Inspection·June 14, 2023

F 0644 The Interim Administrator was unable to locate a policy on PASARR prior to exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 2 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based in observations, record reviews, and interviews the facility failed to ensure that residents received proper treatment and care to maintain mobility by assisting 1 (Resident #39) of 5 residents reviewed for foot care in making an appointment with the podiatrist. Residents Affected - Few The facility failed to ensure Resident #39 was treated by the podiatrist when he visited the facility. This failure placed residents at risk of developing foot issues that could impede their mobility. Review of Resident #39's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included prostate cancer, weight loss, and reflux. Review of Resident #39's quarterly MDS, dated [DATE], revealed his BIMS score was 7, indicating severe cognitive impairment. His Functional Status indicated he required extensive assistance with his personal hygiene. Review of Resident #39's care plan, dated 02/15/23, revealed he was at risk of an ADL self-care deficit related to activity intolerance. Observation on 06/12/23 at 11:15 AM Resident #39's toe nails were long and deformed. Observation on 06/13/23 at 1:28 PM revealed Resident #39's toe nail had not been trimmed. Resident appears to have been recently bathed. Interview on 06/13/23 at 1:33 PM the Social Worker stated the podiatrist comes to the facility every 6 weeks to treat the residents. He stated the nursing staff notify him which residents need to see the podiatrist and he places them on the list. He also obtains any consents that are needed. After the podiatrist visits he sends his notes to the facility to be scanned into their EHR. Review of Resident $39's EHR revealed no treatment notes from the podiatrist. Review of podiatry visits from March 2023 and May 2023 revealed Resident #39 was not on the lists to be seen by the podiatrist. Interview on 06/13/23 at 2:03 PM LVN-C stated a resident's head-to-toe assessment, done weekly, was documented in the Skin Observation Tool. Any bruises, scratches, wounds, etc. would be documented. Review of Resident #39's weekly Skin Observation Tool documentation from 1/24/23 to 5/18/23 revealed no documentation of resident's toe nails being long. Review of the facility's procedure Foot Care, dated 02/15/14, revealed the purpose was to prevent infections of the feet. 4. If the resident has long toe nails, report to the charge nurse for the podiatrist to see. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 3 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 who need respiratory care were provided such care consistent with professional standards of practice for 2 out of 14 residents (Residents #28, and #40) reviewed for respiratory care. Residents Affected - Some 1- The facility failed to change and/or label Resident # 28's oxygen equipment and handheld nebulizer equipment in accordance with professional standards of practice and the facility policy and procedure. 2- The facility failed to change and label Resident # 40's oxygen equipment in accordance with professional standards of practice and the facility policy and procedure This failure has the potential to affect residents by placing them at risk for infections and complications associated with respiratory equipment failure due to exposure to equipment that has been used for an amount of time beyond appropriate or intended use limits. Findings included: 1. Record review of Resident # 28's History and Physical revealed a [AGE] year-old male. His diagnoses included morbid obesity, depressive disorder, gastroesophageal reflux disease, coronary arteriosclerosis, non-rheumatic mitral regurgitation, dyspnea, mixed hyperlipidemia, peripheral vascular disease, arteriosclerosis of coronary artery bypass, acute on chronic diastolic heart failure, impaired mobility, cerebrovascular disease, type 2 diabetes mellitus, essential hypertension, hyperlipidemia, congestive heart failure, mitral valve regurgitation, subsequent non-ST and coronary arteriosclerosis. Record review of Resident # 28's quarterly MDS-The Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes. dated [DATE] revealed a BIMS- score of 13 out of 15 indicating no cognitive impairment. The Brief Interview for Mental Status a structured evaluation aimed at evaluating aspects of cognition in elderly patients. Record review of Resident # 28's physician orders revealed the following orders: Apply oxygen at 2 liters per meter via nasal cannula as needed for shortness of breath. Albuterol Sulfate Nebulization Solution (2.5 milligrams/3milliliters) 0.083% 1 application inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. During an observation on [DATE] at 9:04 AM, Resident #28 was lying in his bed watching television. The resident's oxygen concentrator in the room was next to Resident #28's bed. The humidifier bottle on the concentrator was labeled with a last change date of [DATE]. The nebulizer on the resident's side table was labeled last changed date of [DATE]. Record review of Resident #40's history and physical revealed an [AGE] year-old female with an admit date of [DATE]. Her diagnoses included type 2 diabetes mellitus, hypertension, mixed hyperlipidemia, generalized anxiety disorder, insomnia, allergic rhinitis due to pollen, moderate chronic obstructive pulmonary disease and degenerative joint disease involving multiple joints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 4 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 - Some Record review of Resident #40's MDS- The Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes, dated [DATE] revealed a BIMS- score of 8 out of 15 indicating moderate cognitive impairment. BIMS-The Brief Interview for Mental Status a structured evaluation aimed at evaluating aspects of cognition in elderly patients The MDS- Minimum Data Set, a tool for implementing standardized assessment and for facilitating care management in nursing homes revealed that the resident#40 required extensive assistance from staff with locomotion The MDS also indicated that Resident #40 was receiving oxygen therapy. Record review of Resident #40's physician orders revealed an order for oxygen that read Oxygen at 2 Liters Per Minute via nasal cannula, change oxygen tubing every night shift every Sun, Clean oxygen concentrator every night shift every Sun During an observation on [DATE] at 08:22 AM, Resident #40 was in her room sitting in a side chair. Resident's oxygen concentrator was on at 2 liters per minute being delivered by nasal cannula tubing. Resident's tubing and humidifier labeled with the last change date [DATE]. During an observation on [DATE] at 11am resident was in her room sitting in her side chair. Resident's oxygen concentrator was on at 2 liters per minute being delivered by nasal cannula. The tubing and humidifier remained with the last changed dated [DATE]- one week and 2 days past the doctor's order and the facilities policy. 2. During an interview with the LVN D on [DATE] 10:30 AM who said the facility policy is to change the oxygen and nebulizer tubing weekly on Sunday's. LVN D said if out of stock of oxygen or nebulizer, or tubing/supplies the staff used a confidential texting phone app to notify the staff person that orders supplies. LVN D said she was sure they receive a truck at least 1x per week but not sure exactly when and how often the truck comes. LVN D said if the facility are out (see interview below with LVN E that explains the facility has the supplies in stock) of stock when time to change tubing/hoses on the oxygen or nebulizer machines, the nurse would look to see if the facility had any supplies stashed away LVN D said if unable to change the current past dated tubing it could mean a resident does not receive their oxygen and/or nebulizer treatment that could lead to death. LVN D said if there is not new tubing, and the current tubing was not damaged or corrupted she would continue to use the expired tubing that is outdated to ensure the receives their oxygen and nebulizer treatments. During interview on [DATE] 12:01 PM with LVN E showed surveyor plenty of supply of oxygen and nebulizer tubing/supplies in the supply cabinet. LVN E said if a nurse did not know where oxygen or nebulizer supplies were located, the nurse on duty would ask another nurse on duty if they knew where the supplies were located, then, if necessary, call supervisor to see where supplies may be located, and if no supplies are found then call supplier to see if they can overnight the supplies. LVN E said not changing the tubing could lead to infection. LVN E said it is important to check the concentrator and nebulizer machines to ensure they are in good working order on a regular basis. LVN E said not changing the tubing and checking the machines could lead to respiratory issues that could lead to hospitalization. Record review of facility Policy for maintain oxygen equipment, not titled, or dated, revealed in part: Procedure 4.Change oxygen tubing, cannula/mask with date and initials weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 5 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 5. Change humidifier bottle with date and time weekly. 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: 676033 If continuation sheet Page 6 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to ensure that food was properly stored in the kitchen's dry storage, refrigerator, and freezer. 2. The facility failed to ensure that kitchen's expired foods were discarded. 3. The facility failed to label and date food in the kitchen refrigerator. These failures could place residents at risk for food-borne illness. Findings included: Observation of the facility kitchen's dry storage on 06/12/23 9:50AM revealed: -Several large bins used to store bulk items labeled as to the product but lacked the received and expiration dates. -boxes of Krusteaz Lemon Cake mix, boxes of Krusteaz Pie Crust mix, 2 jars of Maraschino Cherries and cans of diced red peppers were without expiration dates. Observation of the facility's refrigerator on 06/12/23 09:50 AM revealed: - The walk-in/reach-in combo refrigerator had several opened containers of applesauce, and black sliced olives unlabeled and without an expiration date. Interview on 06/14/23 at 10:15 AM with Dietary Supervisor said using expired food could lead to botulism- a food borne illness caused by a toxin produced by clostridium botulinum bacteria, which is p most commonly present in improperly preserved foods. The toxin attacks your nerves and cause difficulty in breathing, muscle paralysis and even death. making the residents sick which at its worse could lead to death. Dietary Supervisor said unlabeled food could lead to a food allergy which could lead to death. Dietary Supervisor said having food without a received date will not allow dietary staff know expiration. The Dietary Manager stated with cooked food there was a certain amount of time to use, for instance 7 days, then throw it out. The dietary supervisor had no explanation as to why there was unlabeled food items other than the staff failed to label and date the items Review of the facility policy titled, Food in Receiving and Safety and Storage, dated September 2012, revealed, Check expiration dates and use-by dates to assure the dates are within acceptable parameters. The Food and Drug Administration Food Code dated 2017 reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 7 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Event ID: Facility ID: 676033 If continuation sheet Page 8 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 maintain an infection control program designed to prevent the development and transmission of infection for 6 of 6 residents observed (Resident #5, Resident# 11, Resident#21, Resident# 28, Resident #30, Resident#41) for infection control. Residents Affected - Some The facility failed to ensure CMA A disinfect the blood pressure cuff in between blood pressure checks for Resident #5, Resident# 11, Resident #30, and Residnet#41 The facility failed to ensure LVN C change glove and perform hand hygiene, after dropping on the floor, then picking up, and putting in the trash a blood sugar lancet (the device used to stick resident finger to get the blood sample); then get a new lancet from the medication cart, and proceed to check Resident#28 blood pressure with the same glove. The facility failed to ensure CNA K completed hand hygiene while performing incontinent care for (Resident #21). These failures could place the residents at risk for infection. Findings include: Review of Resident #41's face sheet, dated 06/14/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included hypertension, Chronic obstructive pulmonary disease, dementia, muscle weaken. Review of Resident #41's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 15 indicating cognitively intact. Review of Resident #41's Care Plan dated 04/18/2023 reflected the following: .Focus: The resident has hypertension. Goal: The resident will remain free of complications related to hypertension through review date. Interventions and task: . Give anti-hypertensive medications as ordered Review of Resident#41 provider orders dated 09/22/2021 reflected the following: AmLODIPine Besylate Tablet 2.5 MG Give 1 tablet by mouth one time a day for hypertension Review of Resident #11's face sheet, dated 06/14/2023, reflected she was a [AGE] year-old female originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Her diagnosis included essential hypertension, diabetes mellitus, depression, insomnia, Chronic obstructive pulmonary disease. Record review of Resident #11's Comprehensive MDS dated [DATE] revealed the resident's BIMS (Brief interview for Mental Status) score of 12 indicating moderate cognition. Review of Resident #11's Care Plan dated 03/24/2023 reflected the following: .Focus: The resident has hypertension. Goal: The resident will remain free of complications related to hypertension through review date. Interventions and task: Give anti-hypertensive medications as ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 9 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 Review of Resident#11 provider orders dated 11/04/2022 reflected the following: Carvedilol Tablet 3.125 MG Give 1 tablet by mouth two times a day for Acute on chronic diastolic congestive heart failure Observation on 06/13/23 07:51 AM reveled: CMA-A get blood pressure device from her pocked checked Resident#41blood pressure then put the blood pressure device, back in her pocket. CMA A give Resident#41 her medications; exit the room, get the blood pressure cuff from her pocket, and logged the blood pressure numbers in the PC over the medication cart, then put the blood pressure cuff back in her pocket. CMA A prepared Resident#11 medications. At 08:00 am CMA A went to Resident#41 pulled the blood pressure cuff from her pocket and check Resident#41 blood pressure, put the blood pressure cuff in her pocked without sanitization. CMA-A sanitize hands, exit the room then procced to administer medications to the next resident. Review of Resident #28's face sheet, dated 06/14/2023, reflected he was a [AGE] year-old male originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. His diagnosis included essential hypertension, diabetes mellitus, depression. Review of Resident #28's Comprehensive MDS dated [DATE] revealed the resident's BIMS (Brief interview for Mental Status) score of 13 indicating cognitively intact. Review of Resident #28's Care Plan dated 04/11/2023 reflected the following: .Focus: The resident has chronic generalized pain related to Diabetic Neuropathy. Focus: The resident has impaired visual function related to Diabetes Review of Resident#28 provider orders dated 04/03/2023 reflected the following: . Insulin Regular (Human) Inject as per sliding scale Observation on 06/13/23 beginning at 8:04 AM CMA-A, failed to sanitize the reusable blood pressure cuff between uses on Residents #5, #11, and #30. Interview on 06/13/23 at 2:45 PM CMA-A, stated the blood pressure cuff should have been sanitized between each resident use but the presence of the surveyor made her nervous. She has sanitizing wipes on her cart. She stated the risk to residents if the cuff is not sanitized is spreading an infection from one resident to another. 06/13/23 02:49 PM Interview on 06/13/23 at 2:49 PM the DON stated her expectation was that re-useable equipment was to be sanitized between resident uses in order to prevent spreading infections from one resident to another 06/13/23 02:56 PM Interview on 06/13/23 at 2:56 PM with CMA-B , she stated re-useable medical equipment had to be sanitized before being used on another resident to prevent cross contamination between residents Observation on 06/13/2023 at 08:15 am reveled: LVN-C enter Resident#28 room with supplies on a wax paper to check his blood sugar. LVN C dropped the lancet (device used to stick residents' finger and get a blood sample) on the floor then picked the lancet throw it in the trash, open the medication cart and get a new lancet. LVN C proceeded to check the resident blood sugar without changing glove, and without hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 10 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 Interview at on 06/13/2023 at 02:48 PM LVN-C stated she should remove glove and perform hand hygiene when she picked the lancet from the floor, before getting the new lancet, and checking resident blood sugar. LVN-C stated the lancet supposed to be sterile, and the risk to residents contamination. Review of Resident #21s face sheet, dated 06/13/2023, reflected he was a [AGE] year-old male admitted to facility 05/15/2019. His diagnoses included hemiplegia (a one-sided muscle paralysis or weakness), and hemiparesis (the weakness of one entire side of the body) following cerebrovascular disease affecting right dominant side, lack of coordination, cognitive communication deficit, dementia, hypertension. Review of Resident #21's most recent Quarterly MDS Assessment, dated 03/17/2023, reflected he had a BIMS score of 10 indicating moderate cognition. The review further reflected the resident required assistance with toileting and he was always incontinent of bladder, and bowel. Review of Resident #21's Care Plan dated 02/15/2023 reflected the following: Focus- (Resident #21) has bladder incontinence related to activity Intolerance, Impaired Mobility. Goal (Resident#21) will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions and task: . The resident uses disposable briefs change every 2 hours if soiled and prn. Clean peri-area with each incontinence episode . Observation on 06/13/2023 at 02:18 PM reveled: CNA K, and CMA A both staff enter the room put on gloves. CNA K open the brief, clean resident front area, tack the brief and dirty wipes between the resident legs, turn resident to his left side with the help of CMA A. CNA-K clean the resident buttocks area, fold the brief, and the dirty wipes in the fitting sheet remove all and put them over the trash can, remove glove and put clean glove without any form of hand hygiene. CNA K continue cleaning the resident, get a clean fitting sheet and clean brief and put them under the resident without changing her glove, put cream on the resident perineal area, remove glove and put a clean glove, and finish putting the brief on the resident. CNA K cover resident, and took the dirty linen to the hamper, and the trash to trach hamper. CNA K remove glove and sanitize hands. Interview on 06/13/2023 at 02:55 PM CNA K: she stated that she supposed to change glove when going from dirty to clean, and perform hand hygiene every time she removes glove, and before she put a clean glove. She stated she was rushing because the resident is combative (per observation resident was complying with the care), and she wants to finish cleaning him as soon as possible. She stated the risk to resident is to get bacteria on the resident skin, and if there is a cut in the skin, there will be infection, and to prevent the resident from getting UTI. She stated we know the purpose of hand hygiene, but she was nervous. Interview on 06/14/2023 at 09:49 AM with interim Administrator reveled: she stated the staff are trained to wash hands, the facility has alcohol-based hand sanitizer, and soap and water available for the staff to use. She further stated the staff supposed to wash hands before, and after peri-care, and there is so many times they (staff) supposed to wash hands, after eating, after toilet use. She stated the risk to resident is spreading infection. Interview on 06/14/23 at 12:50 PM: IP (Infection preventionist): stated the staff supposed to do hand hygiene any time they expected it needed, in between care, anytime the hands are soiled, and during incontinent care before and after. IP stated the risk to residents infection. Review of the facility's undated Hand Hygiene Policy reflected: All staff will perform proper hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 11 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. staff will perform hand hygiene when indicated, 6.a The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 12 of 13 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates 300 Happy LN Hillsboro, TX 76645 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the call system was accessible to the resident at each toilet and bath or shower located in the facility. The call system should be accessible to a resident lying on the floor. Residents Affected - Some The facility failed to ensure the call light system in 2 showers rooms (shower A and Shower B) in the facility are accessible to a resident lying on the floor. This failure could place residents in the shower facility at risk of being unable to obtain assistance in the event of an emergency. Findings included: Observation on 06/13/23 09:11 AM Shower A room next to DON office reveled: call light by the shower area about 3 feet high from the floor, the call light by the toiled set-in shower room higher than 4 inches from the floor. Observation on 06/13/23 09:20 AM Shower room B in hall 300: The call light located behind the wall divider (a 3 feet high wall dividing the shower area into two areas), in the opposite side of the shower. Interview on 06/13/2023 at 03:04 pm with maintenance supervisor: He stated the call light supposed to be waiting reach of a resident on the floor, and if the resident had a fall, he, or she cannot reach the call light the way it's now in the shower rooms. He stated he does not know how far the call light supposed to be from the floor, but he can find out and fix it. He recognized the call light in the shower room Hall 300 was in the opposite side of the shower area wall divider. Interview on 06/13/2023 at 03:15 with the interim Administrator reveled: no resident showered alone, there was always someone with the resident; per the interim administrator: a call light 3 feet high from the floor was waiting reach for the residents. Per the interim administrator the risk for the resident was: anything we do there was a risk to resident, and in the shower room there is no way the resident cannot get to call light system. The interim administrator denied knowing any incident happened related to call light not waiting reach for the residents in the shower rooms use for residents bathing in the facility. Review of the facility's undated policy Call Systems: Accessibility and Timely Response revealed: .7. The call system must be accessible to the resident at each toilet and bath or shower facility 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676033 If continuation sheet Page 13 of 13