Health inspection·April 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 4/13/2022 at 12:33 PM with the Admin revealed she had been employed as The Admin since 9/27/2022 and received an Administrator's license in August of 2022. The Admin said the furniture in the Memory Care Unit had smaller rips when she was hired, but it had become worse because Memory Care Unit residents would pick at the already open areas. The Admin said that is why the corporate offices agreed to purchase new furniture. The Admin said due to the condition of the furniture and the acuity of the residents in the Memory Care Unit the residents could pick the furniture and put the pieces in their mouths. The Admin said she was not aware of any residents putting furniture pieces in their mouths. Interview on 4/13/2023 at 3:41 PM with The Admin, revealed she would provide all communication related to the ripped furniture concerns in the memory care area she had with the corporate representatives for the facility. Record review of an invoice dated 4/12/2023 revealed the facility ordered six couches and six loveseats from Direct Supply. The delivery date for the couches and loveseats was 6/2/2023. No other documentation related to the furniture in the memory care unit was provided by the facility prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 2 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #37) reviewed for incontinent care. - The facility failed to ensure CNA D followed proper infection control procedures and completely clean Resident #37 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #37's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #37 had diagnoses which included type one diabetes mellitus (high blood glucose level is too high because the pancreas con not produce insulin), major depressive disorder (persistent feeling of sadness and loss of interest), cerebral infraction (disrupted blood flow to the brain) and hypertension (a condition in which the blood vessels have persistently raised pressure). Record review of Resident #37's quarterly MDS assessment, dated 03/16/2023, revealed a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Resident #37's functional status revealed she required extensive assistance with one to two staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #37 was incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #37's undated care plan, revealed: Resident #37 had bladder/bowel incontinence related to impaired mobility. Interventions: monitor for signs and symptoms of UTI (urinary tract infection), foul smelling urine, altered mental status and no output. 1.During an observation on 04/11/23 at 1:00 p.m. of Resident #37's incontinent care, provided by CNA D, revealed CNA D walked into the resident room and she did not sanitize or washed her hands. She took gloves from her uniform pockets and donned the gloves. She placed an incontinent brief and a packet of wipes on the resident bedside table with the resident personal items, water pitcher, and snack on the table. She did not disinfect the table before and after use or placed a protective barrier on the table. CNA D used the same gloves, pulled wipes from the container, and placed them on the bedside table. CNA D did not separate the labia or the buttock when she cleaned the resident. When the surveyor intervened, she was about to apply barrier cream on Resident # 37. CNA D separated the resident labia and cleaned them three times; a brown substance was on the wipe. When she separated the buttocks and cleaned them twice, there was a bowel movement. She used her dirty gloved hands and pulled wipes from the container when she ran out of the wipes she pulled before she started incontinent care. She used the same gloves to apply barrier cream and a clean brief. She did not wash or use sanitizer before leaving the resident's room. During an interview on 04/11/23 at 1:13 p.m., CNA D said she was trained to perform incontinent care. CNA D did not respond when asked why she did not disinfected , removed the resident's personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 3 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few items and place a barrier on the table, or separated the labia and the buttocks. CNA D stated if she did not thoroughly clean Resident# 37, the resident could get an infection. CNA D did not respond when asked if she was supposed to carry and use the gloves from her uniform pocket when she provided incontinent care to Resident #37. During an interview on 04/12/23 at 5:44 p.m., the DON said CNA D should had knocked on Resident # 37's door, introduced herself, and explained to Resident #37 what she would do, washed her hands, set up, and provided care and observed infection control and proper incontinent care procedures. She said she taught the staff to set up a clean field on the foot of the bed and then set up supplies. The DON said CNA D should have washed her hands before, during, and after care. She said CNA D should not had pulled more wipes with the dirty gloves because she contaminated the wipes. The DON said CNA D should not have carried gloves in her uniform pocket because her uniform was dirty, and it was cross-contamination. The DON said Resident # 37 could have contacted infections such as UTI, rash, and yeast when Resident #37 was not cleaned appropriately and from the contaminated gloves. Record review of the facility's nurse aide proficiency training revealed CNA D signed the form on 03/10/23, which indicated she was trained on procedural guidelines which included perineal care for female. Record review of the facility procedural guideline #20 for perineal care/incontinent care -female Revised 1/2022 read in part . the purpose: to clean the female perineum without contaminating the urethral area with germs from the rectal area . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 4 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 Residents Affected - Some 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 interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 54 of 56 weekend days reviewed for RN coverage. -The facility failed to maintain RN coverage of eight consecutive hours a day for 54 days. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care and supervision. Findings included: Record review of the facility's March and April 2023 schedules revealed 24-hour LVN and routine CNA coverage. The schedules did not document any RN coverage during the months of March or April 2023. Record review of an invoice from TLC staffing dated 4/11/2023 revealed the staffing agency provided RN coverage to the facility on 3/19/2023 and 4/9/2023. The facility was unable to provide documentation of eight-hour RN coverage on the following weekend dates: o 10/1-2 o 10/8-9 o 10/15-16 o 10/22-23 o 10/29-30 o 11/5-6 o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 5 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 11/12-13 Level of Harm - Minimal harm or potential for actual harm o 11/19-20 Residents Affected - Some o 11/27-28 o 12/3-4 o 12/10-11 o 12/17-18 o 12/24-25 o 12/31 o 1/1 o 1/7-8 o 1/14-15 o 1/21-22 o 1/28-29 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 6 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 o Level of Harm - Minimal harm or potential for actual harm 2/4-5 o Residents Affected - Some 2/11-12 o 2/18-19 o 2/25-26 o 3/4-5 o 3/11-12 o 3/18 o 3/25-26 o 4/4-5 o 4/8 Interview on 4/12/2023 at 3:47 PM with the CM. The CM said the facility did not have RN coverage every day. The CM said the facility utilized agency staff occasionally and the DON provided RN coverage as often as she was able, but there were days with no RN coverage. The CM said he knew the facility was out of compliance because there was not RN coverage daily. Interview on 4/13/2022 at 12:33 PM with the Admin revealed she had been employed as the Admin since 9/27/2022. The Admin said the facility had no tracking system to verify when RN coverage was present at the facility. The Admin said the DON was salaried and did not clock in or out and there was no other tracking mechanism to track the DON's time at the facility. The Admin said the facility had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 7 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 Residents Affected - Some one fulltime RN, the DON, on staff. The Admin said the facility had been actively recruiting for another RN to ensure eight-hour RN coverage daily. The Admin said the facility had relied on agency coverage to ensure RN coverage when the DON was not available. The Admin said the facility would typically not have eight-hour RN coverage one to two times monthly. The Admin said she had been actively recruiting for additional RN help, but that no applicants had accepted the position. The Admin said daily eight-hour RN coverage was mandated to maintain compliance, and RN's were more highly trained than LVN's. Interview on 4/14/2023 at 8:41 AM with the DON revealed she worked most days. The DON said when she was unable to work the facility obtained agency RN coverage to ensure coverage. The DON said she only lived three miles from the facility and would come up to the facility anytime needed. The DON said she did not know of anytime the facility did not have eight hours of RN coverage daily. The RN said if the facility did not have eight hours of RN coverage daily then LVN oversight would not be provided as needed. The DON said there were tasks RNs were required to perform as LVNs were not allowed including staging ulcers and intravenous drug administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 8 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 Staff (CNA D, Laundry Aide E, and MA C) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure CNA D followed proper infection control procedures and did not completely clean Resident #37 during incontinent care. 2. The facility failed to ensure Laundry Aide E followed PPE and infection control procedures while picking up dirty linen from the memory care to 200 hall. 3. The facility failed to ensure MA C followed proper hand hygiene and infection control procedure during medication administration. 4. The facility failed to ensure proper infection procedures were in place when clean linen was stored in memory hall, 200 hall and 300 hall clean linen closet 5. The facility failed to ensure Laundry Aide E followed proper use of PPE and infection control procedure while cleaning resident rooms in 300. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Record review of Resident #37's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #37 had diagnoses which included type one diabetes mellitus (high blood glucose level is too high because the pancreas con not produce insulin), major depressive disorder (persistent feeling of sadness and loss of interest), cerebral infraction (disrupted blood flow to the brain) and hypertension (a condition in which the blood vessels have persistently raised pressure). Record review of Resident #37's quarterly MDS assessment, dated 03/16/2023, revealed a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Resident #37's functional status revealed she required extensive assistance with one to two staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #37 was incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #37's undated care plan, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 9 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #37 had bladder/bowel incontinence related to impaired mobility. Interventions: monitor for signs and symptoms of UTI (urinary tract infection), foul smelling urine, altered mental status and no output. 1.During an observation on 04/11/23 at 1:00 p.m. of, Resident #37's incontinent care, provided by CNA D, revealed CNA D walked into the resident room and she did not sanitize or washed her hands. She took gloves from her uniform pockets and donned the gloves. She placed an incontinent brief and a packet of wipes on the resident bedside table with the resident personal items, water pitcher, and snack on the table. She did not disinfect the table before and after use or placed a protective barrier on the table. CNA D used the same gloves, pulled wipes from the container, and placed them on the bedside table. CNA D did not separate the labia or the buttock when she cleaned the resident. When the surveyor intervened, she was about to apply barrier cream on Resident # 37. CNA D separated the resident labia and cleaned them three times; a brown substance was on the wipe. When she separated the buttocks and cleaned them twice, there was a bowel movement. She used her dirty gloved hands and pulled wipes from the container when she ran out of the wipes she pulled before she started incontinent care. She used the same gloves to apply barrier cream and a clean brief. She did not wash or use sanitizer before she left the resident's room. During an interview on 04/11/23 at 1:13 p.m., CNA D said she was trained to perform incontinent care. CNA D did not respond when asked why she did not disinfected , removed the resident's personal items and place a barrier on the table, or separated the labia and the buttocks. CNA D stated if she did not thoroughly clean Resident# 37, the resident could get an infection. CNA D did not respond when asked if she was supposed to carry and use the gloves from her uniform pocket when she provided incontinent care to Resident #37. During an interview on 04/12/23 at 5:44 p.m., the DON said CNA D should had knocked on Resident # 37's door, introduced herself, and explained to Resident #37 what she would do, washed her hands, set up, and provided care and observed infection control and proper incontinent care procedures. She said she taught the staff to set up a clean field on the foot of the bed and then set up supplies. The DON said CNA D should have washed her hands before, during, and after care. She said CNA D should not had pulled more wipes with the dirty gloves because she contaminated the wipes. The DON said CNA D should not have carried gloves in her uniform pocket because her uniform was dirty, and it was cross-contamination. The DON said Resident # 37 could have contacted infections such as UTI, rash, and yeast when Resident #37 was not cleaned appropriately and from the contaminated gloves. 2.During an observation and interview on 04/11/23 at 1:41 p.m., Laundry Aide E wore gloves while she walked and pushing the laundry cart with clothes in the 200 hall from memory hall. Laundry Aide E said she forgot to remove the dirty gloves she wore when she picked up dirty laundry from the memory hall. She said she should have removed the gloves after she picked up the dirty linen and washed her hands. She said gloves were not worn in the hallway to prevent cross-contamination. During an interview on 04/12/23 at 10:01 a.m., the Laundry Supervisor said laundry aide E should not have worn gloves in the hallway when she picked up dirty linen. She was supposed to remove the gloves after placing the soiled linens in the barrel and washed her hands before going to another hall to pick up more linens to prevent cross-contamination. She said she had not in-serviced Laundry Aide E, but the previous supervisor had in-serviced all the staff. She stated the staff was told not to wear gloves in the hallway. 4. During an observation and interview on 04/12/23 at 7:54 a.m., MA C washed her hand and turned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 10 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some off the water tap with the same paper towel that she dried her hands with, and she also used it to pick a piece of paper off the restroom floor. MA C did not wash or sanitize her hands before she entered another resident's room right after she washed hand and picked the paper from the resident restroom floor. During an interview on 04/12/23 at 8:45 a.m., MA C said she should have used a dry paper towel to turn off the water faucet to prevent contaminating her hand, and she should have washed her hand after she picked the paper from the restroom floor. MA C said she could transfer the germs from the floor, and the water faucet to the resident, and the resident could become sick. She said she was in - serviced on PPE and hand hygiene . During an interview on 04/12/23 at 6:05 p.m., the DON said MA C was supposed to dry her hands and trash the paper towel and use a dry paper towel to turn off the water tap. She stated they had an in-service to use a dry paper towel to turn off the faucet. She said the wet paper would cause cross-contamination. She said the staff was also taught to wash their hands when they picked stuff off the floor. During an observation on 04/12/23 at 7:56 a.m., MA C took the medication cart keys from her uniform, opened the cart, placed it back in her pocket, and did not wash or sanitize her hands before she popped medications for a resident. During an interview on 04/12/23 at 8:47 a.m., MA C said she should not have gone into the resident's room without washing her hand after she picked something from another resident's restroom floor. MA C also said she should have washed her hand after taking the cart key from her uniform pocket to prevent germs from passing to the resident and the blister pack. She said the resident could become sick. During an interview on 04/12/23 at 6:10 p.m., the DON said MA C should have used the sanitizer on her hands before she touched the medication bottle and blister pack after she took and returned the cart keys from her pocket. Again, it was an infection control issue. During an observation on 04/12/23 at 9:15 a.m., MA C placed a resident's nasal spray and eye drop in her left uniform pocket and walked into the resident's room. She took the eye drop from the left uniform pocket and removed it from the packet, and placed the eye drop container in her right pocket. Then she applied her gloves, took the eye container from her left uniform pocket, and administered the eye drop to the resident's eyes. Next, she placed it back into her pocket. Then she took the nasal spray, administered it to the resident nostrils, put it back into her uniform pocket, and walked out of the resident's room. Then she placed them back into the cart. During an interview on 04/12/23 at 9:25 a.m., MA C said she should not have placed the medications in her uniform pockets because it was cross-contamination. MA C stated she may have passed her germs to the resident, who could get sick. MA C said she should have cleaned the medication containers because she had contaminated the inside of the medication cart. She said she was in - serviced on a medication pass, and staff should not carry medication in their uniform pocket. During an interview on 04/12/23 at 6:13 p.m., the DON said MA C was not supposed to carry medication in her uniform pocket because it is an infection control issue. She said she could have contaminated the resident eyes and nose. She said MA C contaminated the top and inside of the medication in the cart when she placed it without disinfecting it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 11 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During an observation and interview on 04/12/23 at 10:00 a.m., the locked unit's clean linen room revealed a black egg crate with socks on the floor and a couple of linen on the floor too. The laundry supervisor said the egg crate and the linen were not supposed to be placed on the floor because the floor was considered dirty. The Laundry supervisor said the linen and socks were contaminated and should not be used on any resident because germs from the floor had contaminated the linens and socks. She said if linen or sock was used on any resident, the germs could be transferred to the resident. During an observation and interview on 04/12/23 at 10:17 p.m., the clean linen in 200 hall had an egg crate full of socks, and it was on the floor and had one mechanical lift pad that was hung, but some parts of it were touching the floor. The Laundry supervisor said none of the linen should brush the floor, and it was an infection control issue. During an observation and interview on 04/12/23 at 10:20 a.m. the clean linen in 300 hall had five Hoyer lift pads which were hung, but all the straps were touching the floor, and an egg crate filled with socks were on the floor, the disposable draw sheet for the bed was on the floor, and it had about 15 incontinent bed liners. The Laundry supervisor said she knew her staff did not place these items on the floor. She stated laundry made rounds in the morning and evening, and when they brought clean linen from the laundry room. The Laundry supervisor said the egg crate, disposable draw sheet, and the Hoyer lift pads that were touching the floor had been contaminated and could not be used on any resident. 6. During an observation and interview on 04/12/23 at 2:17 p.m. Laundry Aide E came out of a resident's room on 300 hall with gloves on, and she was pushing her cart to another resident's room. Laundry Aide E said she had just cleaned the resident's room and was going to clean the next room. Then she asked this surveyor why she should not wear gloves in the hall, and she then said she would go and verify with her supervisor. During an interview on 04/12/23 at 2:55 p.m., the Laundry supervisor and Laundry Aide E came to this surveyor, and Laundry Aide E said she clarified with her supervisor and she should have removed her gloves after she cleaned one resident's room and washed her hands before she left the resident's room. She also said she would washed or sanitized her hands and donned clean gloves before she cleaned the next resident's room. Record review of facility policy on hand hygiene dated 2001 MED - PASS, Inc. (Revised August 2019 0) read in part .this facility considers hand hygiene the primary means to prevent the spread of infection .washing hands . #3 . dry hands thoroughly with a disposable towel . #4 . use towel to turn off the faucet . Record review of the facility policy on laundry and linen dated 2001 MED - PASS, Inc.(Revised January 2014) read in part . the purpose of this procedure is to provide a process for the safe, aseptic . and storage of linen . Record review of the facility policy on infection control dated 2001 MED - PASS, Inc (Revised October 2018) read in part . the policies and practices are intended to . help prevent and manage transmission of disease and infections . Record review of the facility procedural guideline #20 for perineal care/incontinent care -female Revised 1/2022 read in part . the purpose: to clean the female perineum without contaminating the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 12 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 urethral area with germs from the rectal area . 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: 675922 If continuation sheet Page 13 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 freezers reviewed for essential equipment. Residents Affected - Some The facility failed to ensure the walk-in freezer's door closed or sealed properly causing the interior of the freezer to be iced over, and water to gather on the floor outside the door after the ice melted. This failure could place residents at risk of being exposed to damaged foods causing a loss of nutrition and flavor, and possibly freezer burned foods. Findings include: Observation on 4/11/2023 at 6:16 AM of the kitchen revealed the freezer door would not close properly. The freezer was keeping items below 0 degrees Fahrenheit, but there was a layer of frost or ice on all the items in the freezer. The door and the bottom of the door did not seal and a gap of approximately twelve inches at the bottom of the door was always open and cold air escaped from the gap. The interior floor, all shelves, and the boxes on the [NAME] and back of the freezer were covered in a layer of ice and/or frost. Interview on 4/11/2023 at 8:49 AM with the DS revealed the door to the freezer was broken and would not close properly. The DS said the dietary staff used a rope to help close the door and keep the items in the freezer cold. The DS said the door would not close all the way even with the use of the rope because of the door and the wall of the freezer. The DS opened a box of frozen cheese sticks which was covered in ice particles. The DS used a knife to break the ice off the box. The DS observed ice crystals in the bag the cheese sticks were in inside the box. The DS said those ice crystals were indicative of freezer burned foods. The DS said the other boxes in the freezer covered in ice particles may have freezer burned food. The DS said she would go through all the items that were covered in ice particles to ensure there was no freezer burn and remove any foods with freezer burn. The DS said the freezer door had been broken for a long time. Interview on 4/11/2023 at 8:55 AM with the DC. The DC said she had been employed by the facility since September of 2022 and the door to the freezer had been broken since that time. The DC said she had never cooked any food that was freezer burned. Interview on 4/11/2023 at 8:57 AM with the Admin. The Admin said she was unsure how long the door to the freezer had been broken. The Admin said she had informed the corporate offices of the issue through regular weekly email correspondence. The Admin said she had weekly communication with the corporate offices. The Admin said she contacted the freezer manufacturer. The Admin said the manufacturer reported they did not repair the structures but would have to rebuild it. Interview on 4/13/2022 at 12:33 PM with the Admin revealed she had been employed as the administrator since 9/27/2022 and received an Administrator's license in August of 2022. The Admin said because of the freezer's broken door the food provided to the residents could be freezer burned and reduce the quality of the food. Interview on 4/13/2023 at 3:41 PM with the Admin said he would provide all communication related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 14 of 15 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 675922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the freezer repair concerns that she had with the corporate representatives for the facility. No documentation of contact with the corporate office was ever provided by the facility before exit. Record review of an invoice dated 4/12/2023 revealed the facility requested an estimate from Refrigeration Gaskets of Texas, Inc. with email correspondence noting the technician would be at the facility on 4/13/2023. No other records related to the maintenance or repair of the freezer were provided by the facility prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675922 If continuation sheet Page 15 of 15