Health inspection·July 9, 2025

F 0760 Level of Harm - Actual harm Residents Affected - Few flonase, isosorbide mononitrate, nifedipine, levothyroxine, pantoprazole, lubiprostone, metoprolol, sucralfate, and ranolazine. During an interview on 07/08/25 at 9:44 AM with the FM, she stated Resident #1 was in the facility on 06/12/25 and she got a call around 2 AM that resident had to go to the hospital for chest pain. She stated she found out from the facility that resident had missed some of his heart medications which included his newly ordered clopidogrel. She stated the doctor at the hospital had told her he thought that resident missing his clopidogrel is what could have caused him to have chest pain. She stated Resident #1 had discharged home with around the clock sitters after he left the hospital. In an attempt on 07/08/2025 at 10:45 AM to call the MD, he was unable to take a call at that time, detailed message was left for a return call. In an attempt on 07/08/2025 at 1:22 PM to call the MD, he was unable to take a call at that time, detailed message was left for a return call. In an interview on 07/08/25 at 1:49 PM, MA C stated she had worked in the facility for about 7 months. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, she would let the nurse know and they would get it. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could cause death. During an interview on 07/08/25 at 1:57 PM, MA D stated she had worked in the facility for about 4 years. She stated she was in-serviced on medication administration. She stated she has not had any concerns with medication being unavailable to administer to the residents. She stated they keep the medications ordered and coming in pretty good and they also have the emergency kit that they can use when needed. She stated if the emergency kit had not had a medication they needed, they marked the MAR as unavailable and called the pharmacy or hospice and notified the nurse. She stated if a resident missed doses of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a stroke or heart attack. She stated if there was a 9 placed in a spot on the MAR, it meant the medication, or the resident was not available. She stated she was the MA that marked the 9 on Resident #1's MAR dated 06/11/25 on the morning shift. She stated she always put a progress note in to describe why the 9 was there. She stated the progress note she left on 06/11/25 at 10:54 AM was struck out and did not give any details to why the 9 was on the MAR. She stated she could not remember from a month ago what actually happened or if the medications had been available or not. She stated she was not sure why the furosemide medication was signed as given on the evening of 06/10/25 and when she worked on 06/11/25, a 9 was in the spot that showed if medication was administered. In an interview on 07/08/25 at 2:51 PM, the DON stated when they knew they were getting an admission to the facility from the hospital and the resident may be arriving later in the day or evening, the hospital sent over the residents information, and they looked through everything to check and make sure they could accept and care for the resident. He stated they looked over the medications and sent them to the doctor for approval and once the resident arrived in the facility they informed the pharmacy. He stated medications were usually delivered within 1 hour of ordering from the pharmacy. In an interview on 07/08/25 at 3:31 PM, the FM stated Resident #1 was admitted to the hospital when he discharged from the facility, for the diagnosis of chest pain unspecified type, and he stayed in the hospital from [DATE] to 06/16/25 with the diagnosis of atypical chest pain recent NSTEMI. She stated there were no new treatments and the hospital kept resident to observe him for having chest pain and he had just had a recent heart attack. She stated she did not have any names from anyone who had given her information at the facility. In an interview on 07/08/25 at 4:48 PM, MA E stated he had worked in the facility for about 3 years. He stated he was in-serviced regularly on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676047 If continuation sheet Page 2 of 4 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 676047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059 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 0760 Level of Harm - Actual harm Residents Affected - Few medication administration. He stated he had not had any concerns with medication being unavailable to administer to the residents. He stated if a medication was not available, he would try to look for it in the overflow and if they had not had any he would have re-ordered the medication and notified the nurse. He stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a stroke or even death. In an interview on 07/09/25 at 10:09 AM, LVN A stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she has not had any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, she would have called the pharmacy. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused death. She stated she was the nurse that sent Resident #1 out to the hospital for chest pain on 06/12/25. She stated she had worked a split shift that night and the nurse that was leaving had informed her that Resident #1 was having chest pain and had refused to go to the hospital. She stated she went and assessed resident, and resident still complained of chest pain and pain in his left arm. She stated residents heart rhythm was irregular and missed a beat every 7-8 beats or so. She stated resident was still refusing to go to the hospital and she pleaded with him to go, and he finally agreed and was sent out via ambulance. She stated she had not had time to look up anything when she came in, so she was not aware if resident had or had not received any of his medications that day. In an interview on 07/09/25 at 10:47 AM, MA F stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication being unavailable to administer to the residents. She stated anytime they did not have a medication, she would have notified the nurse and charted that the medication was not available. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused death or cardiac arrest. She stated Resident #1's medications had been delivered to the facility, besides the sucralfate and another medication that she could not remember, on the evening of 06/11/25 when she passed medications. She stated if there was not a medication she notified the nurse to try to get it out of the emergency kit and if they did not have it in there, they charted a 9 and made a progress note that they were awaiting arrival from the pharmacy, or the drug was not available. She stated she worked on 06/11/25 in the evening and documented that resident received all of his medications except the ones that were not available in the facility. She stated she put a 9 in the places of the medications that were not given and made a progress note at the time that stated she was awaiting arrival on 06/11/25 at 8:11 PM. In an interview on 07/09/25 at 11:44 AM, LVN B stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication not being available to administer to the residents. She stated if a medication was not available, she would have checked the emergency box to see if the medication was available there, and if not she would have reported it to the doctor, called the pharmacy, let the family and DON know, and she would have documented it. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a lot of cardiac issues such as hypertension, chest pain, and it could affect their vital signs and their physical state. In an interview on 07/09/25 at 11:58 AM, the DON stated staff had been in-serviced staff on medication administration. He stated medication aides and nurse were responsible for administering medications to the residents. He stated it was his expectation that all residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676047 If continuation sheet Page 3 of 4 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 676047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059 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 0760 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete received all of their medications as ordered. He stated he was not aware of any concerns with medication being unavailable to administer to the residents except for once and that had been addressed. He stated if a medication was not available, staff should have immediately notified the nurse and the nurse should have notified the ADON, then it comes to him, and the pharmacy would have been called to ensure the medication was gotten to the facility. He stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused adverse effects or serious consequences, such as death. He stated he was not aware that Resident #1 had not received his medications as ordered on 06/11/25 until resident had already went to the hospital. He stated after they found out about the medications they in-serviced staff on medication administration. In an interview on 07/09/25 at 12:19 PM, the ADM stated staff had been in-serviced staff on medication administration. She stated the MA's, and nurses were responsible for administering medications. She stated it was her expectation that all residents received all of their medications as ordered. She stated she was not aware of any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, staff should have checked the emergency kit and if it was not there they should have notified the ADON and DON and called the pharmacy to see what was going on. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused issues up to death. Review of the facility policy Administering Medications dated 2001, revised April 2019, reflected in part, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the facility policy Medication Therapy dated 2001 reflected in part, Policy Statement: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. 3. All medication orders will be supported by appropriate care processes and practices. Event ID: Facility ID: 676047 If continuation sheet Page 4 of 4