Health inspection·August 9, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. An interview on 08/09/23 at 6:37 PM the ADMN stated the facility had not had a steady HR in the past year. The HR the facility had previously had not kept up with the EMR's or criminal background checks of employee staff. She stated the responsibility of this should have been HR, but being they had no one at that time, the responsibility fell on her as ADMN. She stated the negative impact to residents was, there was not one, as she felt the EMR's, and background checks were somewhere in the facility with management not able to find them. She stated the failure was not having a steady HR and not having a corporate lifeline to guide the upper management on what was needed to run the facility correctly. The ADMN stated her expectations were for the EMR's and background checks to be completed on every facility staff member and expecting the new HR coming in to be trained to her full extent following policies and guidelines. Review of facility policy Background Screening Investigations dated 2001 and revised 2019 revealed: Policy Statement Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants four positions with direct access to residents (direct access employees). Policy Interpretation and Implementation 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long-term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with the patient or resident of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 2 of 14 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 08/09/2023 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 0607 facility or provider, as determined by the state for purposes of the national background check program. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Some The director of personnel, or designee, conducts background checks, reference checks and criminal conviction check (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. 3. For any individual applying for a position, the state EMR search is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or have the property have been entered into the applicants file. Review of the New Hire Application for Employment revealed: the included document DPS Computerized Criminal History (CCH) Verification with the revised date of 09/2015. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 3 of 14 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 08/09/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. Residents Affected - Some The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 10 days of the second quarter of year 2023. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Review of facility's RN nursing schedule for RN for 01/2023-02/2023, 10 of the 59 days (01/07/2023, 01/08/2023, 01/14/2023, 0115/2023, 01/21/2023, 01/22/2023, 02/04/2023, 02/05/2023, 02/18/2023, and 02/19/2023) reflected there was no RN coverage. An interview on 08/09/23 at 6:26 PM the Admn stated it was the DON who was responsible and monitored the RN coverage. She stated when someone calls in, the DON would usually come in and if not, the on-call RN should had been called. The ADMN stated the negative impact for residents was there could possibly be a crisis with a resident requiring the care of an RN, which could have possibly led to an increased risk of possible illness or worse. She stated the failure occurred when the facility tragically lost an RN and at that time, they were searching for another RN leaving them down two RN's. The ADMN stated she was not sure why the DON did not come into the facility to cover for those days previously missed. The ADMN expectations were to have the required RN coverage, following the facility policy and procedures. An interview on 08/09/2023 at 6:40 PM, the DON stated they should follow the protocols, having an RN on a rotation. She stated the protocols were to have an RN or DON. She stated they were down two RN's during that time. The DON stated it would have been herself who was responsible in this being monitored. She stated she felt there were no negative impact as she was confident and trusts in her staff being LVN's. The DON stated her expectations from now on were for the facility to have the proper RN coverage. Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated 2001, revised August 2022, revealed the following: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in according with resident care plans and the facility assessment. Policy Interpretation and Implementation: Sufficient Staff . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 4 of 14 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 08/09/2023 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 0727 .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RN's may be scheduled more than eight hours depending on the acuity needs of the resident. 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: 675687 If continuation sheet Page 5 of 14 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 08/09/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 3 (Resident #18, Resident #41, and Resident #2) of 8 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #18's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #41's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. The facility failed to ensure Resident #2's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. These failures place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Resident # 18 Review of Resident #18's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, and Cerebral Infarction (brain stroke). Review of Resident #18's Annual MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score not performed; Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #18's electronic physician orders revealed: Lorazepam Oral tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 06/28/2022 and no end date. Review of Resident #18's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #18's electronic MAR for August 2023 revealed no doses of Lorazepam had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 6 of 14 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 08/09/2023 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 0758 administered. Level of Harm - Minimal harm or potential for actual harm Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Residents Affected - Some Resident #41 Review of Resident #41's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, Insomnia, and Dementia. Review of Resident #41's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 10 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #41's electronic physician orders revealed: Lorazepam Oral Concentrate 2MG/ML give 1 ml by mouth every 4 hours as needed for Anxiety with a start date of 03/15/2022 and no end date. Review of Resident #41's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #41's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #2 Record review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 99 (indicating resident was unable to complete the interview); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #2's electronic physician orders revealed: Lorazepam Oral Tablet 0.5mg give 1 tablet by mouth every 6 hours as needed for Anxiety with a start date of 06/28/2023 and no end date. Review of Resident #2's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #2's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 7 of 14 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 08/09/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Residents Affected - Some During an interview on 08/09/2023 at 3:40 PM, the ADON stated her, and the facility staff were unaware that PRN psychotropic medications could only be ordered for 14 days. She stated the pharmacist had not mentioned anything about this to the facility. During an interview on 08/09/2023 at 5:58 PM, the DON stated she was not aware of the regulation on PRN psychotropic medications. She stated it was her responsibility to be current and up to date on regulations. She stated she had not seen it on the pharmacy consult review. She stated the harm to the resident could be receiving medication not needed or being over medicated. Review of document titled, Consult Pharmacist Report, dated 04/13/2023 revealed: Recommendations and Additional Comments: .3. PRN psychoactive medication orders should indicate how long the order is to be in effect, otherwise they are only good for 14 days. The physician can indicate a longer duration for the order and hospice can indicate that it is good for the duration of hospice services. The duration must be indicated on the order itself for easy reference. Review of facility policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care, revised July 2022 revealed: Behavior, Mood, and Cognition: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 8 of 14 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 08/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 lunch meal reviewed. The facility failed to follow the recipe when preparing the puree bread. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings included: During an observation on 08/07/2023 at 10:45 AM, [NAME] did not follow the recipe while she pureed sliced bread . [NAME] placed sliced bread into processor and added milk and pancake syrup to the processor. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was cooks follow the recipes. The DM stated staff have always added the pancake to the puree bread. The DM stated residents' diets could have been affected by adding the syrup because it was not calculated in their calorie count. The DM stated what led to failure was that cooks did what they always did and did not follow the menu. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was the cooks should have followed the recipe for puree. The ADMN stated the DM was responsible for ensuring cooks followed recipes. The ADMN stated effect on residents could have been residents' calorie intake could have been altered. The ADMN stated cooks not reading and following recipes led to failure. Record review of facility recipe titled roll, revealed May add liquid to reach desired consistency. Ex[example] reserved liquid/juice, milk. Record review of facility policy titled, Food and Nutrition Services dated October 2017 revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 9 of 14 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 08/09/2023 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 - Some 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 refrigerator. The facility failed to ensure all food was not kept past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: During an observation on 08/07/2023 between 10:20 AM and 11:00 AM revealed: Refrigerator #1 1. One open container of cottage cheese without an open date, labeled with a use by date of 07/02/2023. 2. Two containers of sour cream labeled with a use by date of 07/28/2023. 3.One opened container of sour cream without an open date, labeled with a use by date of 07/07/2023. 4.One bag with a seal contained celery that had brown spots on celery with and open date of 07/02/2023. Freezer #1 1.An open package of chicken strips not labeled with an item description or an open date. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was that food was labeled when received and again when opened and that items be discarded after 5 days of being opened. The DM stated effect on residents could have been residents had gotten food poisoning. The DM stated staff not paying attention to dates led to failure of items not being discarded. The DM stated the cooks, dietary aides and the DM were responsible to ensure items were thrown out. The DM stated they did not have a policy. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was that food items were labeled correctly and were discarded when past the use by date. The ADMN stated receiving food past the 'use by date could have caused residents not to receive flavorful food or could have gotten sick. The ADMN stated staff being confused about not knowing policy was what led to failure. The ADMN stated the DM was responsible for monitoring to ensure food was stored and labeled correctly and not kept past use by date. Review of Food Code 2022 accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 10 of 14 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 08/09/2023 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 annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 11 of 14 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 08/09/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for the failing to conduct criminal history/EMR/NAR verifications on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability reviewed in that: The Facility HR failed to correct and monitor a quality deficiency identified on the previous survey, regarding employee criminal history, and EMR/NAR checks had been performed since previous past noncompliance. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings Include: Record review of the ADMN the personnel file revealed a hire date of 09/08/2014. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DON the personnel file revealed a hire date of 09/13/2021. There was no documentation evidence of an annual EMR/NAR found in the file Record review of the SW the personnel file revealed a hire date of 09/05/2022. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the AD the personnel file revealed a hire date of 08/30/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DM the personnel file revealed a hire date of 11/08/2011. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DE the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of RN-A the personnel file revealed a hire date of 08/15/2011. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 12 of 14 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 08/09/2023 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 0867 EMR/NAR check found in the file. Level of Harm - Minimal harm or potential for actual harm Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Residents Affected - Some Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. Review of the facility's CMS 2567/facility-submitted Plan of Correction dated 07/27/2022 which was submitted in response to the 07/14/2022 SSA recertification survey revealed: Facility failed to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 9 of 13 (DON, AD, DM, LVN-JB, LVN-MM, Cook-A, NA-NC, CNA-AL, RN-WA) employees reviewed for employability. Identification of other residents having the potential to be affected include: All resident that resides in the facility have a potential to be affected. Actions taken/systems put into place to reduce the risk of further occurrences include: Staff reeducated on the requirement from proper background checks in relation to the hiring process, annual checks, and as needed. An interview on 08/15/2023 at 7:10 PM, the ADMN stated previous deficiencies were to be monitored and followed up by the Department Heads and ADMN staff as well as the MD. She stated previous deficiencies of personnel files not being followed up should have been discussed and addressed in the QAPI. She stated they were only discussed in the morning meetings, but remembered them being discussed with HR. The ADMN stated she had not been in the position of ADMN and was not sure how to address previous issues with QAPI and stated she was unaware of these deficiencies previously cited. The ADMN stated it was her responsibility to monitor as well as Department Heads to follow up on previous deficiencies cited. The ADMN stated the negative impact for residents were that it could have interfered with safety and health or their well-being if not addressed in a timely manner. She stated what lead to the failure was, there was no ADMN at that time after the previous survey as well as no leader to oversee or correct those situations. The ADMN's expectations were for those matters of previous citations to be addressed in a timely manner for those issues and not to arise in upcoming surveys. There was no POC policy provided during survey time while in facility prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 13 of 14 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 08/09/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 12 meetings reviewed for QAPI. Residents Affected - Some The facility did not ensure the MD, or a representative attended QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of sign in sheets for QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023 revealed no evidence that the MD attended QAPI meeting. During an interview on 08/09/2023 at 4:38 PM the ADMN stated the only way to verify that MD attended meetings was his signature on the sign in sheets. The ADMN stated that the MD was a required member of the QAPI team but did not attend the meetings. Record review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) ProgramAnalysis and Action dated March 2023 revealed: Quality deficiencies that are identified with feedback and data and will undergo appropriate corrective action. Corrective actions are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems and comprehensive level. Record review of document titled Quality Assurance Committee Members , without a date, revealed MD was a member of the committee. Record review of Medical Director Agreement signed 04/17/2012 and renewed on 11/1/2015 revealed: The agreement addresses the medical director's responsibilities for the following: Serving as a member of the organized medical staff, attending its meetings, and helping to ensure adherence to the medical staff bylaws, rules, and regulations. Participating in establishing policies, procedures and guidelines designed to ensure the provision of adequate comprehensive services. Participation in the resident care management system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 14 of 14