarterly dated 4-17-2023 with a BIMS of 4 indicating he was severely cognitively impaired, and he had a functionality of requiring one to two-person assistance with all his activities. Record review of the clinical record for Resident #3 revealed a care plan with the following: Problem start date 2-10-2023 Code Status: DNR Problem start date 4-6-2023 Resident is on Hospice Record review of the clinical record for Resident #3 revealed an Order Summary with the following order: Admit to Hospice (Start date of 4-4-2023) Resident #3 did not have an order for Code Status of DNR. Record review of the clinical record for Resident #3 revealed a DNR dated 3-30-2023 (by Resident #3's legal guardian) with the following: Section-Physician Statement-there was no date of when the physician signed the DNR form. During an interview on 4-27-2023 at 1:07 PM, LVN A (the nurse for 300 Hall responsible for Resident #1 this shift). LVN A reported that she would look at the shift report sheet to determine if a resident was a full code or a DNR and if they were full code then if that resident was not breathing or did not have a heart rate then she would start CPR but if that resident was a DNR then she would hold CPR and notify the physician. LVN then checked the report sheet and verified that Resident #1 was a DNR. LVN A reported that she would not start CPR if Resident #1 did not have a heartbeat or was not breathing. LVN A checked the computer system and reviewed Resident #1's DNR form and reported that there was no information in the physician section and therefore the DNR was not complete and therefore invalid. When asked again LVN A reported that if Resident #1 was found without a heart rate and/or breathing LVN A would start CPR since Resident #1's DNR was not valid. During an interview on 4-27-2023 at 1:13 PM RN B (the nurse for 100 Hall responsible for Resident #2 this shift). RN B reported that she would verify that a resident was a full code or a DNR. If the resident was a DNR then she would not take measure to resuscitate them. She would notify the family and physician. RN B checked the computer and reported that Resident #2 was a DNR and therefore she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 3 of 7 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 04/27/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm would not start CPR if she found the Resident #2 without a heart rate and/or respirations. RN B then pulled up Resident #2's DNR form on the computer and reported that the DNR form did not have a date of when the physician signed the DNR form. RN B reported that the DNR form was not valid without the physician dating the form and if Resident #2 was found without a heart rate and/or respirations she would have to start CPR. Residents Affected - Few During an interview on 4-27-2023 at 1:21 PM the DON and SW both reviewed Resident #1's DNR form and verified it was missing all the information in the physician's section, Resident #2's was missing the residents second signature and the date of when the physician signed the DNR form, and Resident #3's was missing the date of when the physician signed the DNR form. The DON reported that it is the admitting nurse's responsibility to determine the code status and verify the form, she (the DON) verifies the form, and the social worker is responsible for verifying the accuracy of the DNR forms. The Social Worker agreed with this statement and reported that these three DNR forms were just missed. The DON reported that if the DNR form is not correct then staff will have questionability on what process to follow and that resident wishes will not be honored. The Social Worker reported that resident preferences could be ignored. The DON reported that she had been on this job for two weeks and would have to verify what the facility's current process for checking DNRs was with administration and she would develop a check list to ensure future accuracy. Record review of facility provided policy titled Advanced Directive, revised 10-1-2020, revealed the following: Policy: The facility recognized the residents right to formulate an advanced directive Intent This policy and procedure provide instruction to the facility staff for obtaining honoring and implementing advance directives to the fullest extent of the law. Procedure: The facility can recognize only those advance directive measure or agents for which they have received appropriate documentation. In the absence of appropriate DNR identification or orders, the facility staff will respond to medical emergencies with CPR measures and a full code will be instituted. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 4 of 7 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 04/27/2023 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. Based on observation, interview, and record review; the facility failed to ensure medications were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication carts reviewed for medication storage. The 300 Hall medication cart had a bottle of Novolog inulin that had been in the cart for 45 days. The 100 Hall medication cart had 5 insulin pens that had no resident labeling and no open/expiration dates. The facility's failure to ensure medications were labeled and stored in accordance with currently accepted professional principles could result in ineffective treatment resulting in exacerbation of their disease process. Findings include: During an observation and interview completed on 4-26-2023 at 1:56 PM a bottle of Novolog 70/30 insulin was noted in the 300 Hall medication cart with the open date marked on the box and the bottle for 3-12-2023. LVN C verified that the insulin had been accessed and used and reported that the insulin was out of date. LVN C reported that she would pull the bottle and replace it immediately. LVN C reported that if a resident uses an expired insulin that they will need to monitor for adverse reactions and an incident report will need to be completed. During an observation and interview completed on 4-26-2023 at 2:03 PM the 100 Hall medication cart was reviewed with staff member RN D with the following noted: A Humalog pen with no markings on the pen identifying what resident it was used for. There were no markings of when the pen was opened or when the pen would have expired. The pen cap and safety cover had been removed indicating the medication had been accessed and used. A Tresiba Flex Pen with no markings on the pen identifying what resident it was used for. There were no markings of when the pen was opened or when the pen would have expired. The pen was noted to have been 1/3 of the medication missing. A Tresiba Flex Pen with no markings on the pen identifying what resident it was used for. There were no markings of when the pen was opened or when the pen would have expired. The pen was noted to have been 2/3 of the medication missing. A Lantus Pen with no markings on the pen identifying what resident it was used for. There were no markings of when the pen was opened or when the pen would have expired. The pen cap and safety cover had been removed indicating the medication had been accessed and used. n. The pen was noted to have a sticker on the pen that read Discard 28 days after opening. Humalog pen with no markings on the pen identifying what resident it was used for. There were no markings of when the pen was opened or when pen would have expired. The pen cap and safety cover had been removed indicating the medication had been accessed and used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 5 of 7 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 04/27/2023 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 Per interview with RN D who verified each of the 5 insulin pens were not marked with open/expiration dates or resident information and that they had been used for resident treatment. RN D then reported that if she needed to use one of the insulins, she would check the residents blood sugar as she had this morning and then she would find whatever type of insulin the resident uses, and she would administer it. RN D reported that using an insulin that was expired or for the wrong resident could result in an insulin that does not work which could result in the resident getting sick. It could also mean they are not going to get the insulin they need. During an interview on 4-26-2023 at 2:15 PM the Administration checked the 5 insulin pens from the 100 Hall medication cart and reported that with her limited nursing knowledge she could verify that none of the insulins were marked with the date they were opened or the date that they would have expired. The Administrator reported that she could not respond to marking the insulin pens with the resident's information because that was beyond her knowledge. During an interview on 4-26-2023 at 2:18 PM the DON checked the 5 insulins from the 100 Hall medication cart and verified that the insulins were not marked correctly with the open/expiration date or the resident information. The DON reported that insulins should be marked when they are opened so they can be discarded in 28 days. The DON reported that using the wrong insulin or an expired insulin can result in harm to a resident, it can inflict harm. The DON reported that each nurse each shift should check their cart and review if for cleanliness and compliance with regulations. Review of the facility provided policy titled Medication Management Program revised 7-13-2021 revealed the following: Procedures: 9. Medications supplied for an individual patient/resident are not administered to another patient/resident/ 13. Medications with defaced or illegible labels, or medications with an order change or patient/resident room change are returned to the pharmacy for re-labeling. 15. Outdated medications is destroyed or returned to the pharmacy according to applicable statue rules and regulations. h. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products, (e.g. inhalers, insulins .) with the dated opened and follow manufacturer/supplier guidelines with respect to expiations dates. 14. The authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements. Per accessdata.fda.gov the following was noted Lantus Storage: Opened vials, whether or not refrigerated, must be used within 28 days after the first use. They (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 6 of 7 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 04/27/2023 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 must be discarded if not used wihhing 28 days. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 7 of 7