Health inspection·September 19, 2024

F 0656 on 09/10/2024 indicating a 13.92% weight loss. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's care plan revised on 08/02/2024 revealed no evidence addressing weight loss, catheters, or glucose monitoring. Residents Affected - Some During an on observation on 09/19/24 at 9:50 AM, Resident #1 had an indwelling urinary catheter with the collection bag hanging on the right side of the bed draining by gravity . Resident #32 Record review of Resident #32's electronic face sheet revealed an [AGE] year-old male admitted [DATE] with medical diagnoses of dementia, heart disease, enlarged prostate, and high blood pressure. Record review of Resident #32's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 3 on a 0-15 scale, indicating severe cognitive impairment. Record review of Resident #32's physician's order dated 08/10/2024 revealed Fall mat at bedside every day and night shift for falls. Record review of Resident #32's care plan dated initiated and revised 06/19/2024, indicated the resident was at risk for falls. Utilizing a fall mat was not included in the interventions. Focus: [Resident] is at risk for falls d/t Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Unaware of safety needs, Vision/hearing problems. Goal: The resident will be free of falls throughout the review date. Target date 08/26/2024. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear WHEN UP mobilizing in w/c. Follow facility fall protocol. Record review of Resident #32's Quarterly MDS dated [DATE] in Section J - Health Conditions, subsection J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment. revealed Resident #32 experienced 2 falls without injury and one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall related injury that causes the resident to complain of pain). During an observation on 09/17/24 at 10:43 AM, Resident #32 was in his room with a visitor. No fall mat was seen in the room. Resident #57 Record review of Resident #57's electronic face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of lung cancer, liver cancer, high blood pressure, and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). Record review of Resident #57's admission MDS dated [DATE], Section C - Cognitive Patterns, subsection C0500. BIMS Summary Score revealed a score of 4 on a 0-15 scale indicating severe cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 2 of 12 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 09/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm impairment. Section O-Special Treatments, Procedures, and Programs, subsection K1 revealed the resident was receiving Hospice care. Record review of Resident #57's physician's order dated 08/05/2024 revealed an order to Admit to [provider] hospice. Residents Affected - Some Record review of Resident #57's Comprehensive Care Plan dated 08/14/2024 revealed hospice care services were not addressed. During an interview on 09/19/24 at 2:10 PM, CNA E stated she only looked at care plans when she had a question about a resident. She stated the nurse would pull the care plan up on the computer and show her the information she needed. CNA E stated the nurses were responsible for making the care plans . During an interview on 09/19/24 at 2:15 PM, LVN D stated the DON was responsible for the care plans. LVN D stated catheters should be included on the care plan. She stated not including catheters on a resident's care plan may cause the resident to not receive the care needed. LVN D stated a continuous blood glucose monitor device also should be included on the care plan. During an interview on 09/19/24 at 2:22 PM, with the DON and the MDS Coordinator, the DON stated the MDS Coordinator was responsible for creating the care plan, but the DON was ultimately responsible. The DON stated catheters should be addressed on the care plan. The DON stated she did not think the effect on the resident would be consequential and stated, we still know it's there and have orders for it. The DON stated hospice services should be addressed on the care plan. She stated care plans were reviewed and updated on admission, annually, and when needed. The DON stated her expectations for completing care plans was for all information on how to best assist the residents was included. The MDS Coordinator stated she was new to do doing care plans. She stated she had years of experience with completing the MDS. Training on how to complete care plans was by learning on the job. During an interview on 09/19/24 at 2:41 PM, LVN D stated the continuous glucose monitoring device used by Resident #1 should be addressed on the care plan. She stated the DON made changes to the care plans when needed. LVN D stated the resident could possibly not receive the care needed if the information was not included on the care plan. During an interview on 09/19/24 at 2:43 PM, the DON stated an indwelling urinary catheter should be addressed on the care plan. The DON stated the continuous glucose monitoring device should be addressed on the care plan. The DON stated weight loss experienced by Resident #1 should be addressed on the care plan. She stated the care plan included interventions to prevent further weight loss. She stated the issues would not have a negative effect on residents because the staff had physician's orders for care and the staff were aware the resident had the monitoring system. The DON stated she did not know why these failures occurred. She explained the MDS coordinator was responsible for the care plans and the DON was responsible for monitoring the review and revision of the care plans. Record review of facility policy dated March 2022, Care Plans, Comprehensive Person-Centered, Item 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . Item 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 3 of 12 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 09/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 2 of 2 residents (Resident #4 and Resident #9) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for Resident #4 and Resident #9. These failures could place residents at risk for injury and restricted movement. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of the bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MAY HAVE ½ RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed and were in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed and were in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 4 of 12 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 09/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 was lying in her bed with half rail on left side of the bed in up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on left side of the bed in the up position. During an interview on 09/19/2024 at 8:56 a.m., LVN C stated she did not do risk for entrapment or bed rail assessments. She stated she did not know who performs those assessments . During an interview on 09/19/2024 at 9:00 a.m., the ADON stated she guessed she was who was responsible to perform the risk of entrapment assessments on the residents who had bed rails. She stated both Resident #4 and Resident #9 used bed rails for mobility. She stated no risk of entrapment assessment had been performed. She stated not performing assessment could lead to facility not ensuring safety of residents when using bed rails. During an interview on 09/19/2024 at 9:02 a.m., the DON stated the facility had not performed a risk of entrapment on residents who had bed rails. She stated for safety reasons, assessments should have been performed. The DON stated no negative outcome had occurred from the assessments not being performed . Review of the facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent .Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling off the bed .The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medication(s); e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition; j. communication; k. mobility (in and out of bed); and l. risk of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 5 of 12 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 09/19/2024 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 review 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. 1. The facility failed to ensure foods were heated to a temperature of 165 degrees F and held at least 15 seconds when food temperature was below 140 degrees F. 2. The facility failed to ensure temperature logs were completed for all meal services. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an interview on 09/17/2024 at 10:30 a.m., [NAME] B stated she pureed beef taco meat with cold milk in the blender until it reached appropriate texture. She then placed pureed beef taco meat into a pan and into the steam table. During an observation on 09/17/2024 at 10:33 a.m., beef taco puree was in aluminum pan sitting in the steam table. [NAME] B pureed charro bean soup. She added prepared charro bean soup and cold milk to blender. She blended both together until food reached pudding texture. She then placed pureed charro bean soup into oiled aluminum pan and placed pan into the steam table. During an interview on 09/17/2024 at 10:52 a.m., [NAME] B stated she had performed all steps of pureeing beef and beans. She stated she was done with pureed foods. During an interview on 09/17/2024 at 10:53 a.m., [NAME] A stated she would place food in the oven after pureeing to make sure the food temperature reached a temperature of 140 degrees F. During an observation and interview on 09/17/2024 at 10:54 a.m., [NAME] B stated she forgot to place pureed foods in the oven after pureeing them. [NAME] B obtained the temperature of 110 degrees F of pureed beans from the pan sitting on the steam table. [NAME] B obtained the temperature of 95 degrees F of pureed meat from the pan sitting on the steam table. [NAME] B covered both pans with foil and placed pans into oven. During an observation on 09/17/2024 at 11:30 a.m., binders of food temperature logs in the kitchen revealed: March 25, 2024, no logged food temperatures for items served during supper. March 26, 2024, no logged food temperatures for items served during supper. March 27, 2024, no logged food temperatures for items served during supper. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 6 of 12 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 09/19/2024 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 March 31, 2024, no logged food temperatures for items served during supper. Level of Harm - Minimal harm or potential for actual harm April 17, 2024, no logged food temperatures for items served during breakfast or lunch. April 18, 2024, no logged food temperatures for items served during breakfast or lunch. Residents Affected - Many May 1, 2024, no logged food temperatures for items served during lunch except Meat 1. May 2, 2024, no logged food temperatures for items served during lunch except Meat 1. June 3, 2024, no logged food temperatures for items served during supper. June 4, 2024, no logged food temperatures for items served during supper. June 18, 2024, no logged food temperatures for items served during lunch. June 19, 2024, no logged food temperatures for items served during lunch and only cereal oats temperature logged for breakfast. June 24, 2024, no logged food temperatures for items served during breakfast or lunch. June 25, 2024, no logged food temperatures for items served during breakfast or lunch. June 26, 2024, no logged food temperatures for items served during breakfast or lunch. July 1, 2024, no logged food temperatures for items served during breakfast or lunch. July 2, 2024, no logged food temperatures for items served during breakfast or lunch. September 16, 2024, no logged food temperatures for items served during supper. September 17, 2024, no logged food temperatures for items served during supper. September 18, 2024, no logged food temperatures for items served during supper. September 19, 2024, no logged food temperatures for items served during supper. September 20, 2024, no logged food temperatures for items served during supper. September 21, 2024, no logged food temperatures for items served during supper. September 22, 2024, no logged food temperatures for items served during supper. September 23, 2024, no logged food temperatures for items served during supper. September 24, 2024, no logged food temperatures for items served during supper. September 25, 2024, no logged food temperatures for items served during supper. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 7 of 12 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 09/19/2024 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 September 26, 2024, no logged food temperatures for items served during supper. Level of Harm - Minimal harm or potential for actual harm September 27, 2024, no logged food temperatures for items served during supper. September 28, 2024, no logged food temperatures for items served during supper. Residents Affected - Many During an observation on 09/17/2024 at 11:36 a.m., [NAME] B obtained temperature of 148 degrees F of pureed beans in the pan taken out of the oven. She placed the pan of beans onto the steam table. [NAME] B obtained temperature of 127 degrees F of pureed meat. She placed the pan back into the oven. During an observation on 09/17/2024 at 11:45 a.m., [NAME] A obtained temperature of 151.7 degrees F of pureed meat. She placed the pan of meat onto the steam table. During an interview on 09/17/2024 at 10:42 a.m., the ADMN stated all residents eat out of the kitchen. During an interview on 09/17/2024 at 12:31 p.m., the DM stated she expected for food recipes to be followed. She stated if a recipe stated to bring up food temperature to 165 degrees F, then the kitchen staff should have heated food to 165 degrees F. She did not state any negative effects on the residents. The DM would not comment on if food had been in danger zone or what effect not reheating to 165 degrees F could have on the residents. She stated she monitored that food temperatures were logged, and the recipes were followed. She stated she expected for temperature logs to be filled out with the temperatures for all meals. She stated the kitchen staff may have forgotten to fill in the log and staff turnover may have led to failure of temperature logs to be completed. She stated not filling out temperature logs could lead to infections in residents . During a telephone interview on 09/19/2024 at 8:13 a.m., the Dietitian stated the kitchen staff could add cold milk into the food to be pureed but the food would need to be reheated to 165 °F for 15 seconds after it was pureed. She stated if the recipe stated to heat food to 165 °F she expected for the kitchen staff to follow the recipe. She stated the guidelines state, the goal was for food to be heated to 165 °F for 15 seconds for food safety. After food had been heated to 165 °F it could be maintained at 135 °F. The Dietitian stated she expected for food temperature logs to be completed with temperatures of the food that was obtained prior to serving. She stated failing to log food temperatures could lead to the DM not knowing temperatures of food for that meal service. She stated the DM monitored the food temperature logs were completed. She did not know why the food temperature logs had not been completed for all meal services or why the Cooks did not heat the food to 165 °F during preparing steps . During an interview on 09/19/2024 at 8:29 a.m., the ADMN stated she expected for kitchen staff to heat the food to 165 °F if the recipe stated to. She stated not heating food to appropriate temperatures could lead to food not being safe to eat. She stated she expected for the food temperature binder to be filled out every meal. She stated the food temperature log was proof that the temperature of the food had been correct for the safety of serving out to residents. She stated the DM monitored recipes were followed and the temperature of foods were appropriate. The ADMN stated the DM monitored that the food temperature logs were filled out every meal. She stated she did not know why foods were not heated to 165 °F for 15 seconds after food temperature dropped below 140 °F or why the temperature logs were not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 8 of 12 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 09/19/2024 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 Record review of policy titled, Daily Food Temperature Control with no date revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges .Prior to meal service, the cook shall take the temperature of all hot and cold foods .Temperatures are recorded on the Temperature Log form .All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. Record review of pureed charro bean soup recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of >140F for only 4 hours. Record review of pureed soft beef taco recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of 140F for only 4 hours. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/19/2024), revealed: 3-403.11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) for 15 seconds. (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57°C (135°F) when being reheated for hot holding. (D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the food is between 5ºC (41ºF) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours. (E) Remaining unsliced portions of MEAT roasts that are cooked as specified under 3-401.11(B) may be reheated for hot holding using the oven parameters and minimum time and temperature conditions specified under 3-401.11(B). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 9 of 12 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 09/19/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 of 2 (Residents #4 and #9) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #4 and #9's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MMAY HAVE ½ RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 10 of 12 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 09/19/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 lying in her bed with half rail on the left side of the bed in an up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on the left side of the bed in the up position. During an interview on 09/19/2024 at 8:24 a.m., the MD stated he installed the bed rails to bed frames. He stated he did not perform routine bed rail, mattress, or bed frame assessments for risk of entrapment. He stated he would inspect the bed rail if he had been told rails were loose by housekeeping or the nursing staff. He stated he did not keep a log of those inspections. He stated he did not know who monitored that those inspections had been performed. The MD stated he had not performed inspections because he had not known to routinely inspect bed frames, mattresses, or bed rails . During an interview on 09/19/2024 at 8:31 a.m., the ADMN stated the MD would check bed rails if he had been told by a CNA that something was wrong with bed rails. She stated she did not know who monitored inspections were done but would get the facility policy to review. During a follow up interview on 09/19/2024 at 10:40 a.m., the ADMN stated the facility ensured the inspection of all bed frames, mattresses, and bed rails by the maintenance director who would correct any issues when staff brought issues to his attention. She stated the CNAs knew when a bed rail was not working appropriately and could monitor the equipment was working appropriately. She stated the equipment was inspected and maintained according to manufacturer's recommendations since no regular inspections were listed in Medline's instructions for installing rail. The ADMN stated she did not know if inspections were documented but would look in the maintenance log. She stated no negative effect had occurred to residents. She stated the maintenance director would report that he had repaired a bed rail in some of the morning meetings, but no documentation could be given to show what bed or room he had performed the repair . Review of facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 11 of 12 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 09/19/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675687 If continuation sheet Page 12 of 12