Inspection·April 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety [Resident #1] stated [her] wheelchair was not secure in transport van, and that it tipped back a few inches and she hit her head on ramp behind her. Transport Driver [Driver A] stated that she secured [the] wheelchair, but discovered it was loose when she started to drive. Immediately pulled over and re-secured it. .Name and title of person who completed assessment: [RN D] Residents Affected - Some Description of assessment including extent of injuries No sign of bump, bruising, or redness on head where resident states she hit it. Sent to ED for additional evaluation due to c/o head injury. .Provider Response .Driver [Driver A] suspended pending investigation. Resident [Resident #1] assessed by DON and sent to ED for CT scan due to hitting head - no bruising, laceration, or raised a red noted. CT at ED negative. Physician, ombudsman notified. Resident is RP. Investigation Summary .DON was notified by COTA (Therapy) that [Resident #1] refused therapy due to headache pain resulting from hitting head during transport the previous day. COTA .immediately report this incident to DON (was in office next to therapy gym) and provided written statement and report to Admin. Driver provided statement to Administrator that she did fail to completely secure [Resident #1's] wheelchair prior to driving. She noticed the wheelchair tip back 3-5 inches and immediately pulled off the road and properly secured [Resident #1's] wheelchair. [Resident #1] stated that she hit her head on the ramp in the van when she tipped back. Driver was talking about this incident at the nurse[s'] station upon return to the facility, and Administrator was at the nurse[s'] station at the same time. Driver assumed Admin was aware. Admin was conducting in-service/monitoring with another staff member at the time and did not hear the report of an incident in the van. Admin provided to [sic] coaching to driver regarding reporting any and all incidents or potential for incident or injury directly to him, not just when it could be heard. Investigation revealed driver [Driver A] had reported complaint of pain by resident [Resident #1] - upon return to facility to resident's nurse. Nurse stated that she was unable to provide prn pain medication at that time due to caring for another resident and then forgot to get back to it. Nurse did assess resident for pain a few hours later and there was no c/o of pain or signs of distress. Resident does receive routine pain medications and has order for PRN, which she used most days. PRN order was changed to routine in AM with additional PRN available later in the day as needed. Admin identified all residents who had been on transport in last 30 days (from appointment calendar) and Social Worker completed safe survey assessments with each of them as well as safe survey pain assessments with several residents. No additional transport or pain issues were reported in surveys. Investigation showed that driver [Driver A] had been properly and completely trained on all policies and procedures for properly securing residents in transport van and properly transporting them. Driver [Driver A] failed to follow proper procedures. Driver [Driver A] failed to report complaint of injury during transport and failed to report failure to properly secure resident and wheelchair prior to transport. Driver [Driver A] resigned her position and employment. .Provider Action Taken Post-Investigation: All staff in-serviced on recognizing, preventing, and immediately reporting abuse and neglect directly to Abuse Coordinator. Nursing staff in-serviced on pain management policies and procedures. All drivers of van retrained on pre and post trip inspections as well as safety attestations to be completed prior to each trip. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 2 of 7 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 04/30/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Driver A's written statement, dated 03/19/25, reflected: On Tuesday March 18, 2025 at approximately 1515 [3:15 PM] hrs. I, [Driver A], was transporting [Resident #1] from a doctor apt. She had complained about having a headache. I loaded [Resident #1] into [the] back of transport van and secured the chair using the straps and seat belt. I started driving and her chair tipped backwards about 4 inches. I immediately pulled over and re-secured the straps to her chair. She claimed she hit her head, but I am not positive she did. We got back to [the] facility where she asked the nurse for tylenol. It was mentioned in front of [the Administrator] about her hitting her head. Interview on 04/30/35 at 9:50 AM with Resident #1 revealed she was in the van on 03/19/25 in her wheelchair when her wheelchair tipped backwards 4-5 inches. Resident #1 stated when Driver A accelerated it caused her to hit her head on the lift of the van. The resident stated she had a headache, but she had a headache prior to the incident, so she did not have any injury. Resident #1 stated she was more startled than anything. Resident #1 stated she had not been in the van since, but she was not afraid to be transported again. Record review of Resident #1's nursing notes reflected the resident was sent to the ER via ambulance since she stated she had hit her head on a piece of metal. Nursing assessment revealed no obvious injury. The resident returned from the ER with no abnormal findings after examination and CT scan of her head. Record review of text communications, undated but timed 1:55 PM, with Driver A reflected: Can you please clarify for me exactly what process you did to secure [Resident #1]? I attached the ratchet straps to the frame of her chair in the back and front. When I re-secured the chair, I adjusted the positions of the straps to better secure the chair in place, ensuring it did not move again. I secured the seat belt across her lap to ensure she did not slip from the chair in case of an incident. The seat belt was placed prior to initially moving the van the first time. This belt was not needed to be adjusted after the incident. Record review of an Employee Disciplinary Report Action Request, dated 03/19/25, reflected Driver A had a written counseling and investigatory suspension due to an infraction that occurred involving Resident #1. This was signed by the Administrator on 03/19/25. Record review of a Coaching Form, dated 03/19/25, signed by both Driver A and the Administrator reflected: Situation: Incident in van. Wheelchair not properly secured. Resident claims wheelchair tipped back and she hit her head on the ramp (she was in position closest to ramp). Specific Coaching/Education given to the Employee: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 3 of 7 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 04/30/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some All residents must be properly secured prior to vehicle movement. Auto transport training to be completed prior to return to transport. All incidents must be reported immediately to Administrator. Record review of a Vehicle Inspection Report, dated 03/19/25, reflected the facility completed an inspection of the van's interior to include seat belts and wheelchair tie-downs, and there were no issues identified. Record review of Life Satisfaction Rounds forms, dated 03/20/25, reflected the facility conducted interviews with residents to determine if they felt safe at the facility and if there were any issues with transportation. These interviews revealed no concerns regarding transportation. Record review of an In Service Training Attendance Roster, dated 03/19/25, reflected facility staff received in-service training on the topic of Vehicle Training/Secure Passengers/Report Immediately. Record review of an In Service Training Attendance Roster, dated 03/21/25, reflected facility staff received in-service training on the topic of Safety Attestation presented by the Administrator. Record review of the Employee Auto Attestation Form, which was the topic of the in-service Training, reflected: I, ____________, attest that all of the following safety checks have been completed before taking ________(resident) to their appointment. 1. Before driving a company automobile, the driver must be satisfied that it is in safe operating condition. Any defects or unsafe conditions should be reported to appropriate individual(s) immediately. 2. All safety devices, including seat belts/restraint devices/wheelchair tie downs, will be used by anyone operating or riding in a vehicle. There shall be no more passengers in a vehicle than the number of seat belts available. Driver will check straps by attempting to move wheelchair on all 4 corners. 3. Driver will conduct a final visual inspection to ensure all residents have been safely secured [in] the vehicle before driving. Interview on 04/30/25 at 3:45 PM with the Administrator revealed Driver A had been the primary driver and Driver B was the back up driver who covered when Driver A was off. Driver B took over the primary driving responsibilities after Driver A had been terminated. The Administrator stated Driver A had also failed to call him or the DON from the scene, instead she waited until she returned from the transport. Driver A stated in her interview she had told the nurse and himself when she returned, she had assumed he heard her tell the nurse, but he stated he was speaking with another employee and did not hear Driver A report to the nurse. The Administrator stated Driver B had participated in the in-service and training on 03/20/25 and she did not follow procedures on 4/07/25, so she was terminated as well. The Administrator stated they now have two drivers on the van when transporting to improve safety and reduce the risk of procedure violation. He stated the facility did not have a policy covering transporting the residents, they relied on the company's driver training manual. Record review of Resident #1's hospital record reflected she was treated for abrasions after a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 4 of 7 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 04/30/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An attempt was made to interview Driver A via telephone on 04/30/25 at 1:15 PM. A voicemail message was left for Driver A; however, she did not return the call. Record review of Drivers A's driver training revealed Driver A had been initially trained for driving the van on 04/13/23 and her last re-training had been completed on 01/30/25. 2. Record review of Resident #2's undated admission Record, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure, diabetes, heart failure, and Parkinson's disease. Record review of Resident #2's quarterly MDS, dated [DATE], revealed he had a BIMS score of 15, indicating he was cognitively intact. His Functional Ability assessment reflected he required minimal assistance with his ADLs. Record review of Resident #2's care plan, dated 03/12/25, reflected he required the use of a wheelchair for mobility, he was on blood thinning medication, and he required assistance with transfers to and from his wheelchair. Record review of the facility's Provider Investigation Report, completed by the Administrator on 04/14/25, reflected the following incident occurred on 04/07/25 at 11:00 AM involving Resident #2 and Driver B: .Description of the Allegation: Driver [Driver B] was walking to take resident off of van, driver tripped and fell on resident causing the resident to flip backwards in wheelchair. Back ramp strap was not done. Resident complained of pain and was sent to ER [sic]. CT was negative and resident returned to facility. Driver suspended. .Description of assessment including extent of injuries Resident returning from doctors [sic] appt on facility van, Per the staff driver [Driver B] of the day, patient fell back while on the wheelchair. Resident [Resident #2] complained of head and neck pain. This LVN [LVN E] sent resident out EMS for eval. .Provider Response .Driver [Driver B] reported incident immediately, resident was assessed by nurse. All resident transports will require 2 staff members to be present to ensure resident safety. Investigation Summary .Driver [Driver B] immediately reported incident to DON (Admin Offsite) .per facility protocol. Resident was assessed by a nurse prior to being moved. Resident did not have any injuries but did complain of pain. Resident was transferred to ED for additional evaluation and treatment. CT negative for head and neck, resident returned to facility in stable condition. Driver was suspended pending investigation. It was determined that driver did fail to properly secure seatbelt on lift, and that driver stood on ramp with resident, both being failure to follow company policy and procedure. Driver [Driver B] had been fully trained and given additional training and in-services on van/transport protocols. Driver [Driver B] was terminated for failure to follow company policies. All drivers were re-trained on protocols and procedures prior to resuming transports. Facility has instructed all drivers that 2 staff members must be present for each transport to ensure safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 5 of 7 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 04/30/2025 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 0689 .Provider Action Taken Post-Investigation: Level of Harm - Immediate jeopardy to resident health or safety Abuse and neglect in-service Van retraining completed for all drivers before van returns to driving. Record review of Resident #2's hospital records reflected he was treated on 04/07/25 for a fall and scalp abrasion. The hospital record reflected the resident did not sustain any serious injuries. Residents Affected - Some Interview on 04/30/25 at 10:55 AM with Resident #2 revealed on 04/07/25 he was being unloaded from the facility's van. After he had been lowered to the ground on the lift, the driver fell onto him causing his wheelchair to roll backwards, and he tipped backwards. He stated he hit his head on the ground and had back pain. He denied losing consciousness. He was sent to the hospital via ambulance. He has been on the van three times a week since the incident for dialysis without incident. Interview on 04/30/25 at 11:05 AM with the Administrator revealed their investigation revealed Driver B failed to secure the safety strap at the back of the lift that is designed to prevent the resident from rolling off the back of the ramp. He stated Driver B had unlocked the wheelchair's locks, lost her balance, and fell onto the resident. The resident rolled backwards off the lift, at ground level, and tipped over backwards. Resident #2 was assessed by the nurse before being moved, he was found to have a minor abrasion to the back of his head and was sent to the hospital via ambulance. The Administrator stated Driver B was in-serviced on 03/20/25 on van transport procedures, after the incident with Resident #1, but still did not follow procedures with Resident #2. As a result she was terminated. The Administrator stated all six people authorized to drive the facility van were in-serviced again on 04/07/25, and all six were given the company's driving test again. The procedure had also been changed to have two drivers on the van for all transports in the future. Driver B was suspended on 04/07/25 and terminated on 04/08/25. Record review of the facility's in-services and training documents from 03/20/25 and 04/07/25 reflected six staff had been in-serviced by the regional trainer on transport procedures including loading and unloading the resident, and proper securement of the wheelchair in the van. All six staff had passed the company driving test administered by the regional trainer. Observation on 04/30/25 at 11:45 AM of van transport procedures, performed by Driver C, with Resident #3, revealed the resident was secured in his wheelchair with two straps to the front frame of the wheelchair, and two straps to the back frame of the wheelchair. A lap belt was placed and secured to the floor behind the wheelchair, and a chest strap was secured across the left shoulder to the lap belt, similar to a car seatbelt. The wheelchair locks were then secured. Unloading Resident #3 was accomplished by securing the safety strap across the back of the lift, rolling the wheelchair backwards onto the lift, securing the wheelchair breaks, and lowering the resident to ground level. The wheelchair locks were released before the safety strap was removed and the resident was rolled off the lift. Interview on 04/30/25 at 11:50 AM with Resident #3 revealed the procedure Driver C had performed for the transport was how all of his previous transports had been done. He stated he had no concerns with being transported via the facility van. Interview on 04/30/25 at 11:53 AM with Driver C revealed she had been re-trained on driving and transport procedures in March and April, and they now had two drivers present in the van to minimalize the risk for errors or injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 6 of 7 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 04/30/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Interviews on 04/30/25 from 12:00 PM-12:35 PM with four residents (Residents #3, #4, #5, and #6) that had been transported via the van on a regular basis for dialysis or other appointments revealed none had any concerns about how they were secured in the van, and all felt confident in the skills of the drivers. Interview on 04/30/25 at 4:23 PM with the Maintenance Director revealed his inspection of the van after both incidences revealed all equipment was in working order. Residents Affected - Some An interview was attempted with Driver B via telephone; however, the attempt was unsuccessful. A voicemail message was left for Driver B, but Driver B did not return the call. Record review of Driver B's driver training revealed Driver B had initially been trained for driving the van on 05/17/23 and her last re-training was on 01/30/25. Record review of in-service training records reflected the facility provided Van Training to staff, who drove the facility van following the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676004 If continuation sheet Page 7 of 7