Health inspection·July 14, 2022

F 0607 Level of Harm - Minimal harm or potential for actual harm AD with a hire date of 1/17/13 with a last EMR/NAR date of 7/13/22 with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of 1/25/16 with no previous criminal history run date and EMR/NAR date of 7/13/22, HR unable to determine last annual criminal history/EMR/NAR run date. Residents Affected - Some LVN-MM with a hire date of 5/2/22 with an EMR/NAR date of 7/13/22, HR unable to determine previous EMR/NAR run date. RN-WA with a hire date of 3/20/18 with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of 8/13/21 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. CNA-AL with a hire date of 3/28/22 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. Record review of facility Resident Abuse Policy revised March 2017 revealed: Our policy is based on the October 3rd in 2006 provider letter number O6-32 regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities (Residents #28, #58, #38). Residents Affected - Some The facility failed to provide activities to Residents #28, #58, and #38 and to the rest of the residents who resided on the Alzheimer's unit. This failure could place residents at risk for decline in social and mental psychosocial wellbeing. Findings included: Review of the face sheet on 07/14/2022 for Resident #28 revealed he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Paralysis of right dominant side, Cognitive communication deficit, Anxiety Disorder, and Loss of expressive speech. Review of Resident #28's MDS dated [DATE] revealed Section C BIMS score was 00 which indicated he had severe cognitive Impairment. Review of Resident #28's Care Plan dated 04/21/2022 for activities revealed: Remind/encourage to attend, assist to activities as needed. Provide for in-room activities as needed and required. Review of Resident #28's Physician's Orders dated 07/01/2022 revealed the resident may participate in activities as tolerated. Review of the face sheet on 07/14/2022 for Resident #58 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified dementia (impaired ability to remember) with behaviors, Osteoarthritis, and High blood pressure. Review of Resident #58's MDS dated [DATE] revealed Section C BIMS score was 00 which indicated she had severe cognitive impairment. Review of Resident #58's Care Plan dated 06/23/2022 for activities revealed: Remind/encourage to attend, assist to activities as needed. Provide for in-room activities as needed and required. Review of Resident #58's Physician's Orders dated 07/01/2022 resident may participate in activities as tolerated. Review of the face sheet on 07/14/2022 for Resident #38 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified dementia (impaired ability to remember) with behaviors, High blood pressure, and Unsteadiness on feet. Review of Resident #38's MDS dated [DATE] revealed Section C BIMS score 03 which indicated severe cognitive impairment. Review of Resident #38's Care Plan dated 05/26/2022 revealed: Remind/encourage to attend, assist to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0679 activities as needed. Provide for in-room activities as needed and required. Level of Harm - Minimal harm or potential for actual harm Review of Resident #38's Physician's Orders dated 07/01/2022 resident may participate in activities as tolerated. Residents Affected - Some Observed on 07/12/2022 at 2:23 PM the activities calendar had dominoes scheduled at 3:30 PM. Observed on 07/12/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of the July 2022 activities calendar revealed at 9:30 AM puzzles was scheduled. Observed on 07/13/2022 at 9:30 AM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar revealed craft time was scheduled for 03:30 PM. Observed on 07/13/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar revealed at 9:30 AM revealed building was scheduled. Observed on 07/14/2022 at 9:30 AM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar Memory Game was scheduled for 03:30 PM. Observed on 07/14/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Interview with the AD on 07/14/2022 at 10:16 AM she stated she comes over to the certified Alzheimer's unit two times a day. She stated only one resident that participates with her in the activity for that day. She stated there is a calendar with scheduled activities for the residents. She stated yesterday (07/13/2022) she had an appointment, and she did not make it over to certified Alzheimer's unit. She stated usually the staff will engage the residents in activities if she was not available. Interview with the DON on 07/14/2022 at 2:20 PM she stated that there should be activities for the residents on the certified Alzheimer's unit. The DON stated they try to have the aides do puzzles and coloring with the residents. The DON stated she was am not sure why the AD was not over there Tuesday (07/12/2022) and Wednesday 07/13/2022. She stated that most of the residents on that unit were not able to do activities due to their cognitive status. The DON stated the residents should have activities at least daily. She stated their activity schedule has at least 2 activities a day. She stated she was responsible for overseeing the AD and her schedule. Review of facility's Activity Programs policy dated Revised August 2006: Policy statement: Activity programs designed to meet the needs of each resident are available on a daily basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0679 1. Level of Harm - Minimal harm or potential for actual harm Our activity programs are designed to encourage and maximum individual participation and are geared to the individual's needs. Residents Affected - Some 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the need and interests of each resident. Review of facility's policy titled: Individual Activities and Room Visit Program dated Revised August 2006 Policy Statement: Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities. The activities offered are reflective of the resident's individual activity interests, as identified in the Activity Assessment, progress notes and the resident's Comprehensive Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 3 (DM, [NAME] A and Dietary Aide A) of 9 dietary staff did not have Food Handler's certificates. The facility failed to ensure that dietary staff (DM, [NAME] A and Dietary Aide A) serving in the kitchen were working with a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses due to lack of dietary staff training. Findings include: Record review of the DM's employee file revealed no evidence of Food Handler certificate. Record review of [NAME] A's employee file revealed no evidence of Food Handler certificate. Record review of Dietary Aide A's employee file revealed no evidence of Food Handler certificate. Record review of CMS Form 672 dated 7/12/2022 revealed all residents ate from the kitchen. During an interview on 07/14/22 at 2:00 PM with the DM, she stated she did not have her food handlers certificate up to date. The DM stated [NAME] A and Dietary Aide A did not have current food handler's certificates, that they had expired. During an interview on 07/14/22 at 2:21 PM with the DON, she stated all dietary staff should have a food handler certification upon hire and keep their certification updated. The DON stated staff not having a current food handlers certification can affect residents by residents not receiving food prepared properly which could make residents sick. The DON stated the DM was responsible for ensuring food handlers certificates were up to date. The DON stated she was not sure what lead to the failure of dietary staff not having current food handler certificates. Record review of Job Description for Food Service Worker, not dated, revealed: Job Qualifications . Licensure, Registry or certification: Texas Food Handlers Certification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 07/12/2022 between 10:15 AM and 11:00 AM revealed: Dry Storage 1. One 28 oz can of diced tomatoes that was dented. 2. One 10.5 oz can of chicken broth that was dented. 3. One can 104 oz can of apple slices that was dented. 4. Two 115 oz cans of ketchup that were dented. 5. One open 50 lb bag of flour that was not sealed and exposed to air. Fridge #1 1. One opened 5lb container of cottage cheese with a use by date of 6/24/22. 2. One opened 5lb container of cottage cheese with a use by date of 6/11/22. 3. Two unopened bags of coleslaw with a use by date of 7/10/22. 4. One unopened bag of lettuce with a use by 7/11/2022. 5. One open bag of lettuce with a use by date of 7/11/22. 6. One open bag of carrots with a use by date of 6/27/22. 7. One unopened bag of carrots with a use by date of 6/27/22. Fridge #2 1. One 10 lb tube of defrosted hamburger meat not in original container was not labeled with a date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 or item written on the tube. The hamburger meat was in a container labeled ground meat with a date of 7/7/22. Level of Harm - Minimal harm or potential for actual harm 2. Five single serving tubs containing ranch dressing that were not labeled with item or an open date. Residents Affected - Many 3. One container (previously purposed for cottage cheese) containing apple crisp that was not sealed. 4. One cool whip container containing chocolate pudding not in original packaging. During an interview on 07/12/2022 between 10:15 AM and 11:00 AM with the DM, she stated that she was the DM and started in June 2022. The DM stated the dented cans should not have been in the storeroom, that they are taken to a separate room down the hall. The DM stated dented cans should not be used, they need to be thrown out or sent back to supply company. The DM stated the hamburger meat should be defrosted in the fridge and used within 24 hours or thrown out. The DM did not know why the hamburger meat was not dated or how long it had been in the fridge to defrost. The DM stated that everyone was responsible for dating and throwing out expired items. The DM stated it was her responsibility to go behind kitchen staff to ensure they were doing what needed to be done. The DM stated leftovers should have been thrown out after 3 days. The DM stated that leftovers should have been stored in clear plastic containers not reusing cool whip or cottage cheese containers. The DM stated she had told staff not to reuse cool whip or cottage cheese containers to store leftovers. The DM stated the cool whip and cottage cheese containers to do not seal properly and containers not sealing properly could cause food to spoil, loose flavor, take on flavors from the fridge, and could develop bacteria. The DM stated these failures could lead to residents becoming sick with food poisoning from salmonella or other bacteria. DM stated what lead to the failures in kitchen was that she was new and is trying to get everything in order. During interview on 07/14/22 at 2:21 PM with the DON, she stated her expectation in the kitchen was food needs to be labeled with date opened and item description. The DON stated food should be thrown out when the expiration date is met. The DON stated leftovers should be stored in appropriate containers, not in reused cool whip or cottage cheese containers because the reused containers do not seal properly. The DON stated hamburger meat should have been used or discarded within 24 hours, after setting out for defrosting. The DON stated the failures in the kitchen could affect residents by residents becoming sick from food born illness. The DON stated what led to failures in kitchen was staff refusing to follow the policy and the DM not going back and checking. DON stated the DM was responsible for the kitchen. During interview on 07/14/22 at 3:38 PM with the DM, she stated staff were trained when hired on proper storage and labeling and thinks there was a check off list but does not know where to find the check off list. The DM also stated they have had some in-services but does not know where previous DM stored them. During interview on 07/14/22 at 3:39 PM with HR, she stated she has not seen any type of check off list or trainings on food handling, storage, or labeling. Record review of CMS Form 672 dated 7/12/2022 revealed all residents ate from the kitchen. Record review of the policy titled, Refrigerators and Freezers, dated December 2014 revealed: All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food should be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' date will be completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food will be observed and 'used by' dates indicated once food is opened. Supervisors will be responsible for ensuring food items and pantry, refrigerators, and freezers are not expired or past perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Record review of policy titled, Food Receiving and Storage, dated July 2014 revealed: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date). Such foods will be rotated using a 'first in- first out' system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for administration. Residents Affected - Many There was no active licensed administrator in the facility from [DATE] to [DATE]. The facility did not report the 3 new active positive cases of Covid 19 that began on [DATE]. The facility had not been doing criminal history, EMR/NAR checks prior to employment and/or annually for 9 of 13 staff reviewed. The facility was not ensuring employees had dementia training for employees that included staff for the certified Alzheimer's unit of the facility for 3 of 13 staff reviewed. These findings placed all residents at risk of not achieving their highest practicable physical, mental, psychosocial well-being. Findings included: During an interview with DON and ADON on [DATE] at 10:00AM, DON said the facility did not have an ADM at the moment for the facility. ADON said ADM-A left in mid-April of 2022 or May of 2022 and the facility had a consultant in the building as acting ADM-B, but he had a Louisiana license, and he could not get it transferred to Texas, so he left in mid -[DATE]. DON said she was the acting ADM as well as the DON for the facility at that time. DON said she did not have an active ADM license. ADON said the ADM was who usually reported Covid-19 cases to HHSC and did a spreadsheet that tracked the positive Covid-19 cases to the HHSC program manager of the facility. ADON said she had looked online and did not find that Covid-19 was a reportable illness. During an interview with HR on [DATE] at 2:30PM, she said the former HR person had removed a lot of the computerized training, and HR did not realize the staff was not completing the orientation or annual training prior to the review of personnel files. HR said she was working on getting the computerized training added back for the staff to be able to complete all required trainings. She said that while she was getting requested personnel records ready for surveyor review, she was not able to find that some of the employees had a criminal history check and/or an EMR/NAR run prior to their employment or annually. She said she had been working as HR for a short time and those employees were hired prior to her assuming the responsibilities of HR. During an interview with HR on [DATE] at 9:30AM, she said the facility was not in compliance with employee background checks or trainings prior to [DATE]. During an interview with DON and ADON on [DATE] at 3:11PM, DON said she was the acting ADM, DON, and abuse coordinator for the facility. DON said the former HR person was not doing criminal history checks and/or EMR/NAR checks prior to new staff employment and the DON did not realize they were not being completed. DON said the former HR person was not sure about which staff needed what trainings, so she removed a lot of the trainings from the facility's computerized training system and DON did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not realize they were not being completed by new staff on orientation or annually. DON said the facility had an active licensed certified Alzheimer's unit in the facility. ADON said the HR department sent out a weekly delinquent training schedule for the staff of each department to each of the department managers that they followed, but if it was not in the system then it would not show that it was delinquent anyway. DON said she felt that the reason for the failure of the trainings and background checks were in part, because of the changing of the former to the new HR personnel and the new HR personnel not being properly trained. DON said that some of the failures with the reporting of Covid 19 were due to no actual ADM at that time and the DON and ADON not knowing that it was reportable. DON said the facility did not notify HHS about either administrator leaving and the facility not having an administrator. Record review of ADM hire dates on [DATE] were as follows: ADM-A with an active NFA license with expiration date of [DATE] with last renewal of [DATE]. Hired [DATE] and a termination date of [DATE]. ADM-B with an expired NFA license as of [DATE] with a hire date of [DATE] and a termination date of [DATE]. Record review of Administrator Job Description dated February 2017 revealed: Plans, organizes and directs the operations of the center home. Takes all reasonable steps to assure that quality long term care services are provided through the center home. Coordinates long term care activities with outside agencies and offices . Licensure, Registry or Certification: Current licensure by the Texas Board of Licensure for Nursing Home Administrator . Adopts and enforces rules and regulations relative to the level of health care and safety of the residents, and others, and for the protection of their personal property and civil rights ensures that a person in authority is designated if the facility does not have an administrator and ensures that the designated person notifies the Texas Department of Human Resources. Assures that in the absence of an administrator another employee of the facility is authorized, in writing, to act on the administrator's behalf. Record review of facility policy labeled Covid-19 Novel Coronavirus dated [DATE] revealed: Positive Staff . Immediate Action (0-24 hours) . Complete Self Report to HHSC . within 2 hours . If a resident receives a positive test result . Self-Report to state within 2 hours via TULIP. Record review of TULIP intake 363488 accessed on [DATE] at https://txhhs.lightning.force.com/lightning/r/RS_Case__c/a2e8y0000002QTTAA2/view revealed: Date Received: [DATE] 4:03 PM . Facility First Learned of Incident [DATE] 3:00 PM . Date and Time of the Incident [DATE] 3:00 PM . NOTE [DATE]: THE FACILITY IS ON THE [DATE] RECOVERED COVID-19 SPREADSHEET. NO OTHER COVID-19 INCIDENTS FOUND IN TULIP WITHIN THE PAST 14 DAYS . Narrative of the incident: This employee began to feel ill during work, congestion, and fatigue. We at the facility tested this employee and he showed positive for COVID 19. Actions and notifications: Employee was removed from facility and placed on 10-day quarantine, He is fully vaccinated Record review of Personnel Files on [DATE] revealed: DON with a hire date of [DATE]. Last criminal history was run [DATE] with HR unable to determine when previous criminal history was run, and last EMR/NAR date was [DATE]. DM with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 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 0835 previous EMR/NAR had been run. Level of Harm - Minimal harm or potential for actual harm Cook-A with a hire date of [DATE] with a criminal history and EMR/NAR date of [DATE]. Residents Affected - Many AD with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of [DATE] with no previous criminal history run date and EMR/NAR date of [DATE], HR unable to determine last annual criminal history/EMR/NAR run date. LVN-MM with a hire date of [DATE] with an EMR/NAR date of [DATE], HR unable to determine previous EMR/NAR run date, no dementia training. RN-WA with a hire date of [DATE] with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date, no dementia training. CNA-AL with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date. CNA-SJ with a hire date of [DATE] with no dementia training. Record review of facility Resident Abuse Policy revised [DATE] revealed: Our policy is based on the [DATE]rd in 2006 provider letter number O6-32 regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator. Record review of Employee Handbook undated revealed: Education and Training. All employees are required to fulfill regulatory training requirements per Long Term Care/Skilled Nursing Facility license mandates per Texas Department of Health and Human Services Commission .All employees . will have monthly and/or annual training assigned . It is requirement of successful employment . Human Resources assigns and tracks completion of all online training . In-service training is provided as needed, in an effort to improve and maintain knowledge of ever-changing health care and Long-Term requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 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 675687 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Hill Inc 245 State Hwy #153 West Coleman, TX 76834 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to maintain an infection control program for identifying and reporting a communicable disease for 2 of 75 employees and 1 of 56 residents reviewed for mitigation of Covid-19. Residents Affected - Few 1 staff member tested positive for Covid 19 on 6/30/22 and the facility did not report the case to HHSC until 7/12/22. 1 staff member tested positive for Covid 19 on 7/3/22 and the facility did not report the case to HHSC until 7/12/22 1 resident tested positive for Covid 19 on 7/8/22 and the facility did not report the case to HHSC until 7/12/22. These failures placed all residents and staff at risk of adverse effects of Covid 19 infections. Findings included: During an interview on 7/12/22 at 10:00AM with DON and ADON, the DON said they had 1 resident on transmission-based precautions due to testing positive for Covid 19. ADON said they had a staff member test positive for Covid 19 on 6/30/22. They began doing outbreak testing and then another employee tested positive on 7/3/22, then they had 1 resident test positive for Covid 19 on 7/8/22. ADON said the facility did not report the positive cases to HHSC because she was unaware the facility was supposed to report the cases to HHSC. ADON said the administrator usually handled reporting things to HHSC, but the facility did not have an administrator at the time of the first positive case. DON said she was not aware that Covid 19 was a reportable illness. ADON said she had looked online, and it did not show Covid 19 as an illness that was reportable, so she thought it was fine. The ADON said she reported to NHIS weekly for illnesses and vaccination status and thought that was how HHSC found out about the facility cases and not through facility doing their own self-reporting to HHSC. Record review of TULIP intake 363488 accessed on 7/20/22 at https://txhhs.lightning.force.com/lightning/r/RS_Case__c/a2e8y0000002QTTAA2/view revealed: Date Received: 7/12/2022 4:03 PM . Facility First Learned of Incident 6/30/2022 3:00 PM . Date and Time of the Incident 6/30/2022 3:00 PM . NOTE 07/14/22: THE FACILITY IS ON THE 07/11/22 RECOVERED COVID-19 SPREADSHEET. NO OTHER COVID-19 INCIDENTS FOUND IN TULIP WITHIN THE PAST 14 DAYS . Narrative of the incident: This employee began to feel ill during work, congestion, and fatigue. We at the facility tested this employee and he showed positive for COVID 19. Actions and notifications: Employee was removed from facility and placed on 10-day quarantine, He is fully vaccinated Record review of facility policy labeled Covid-19 Novel Coronavirus dated 7/14/2021 revealed: Positive Staff . Immediate Action (0-24 hours) . Complete Self Report to HHSC . within 2 hours . If a resident receives a positive test result . Self-Report to state within 2 hours via TULIP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 13 of 13