Health inspection·September 28, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #7's quarterly MDS assessment, dated 08/17/23, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. MDS revealed the quarterly assessment was submitted on 08/28/23. Review of Resident #7's care plan, revised dated 08/30/23, revealed the care plan addressed the resident's code status as Full Code (date initiated 12/07/21). Record review of Resident #7's physician orders, date 09/18/23, revealed the resident had an order for DNR (order date 09/18/23). Record review of Resident #7 advance directive, revealed resident had an Out-of-hospital DNR dated 09/15/23. Review of Resident #104's face sheet, dated 09/28/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, acute respiratory failure and diabetes mellitus. Resident #104 face sheet reflected advance directive of DNR. Review of Resident #104's admission MDS assessment, dated 09/07/23, revealed the resident had a BIMS score of 09, which indicated the resident was cognitively moderately impaired. MDS revealed the quarterly assessment was submitted on 09/19/23. Review of Resident #104's care plan, dated 09/01/23, revealed the care plan addressed the resident's code status as Full Code (date initiated 09/01/23). Record review of Resident #104's physician orders, date 09/18/23, revealed the resident had an order for DNR (order date 09/18/23). Interview on 9/27/23 at 1:35 PM with LVN B revealed a care plan was used to keep all staff updated on individual resident rationale/goals and measurable goals. LVN B revealed staff used care plans to determine interventions and determine outcome by assessing resident every shift. LVN B revealed a care plan would change with any new order or change in status. LVN B revealed nurses/therapy staff all used care plan information to determine resident need and current status. LVN B revealed the resident care plan would need to be adjusted when orders changed or were discontinued. LVN B revealed nurse assigned to resident was responsible for ensuring care plan was updated timely. LVN B revealed code status should be a reflection of the doctor's order on resident face sheet and care plan to ensure resident received intended services at critical time. She revealed potential for resident receiving DO NOT RESUSCITATE response when resident was actually a FULL CODE and vice versa. Interview on 9/28/23 at 9:45 AM with LVN C revealed she had been employed in facility 3 weeks. LVN C revealed nursing management were responsible for checking care plans to ensure plans reflected current physician orders and care LVN C revealed all charts were set to trigger quarterly for review by DON, ADON , corporate nurse and MDS coordinator. LVN C revealed she reviewed the resident chart to ensure orders were reflected in care plan. She revealed any changes, additions to resident care were discussed in morning stand-up and LVN C would follow-up by doing a care plan check. Interview on 09/28/23 at 9:52 AM with DON revealed she was ultimately responsible for ensuring Code Status was accurate across Face sheets, Care Plans, etc. DON revealed all should reflect physician order. The DON revealed failure to accurately document Code Status order could mean a resident that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 2 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some requested a Do Not Resuscitate could be provided full code, life-saving measures which could result in poor outcome for resident and ultimately, lawsuits. DON revealed all staff utilized resident care plans for information on resident care requirements. She revealed care plans should be updated quarterly and as needed. Interview on 09/28/23 at 12:55 PM with LVN A revealed a care plan was used by nursing staff to determine type of care. LVN A revealed she expected the care plan to reflect accurate code status. She revealed if any question of status she would perform full code. Interview on 09/28/23 at 4:25 PM with the Administrator stated she expected resident care plans, face sheets to accurately reflect Code Status as ordered by the physician. The administrator revealed failure to correctly document Code Status placed all residents at risk of not receiving requested/ordered code response services. Record review of the facility's current, undated Comprehensive Care Planning reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 3 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #12) reviewed for tube feeding. The facility failed to follow physician order's for Resident #12 when cleaning the resident's enteral stoma site by not applying a gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations. Findings included: Record review of Resident #12's quarterly MDS assessment, dated 07/01/23, revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty swallowing) and gastrostomy status (surgical opening into the stomach). MDS revealed a BIMS score of 0 which indicated Resident #12 had severe cognitive impairment. The assessment reflected Resident #12 required extensive assistance with eating, two-person physical assist. Resident #12's weight was 160 pounds, and the resident's nutritional approach was feeding tube. Record review of Resident #12's Resident Care Plan, revised dated 04/13/23, revealed the following: Resident #12 requires tube feeding r/t dysphagia. The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Clean insertion site daily as ordered, monitoring for s/s infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to MD if symptoms arise. Record review of Resident #12's physician order, dated 01/19/22, revealed an order for: Enteral Stoma Site Care: (With Dressing - Routine) Cleanse G-tube area and change dressing one time a day every Tuesday and Saturday for prevention. Observation on 09/27/23 at 11:10 AM revealed Resident #12 lying in bed. Observation of Resident #12's g-tube revealed there was no dressing around the g-tube site. There were no signs of infection or discharge noted. Observation on 09/28/23 at 12:45 PM with LVN A revealed Resident #12 lying in bed. Observation of Resident #12's g-tube revealed there was no dressing around the g-tube site. There were no signs of infection or discharge noted. An attempt was made to interview resident; however, the resident was unable to respond. Interview on 09/28/23 at 12:55 PM with LVN A revealed she was the nurse for Resident #12. She stated she cleaned Resident #12 g-tube daily; however, she did not put a dressing on the area and had not put one on the site since she had worked here. LVN A stated there was an order to clean the site; she stated she was unaware that she needed to put a dressing on. LVN A stated the risk of not putting a dressing on was that it could cause an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 4 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 0693 Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 09/27/23 at 3:46 PM revealed there was an order for cleaning the g-tube site and applying a dressing twice weekly for Resident #12. The DON stated there should be a dressing on the resident if there was an order. She also stated that physician's orders should be followed. Record review of the facility's Enteral Nutrition policy, dated 03/02/21, reflected the following: Residents Affected - Few .9b. Cleans the skin area around the catheter or stoma with wound cleanser or normal saline in a circular motion from the center outward. c. If ordered, apply any ointments, creams or other skin treatments d. If ordered, place gauze dressing on the stoma and tape . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 5 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that residents were provided with respiratory care consistent with professional standards for 1 of 6 residents (Residents #5) reviewed for respiratory care in that: Residents Affected - Few Resident #5's humidifier bottle attached to the oxygen concentrator was empty and had not been changed since 09/17/23. These deficient practices could affect residents who received oxygen with inadequate oxygen support, infections and could result in a decline in health. Findings included: Review of Resident #5's face sheet, dated 09/28/23, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, and pneumonia. Review of Resident #5's quarterly MDS assessment, dated 07/23/23, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS reflected Resident #5 received oxygen therapy. Review of Resident #5's care plan, revised dated 08/12/23, revealed the following: Resident #5 has dx COPD. The care plan reflected resident will be free of s/sx of respiratory infections through review date. The care plan interventions reflected give oxygen therapy as ordered by the physician. The resident has Oxygen Therapy continuous. The care plan reflected resident will have no s/sx of poor oxygen absorption. The care plan interventions reflected to notify the nurse if the oxygen is off the resident and continue reminders to leave oxygen on and oxygen at 2/lpm per nasal canula. Review of Resident #5's physician orders revealed: Change Respiratory Tubing, Mask, Bottled Water, clean filter q7d every night shift every Sunday. Start date - 04/10/22 times: Night 6p-6a. Review of Resident #5's September 2023 MAR revealed the bottle water was last changed on 09/24/23. Observation and interview on 09/26/23 at 11:06 AM revealed Resident #5 lying in bed. Resident #5 stated she was getting ready for lunch. Resident #5 had an oxygen nasal canula in her nose. Observation of the tubing revealed no date and the humidifier bottle was empty with a date of 09/17/23. Resident #5 stated the facility was supposed to change out the oxygen tubing and water bottle weekly. Resident #5 stated she was not aware of when the last time staff had come to change out the tubing and water. Resident #5 stated so far, she had not had any issues with her breathing or feeling ill due to the tubing and water not being changed. Observation on 09/26/23 at 12:48 PM revealed Resident #5 eating lunch. Resident #5 had an oxygen nasal canula in her nose. Observation of the humidifier bottle revealed it to be empty with a date of 09/17/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 6 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 09/26/23 at 1:49 PM revealed Resident #5 lying in bed. Resident #5 had an oxygen nasal canula in her nose. Observation of the humidifier bottle revealed it to be empty with a date of 09/17/23. Interview and observation on 09/26/23 at 2:41 PM with LVN D revealed she was the nurse for Resident #5. LVN D stated Resident #5 was the only resident on E Hall with continues oxygen. LVN D stated the nursing staff were suppposed to change out resident oxygen tubing and water bottles with labeling and dates on both. LVN D stated she had not noticed Resident #5 humidifier bottle to be empty. LVN D observed humidifier bottle and stated it had a date of 09/17/23, she stated it should have been changed out. LVN D stated she failed to notice humidifier bottle was empty when she completed her rounds this morning. LVN D stated tubing should also be dated and timed. LVN D stated the risk of the humidifier not having water could cause dryness and mucous. Interview on 09/26/23 at 10:22 AM with the DON revealed her expectations were for her nursing staff to verify the orders, update them, and to follow the physician orders. The DON stated Resident #5's orders were incorrect. The DON stated they no longer changed the humidifier bottle and tubing every Sunday; however, staff should still be following physician orders. The DON stated the risk of humidifier bottle not having water was that it could cause dryness. Record review of the facility's Oxygen Administration, revised date 02/13/07, revealed the following: All sources require humidifier to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. 5. a. Fill the humidifier container to the marker level with distilled water. b. Turn on the flow and set the desire rate. Note that the water in the humidifier is bubbling and hold hand near the device to feel the flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 7 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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 failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #121 and #122) of ten residents observed during medication pass. Reviewed for infection control, in that: Residents Affected - Some 1. Medication Aide C failed to clean the blood pressure wrist cuff after checking vitals of Residents #121 and #122. 2. Medication Aide C failed to disinfect the medication cart prior to it being used. These failures could affect the 4 residents on the Quarantine Hall who received medications by Medication Aide C by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Record review of Resident #121's undated face sheet, revealed that of a [AGE] year-old white female admitted [DATE] with a history that included Cerebrovascular accident, hypertension, Coronary Angioplasty implant and graft, Atherosclerotic heart disease, congestive heart failure, Angina, chronic obstructive pulmonary disease, Diabetes, Gastroparesis, chronic kidney disease (stage 4) , above knee amputation (left), below knee amputation (right), depression and dementia. Review of undated Face Sheet for Resident #122 revealed that of an [AGE] year-old female admitted [DATE] with a history that included hypertension, Atherosclerotic heart disease of native coronary artery, chronic combined systolic and diastolic congestive heart failure, chronic kidney disease (stage 4), Diabetes Mellitus, anxiety and depression. 1. Observation on 9/27/23 at 7:00 AM revealed Medication Aide C entered the room of Resident #121 with a blood pressure wrist cuff and obtained vitals of Resident #121 then returned to medication cart and placed the contaminated wrist cuff on top right of medication cart. Medication Aide C was observed to remove the wrist cuff from the cart, disinfect the wrist cuff using a disinfectant wipe and returned the cuff to the top of the cart in the same place the soiled cuff had rested without disinfecting the cart top. 2. Observation on 9/27/23 at 7:15 AM revealed Medication Aide C exit room [ROOM NUMBER] and temporarily place the contaminated wrist cuff on the PPE container and then returned to cart and placed the contaminated cuff on top right of cart. 3. Observation on 9/27/23 at 7:19 Am revealed Medication Aide C placed a dose cup containing Vitamin D on PPE container in the same spot the soiled cuff had rested and then enter room [ROOM NUMBER] and administer Vitamin D to Resident #122. 4. Observation on 9/27/23 at 7:29 AM revealed Medication Aide C enter room [ROOM NUMBER], place wrist cuff on Resident #122, obtained vitals, and return to cart where she placed the contaminated wrist cuff on top of the cart. Medication Aide C was observed to disinfect the wrist cuff and returned it to the top right of the medication cart without disinfecting the cart top. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 8 of 9 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 676004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Nursing & Rehabilitation 201 E Thompson St Decatur, TX 76234 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. There was no observation of Medication Aide C disinfecting the medication cart top during this medication administration. Interview with Medication Aide C on 9/27/23 at 7:35 AM revealed she was supposed to disinfect the wrist cuff after each use and before placing cuff on cart. Medication Aide C stated she should not have placed the wrist cuff or dose cup on the PPE container. Medication Aide C stated both actions placed residents at risk of infection. Interview with ADON on 9/27/23 at 3:02 PM the ADON stated equipment should be thoroughly cleaned after each resident use and following manufacturer's recommendations. The ADON stated contaminated equipment should be placed on some type of barrier such as Styrofoam trays, prior to cleaning to prevent further contamination. The ADON stated when Medication Aide C had placed the contaminated wrist cuff on the PPE container on the quarantine hall, everything should have been removed and the container thoroughly cleaned/sanitized. The ADON stated her intent to provide infection control in-service to Medication Aide C. The ADON stated she was responsible for staff training and staff performed return demonstration. The ADON stated she spent approximately 20 hours per week providing training and in-services, including infection control, to staff. Interview with DON on 9/27/23 at 1:55 PM the DON stated contaminated equipment should not be placed on medication carts. The DON stated re-usable equipment should be disinfected after each use. The DON stated failure to disinfect increased the risk of disease spread. Review of the facility's Infection Prevention and Control Program, Transmission-Based Precautions policy, dated December 2012, reflected: .Clean and disinfect objects and environmental surfaces that are touched frequently with an EPA-registered disinfectant for healthcare at least daily and when visibly soiled. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 9 of 9