Health inspection·June 19, 2025

F 0582 Resident #73. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #73's quarterly MDS assessment dated [DATE] which indicated Resident #73 was understood and had the ability to understand others. Resident #73's BIMS score was 8 which indicated moderate cognitive impairment. Resident #73 received occupational therapy starting on 04/03/25. Residents Affected - Few Record review of the Resident #73's Notice of Medicare Non-Coverage (NOMNC) dated 06/10/25 indicated it had been completed with signature confirmation of understanding from Resident #73's Responsible Party on 06/10/2025 with services ending on 06/12/2025. However, the Skilled Nursing facility Advanced Beneficiary Notice (SNF ABN) CMS form 10055 was not completed which would have informed Resident #73 and/or Resident 73's Responsible Party of the option to continue services at a private pay rate. During an interview on 06/18/25 at 1:12 p.m., the Social Service said she had been employed at the facility for 5 years. She said she was responsible for NOMNC and SNF ABN letters. She said the SNF ABN form was supposed to be given to the resident or responsible party 48 hours prior to the service(s) ending. She said she also informed the resident and/or responsible party of the appeal process. She said the form titled Detailed Explanation of Non-coverage , form CMS 10124-DENC, was what she had been using as the SNF ABN letter. She said she thought, the CMS Form for SNF ABN notification had changed since the last survey. She said some time last year, she had received the CMS 10124-DENC Form from MDS Coordinator F to use as the SNF ABN letter. She said the SNF ABN form usually had the reason for discharge, price of service, and options. She said it was important for the residents to receive the correct SNF ABN form. She said the SNF ABN form let the residents know why they were coming off services which was normally because they met their goals or refused therapy. She said when a resident was not given the SNF ABN form, the resident may not get to appeal the discharge in time. She said the ADM was responsible for ensuring she provided the residents SNF ABN letters. During an interview on 06/18/25 at 1:46 p.m., the MDS Coordinator F said corporate sent the facility which forms to use for the NOMNC and SNF ABN. She said recently she had received an updated NOMNC form but not an SNF ABN form. She said she never instructed the Social Service to use the CMS Form 10124 instead of CMS Form 10055. During an interview on 06/19/25 at 12:19 p.m., the ADM with the ADO and RCN present said, the Social Service was responsible for using the correct the SNF ABN form and giving it to the residents. She said the SNF ABN form was important to let the residents know how many more days they had remaining and when they would be discharged . The ADO said it was important for the resident to receive the SNF ABN because the resident could lose coverage. The ADO said it was the ADM responsibility to ensure the Social Service was providing the resident, the correct SNF ABN form and giving timely notice. The ADM said the facility did not have a policy related to NOMNC/SNF ABN but followed the RAI manual. Record review of the facility's undated Resident Rights policy indicated, .the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate . Record review of the Medicare Claims Processing Manual (Section 70- 70.2), implemented on 10/02/24, indicated the following are standards for use by Skilled Nursing Facilities (SNFs) in implementing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 2 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the SNF ABN (CMS-Approved Model Form CMS-10055) requirements. A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items, or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in 70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. EVENT DESCRIPTION Initiation In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary. Reduction In the situation in which a SNF proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary. Termination In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 3 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 of 20 residents reviewed for care plans (Resident #71). The facility failed to care plan Resident #71's oxygen therapy usage. Resident #71 was coded for oxygen therapy on the 04/29/25 MDS assessment. This failure could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: Record review of Resident #71's face sheet dated 06/17/25 indicated Resident #71 was an 80-years-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #71 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), cough, and atrial fibrillation (is a common heart condition where the heart's upper chambers (atria) beat irregularly and sometimes rapidly). Record review of Resident #71's quarterly MDS assessment dated [DATE] indicated Resident #71 was usually understood and usually had the ability to understand others. Resident #71 had a BIMS score of 5 which indicated severe cognitive impairment. Resident #71 used oxygen while a resident and continuously at discharge. Record review of Resident #71's care plan dated 06/16/25 did not reflect a care area for oxygen therapy. Record review of Resident #71's consolidated physician order dated 06/17/25 indicated: *May use oxygen at 2-3 liters per minute via nasal cannula (is a thin, flexible tube that wraps around your head, typically hooking around your ears) every shift. Start 02/25/25. *Oxygen at 2-3 liters per minute via nasal cannula as needed for dyspnea (difficulty breathing)/desire/comfort measures every shift. Start 06/12/25. Record review of Resident #71's Treatment Administration Record dated 6/1/25-6/30/25 indicated: *Oxygen at 2-3 liters per minute via nasal cannula as needed for dyspnea (difficulty breathing)/desire/comfort measures every shift. Start 06/12/25. Documentation noted 11 out of 11 shifts. *May use oxygen at 2-3 liters per minute via nasal cannula every shift. Start 02/25/25. Documentation noted with oxygen saturations 45 out of 48 shifts. During an observation on 06/16/25 at 11:02 a.m., Resident #71 was asleep in her bed. Resident #71 had a nasal cannula on her face connected to an oxygen concentrator (is a medical device that gives (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 4 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0656 you extra oxygen). The oxygen concentrator was set on 2.5 liters per minute. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/17/25 at 8:48 a.m., Resident #71 was lying in her bed. Resident #71's nasal cannula was on her face but not in her nose. Resident #71 nasal cannula was connected to an oxygen concentrator. The oxygen concentrator was set on 2.5 liters per minute. Residents Affected - Few During an interview on 06/18/25 at 12:26 p.m., the MDS Coordinator F said both MDS Coordinators worked on the resident's care plans. She said if Resident #71's oxygen was as needed then it might not have been care planned. She said if Resident #71 was using oxygen continuously then it needed to be care planned. She said she was surprised Resident #71 did not have a care plan for oxygen. She said the facility's system pulled over information from new admissions, orders, and medications and built care plans. She said the nurses could also start care plans for things like oxygen. She said the MDS Coordinator and the nurses should have initiated Resident #71's oxygen therapy care plan. She said acute care plan were done by the nurses with the MDS Coordinators help. She said the care plan developed after MDS assessments were done by the MDS Coordinators. She said the care plans were important because it was a picture of how the facility was supposed to take care of the residents. She said it was also a guideline of the resident's care. She said when the care plan was not done, things could be missed. During an interview on 06/18/25 at 2:05 p.m., the LVN J said, the nurses reported changes to the MDS Coordinators or DON so the care plan was updated. She said a care plan was important to know what is going on, to be safe, and provide routine care. She said the care plans were developed to provide patient centered care. She said when the resident did not have a care plan, the staff may not know what to do and would not know the resident's needs. During an interview on 06/19/25 at 11:46 a.m., the DON said, she had been in the position since September 2023. She said the MDS Coordinators were responsible for care plans related to oxygen therapy. She said the MDS Coordinators developed the care plans from the MDSs and the information learned from the morning meetings. She said the nurses did the acute care plans. She said the Regional MDS Coordinator monitored the MDS Coordinators to ensure the care plans were developed. She said the care plans were important, to have a plan of care that the staff could view. She said without a care plan, the residents may not get proper care. During an interview on 06/19/25 at 12:19 p.m., the ADM with the ADO and RCN present said, the nursing staff were responsible for the care plans. The ADO said the IDT was also responsible for the care plans. The ADM said the care plans were important to know how to treat the resident. She said the residents would not get the treatment they needed if the care plans were not developed. She said the DON was responsible for ensuring the nursing staff and the IDT were developing care plans. She said the DON should be monitoring that process during weekly standard of care meetings. Record review of a facility's undated Comprehensive Care Planning policy indicated, .the facility will develop and implement a comprehensive person-centered care plan for each resident .to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .when developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 5 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 3 Residents (Resident #26) whose record were reviewed for skin integrity. Residents Affected - Few The facility failed to ensure Resident #26's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings on 06/16/25 and 06/17/25. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings included: Record review of Resident #26's face sheet dated 06/17/25 indicated Resident #26 was an 89-years-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #26 had diagnoses including heart failure (is a condition where the heart cannot pump enough blood to meet the body's needs), pressure ulcer of right heel, unstageable (is a type of pressure injury where the depth of the wound cannot be determined because the wound bed is obscured by slough (yellowish, tan, gray, green, or brown tissue) and/or eschar (tan, brown, or black tissue)), open wound to right ankle, chronic venous hypertension with ulcer of left lower extremity (is a condition where the veins in the legs don't efficiently return blood to the heart, leading to a buildup of pressure in the veins and surrounding tissues), non-pressure chronic ulcer (is a persistent open sore on the skin, typically on the lower limbs, that develops due to factors other than prolonged pressure) of left calf with fat layer exposed, pressure ulcer of other site, stage 4 (is the most severe stage of a pressure injury, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle) and dementia (is a general term for a decline in mental ability severe enough to interfere with daily life). Record review of Resident #26's annual MDS assessment dated [DATE] indicated Resident #26 was understood and had the ability to understand others. Resident #26 had a BIMS score of 7 which indicated severe cognitive impairment. Resident #26 required supervision for oral hygiene and upper body dressing, partial/moderate assistance for toileting and personal hygiene, substantial/maximal assistance for lower body dressing and putting on/taking off footwear, and dependent for shower/bathe self. Resident #26 was at risk for developing pressure ulcers/injuries. Resident #26 had one or more unhealed pressure ulcers/injuries. Resident #26 had one stage 4 pressure and one unstageable ulcer/injury. Resident #26 had pressure reducing device for bed. Record review of Resident #26's care plan dated 09/30/24 indicated Resident #26 had a pressure ulcer or potential for pressure ulcer development. Stage 4 right heel and left distal (parts of the body further away from the center) medial (situated near the median plane of the body) foot, and stage 3 left heel. Intervention included follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #26's consolidated physician order dated 06/17/25 indicated may have pressure relieving mattress every shift. Start date 02/14/24. Record review of Resident #26's Treatment Administration Record dated 6/1/25-6/30/25 indicated may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 6 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0686 have pressure relieving mattress every shift. Documentation noted for 33 of 33 shifts. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #26's VOHRA Wound Evaluation and Management Summary dated 06/05/25 indicated Stage 4 pressure wound of the left, distal, medial foot full thickness .wound size (LengthxWidthxDepth): 1.3x1.3x0.1 centimeters .wound progress: at goal .duration: greater than 342 days . Residents Affected - Few Record review of Resident #26's VOHRA Wound Evaluation and Management Summary dated 06/12/25 indicated Stage 4 pressure wound of the left, distal, medial foot full thickness .wound size (LengthxWidthxDepth): 2x1.9x0.1 centimeters .wound progress: at goal .duration: greater than 356 days . Record review of Resident #26's progress notes dated 05/18/25-06/18/26 indicated: *06/05/25 at 2:20 p.m. by WCN E, Weekly Skin Assessment, Stage 4 pressure ulcer to left distal medial foot measuring 1.3x1.3x0.1 centimeters. *06/05/25 at 2:26 p.m., by WCN E, Weekly Ulcer Assessment, left distal medial, stage 4 pressure, length: 1.3 centimeters, Width: 1.3 centimeters, Depth: 0.1 centimeters, intervention: air mattress, pressure injury not present on admission. *06/12/25 at 1:56 p.m. by WCN E, Weekly Skin Assessment, Stage 4 pressure ulcer to left distal medial foot measuring 2x1.9x0.1 centimeters. *06/12/25 at 2:07 p.m. by WCN E, Weekly Ulcer Assessment, left distal medial, stage 4 pressure, length: 2 centimeters, width: 1.9 centimeters, depth: 0.1 centimeters, intervention: air mattress, pressure injury not present on admission. Record review of Resident #26's weight recorded accessed on 06/19/25 indicated: *06/09/25 at 3:05 p.m.: 123.6 pounds *05/30/25 at 4:45 p.m.: 123.0 pounds *05/23/25 at 10:38 a.m.: 123.1 pounds *05/12/25 at 3:36 p.m.: 121.9 pounds *05/09/25 at 10:18 a.m.: 120.8 pounds During an observation and interview on 06/16/25 at 11:44 a.m., Resident #26 was in his wheelchair by the bedroom door. Resident #26 had disorganized thoughts and was not interviewable. Resident #26 had socks on his feet and unable to visualize wound. Resident #26's low air loss mattress was on 300 pounds. During an observation on 06/17/25 at 9:15 a.m., Resident #26 was wandering down the hall but not exit seeking. In Resident #26's room, Resident #26's low air loss mattress was on 300 pounds. During an observation on 06/17/25 at 1:50 p.m., Resident #26 was in his wheelchair by the bedroom door. Resident #26's low air loss mattress was on 300 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 7 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/18/25 at 12:26 p.m., WCN E said the central supply ordered and set up the low air loss mattresses. She said she checked the weight settings on the low air loss mattress about once a week. She said she could not remember the last time she checked Resident #26's weight setting. She said Resident #26 weighed about 100-120 pounds. She said Resident #26's weight setting being on 300 pounds was not appropriate. She said Resident #26 had recently moved into a new room with a family member. She said Resident #26's weight setting may have been accidently changed with the room change. She said the nurses had an order to check the pressure relieving mattresses on the treatment administration record. She said she did not know who was responsible for ensuring the residents on low air loss had the correct weight setting. She said the wrong weigh setting could cause more breakdown because the bed was too hard. During an interview on 06/18/25 at 2:05 p.m., LVN J said the low air loss mattresses were for wounds. She said she did not know the dial on the low air loss mattress machine was supposed to match the resident's weight. She said she looked at the machine to make sure it said alternating and static. She said she thought the number on the machine indicated the amount of pressure needed to keep the mattress inflated. She said the nursing order on the treatment administration record was signing off the resident had the pressure relieving mattress and it was inflated. She said Resident #26 was on hospice services so the durable medical equipment company brought and set up his bed. She said Resident #26's low air loss mattress being on 300 pounds was too much pressure. She said Resident #26's wounds could deteriorate on a too hard bed. During an interview on 06/19/25 at 11:46 a.m., the DON said she had been in the position since September 2023. She said the WCN E was responsible for the low air loss mattress weight setting. She said the WCN E should be ensuring the setting was not too hard or too soft. She said the wrong weight setting, on the low air loss mattress could cause skin breakdown. She said the DON was responsible for monitoring WCN E. During an interview on 06/19/25 at 12:19 p.m., the ADM with the ADO and RCN present said, the nursing staff and WCN E were responsible for placing the low air loss mattress order in the resident's EMR. She said the nursing staff were responsible for the weight setting on the low air loss mattress. She said the wrong setting on a low air loss mattress could cause a resident's wounds not to heal properly. She said the DON should be ensuring the nursing staff were checking weight setting. She said the DON should be monitoring that process by rounding and chart audits. Record review of a facility's undated Wound Treatment Management policy indicated, .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of Evaluation of a low-air-loss mattress system in the treatment of patients with pressure ulcers (1995) www.pubmed.ncbi.nlm.nih.gov/7612140 was accessed on 06/23/2025 indicated .our observation indicate that use of the low-air-loss mattress system reduces the size and facilitates the healing of previously stable, chronic pressure ulcers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 8 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #40's face sheet, dated 06/17/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die) and unstable angina (a serious heart condition characterized by chest pain or discomfort that occurs at rest). Record review of Resident #40's quarterly MDS assessment dated [DATE] indicated Resident #40 usually understood and usually understood others. Resident #40's had BIMS score of 5 which indicated severe cognitive impairment. Resident #40 required maximal assistance with toileting and showering. Resident #40 was dependent with lower body dressing and personal hygiene. Record review of Resident #40's care plan dated 12/26/23 indicated the resident has an ADL self-care deficit. Interventions indicate anticipate needs, reorient, educate and assist resident with ADL's to help prevent her coming out of her wheelchair. Assist with personal hygiene as required: hair, shaving, oral care as needed. Bathing: requires staff x1 for assistance. Bed mobility requires staff x1 for assistance. During an observation on 06/16/25 at 11:11 A.M., Resident #40's frayed call light on nightstand in her room. During an observation and interview on 06/16/25 at 2:33 P.M., Resident #40 was sitting up in her wheelchair in her room. She said when she got on her call light staff came to see what she needed. Resident #40's frayed call light was on the nightstand in her room. During an observation on 06/17/25 at 12:47 P.M., Resident #40's frayed call light was on the nightstand in her room. During an interview on 06/17/25 at 3:00 P.M., LVN L said the frayed call light in Resident #40's room was a safety issue, because the cord was damaged and exposed. She said the frayed call light was a hazard. She said she would get the frayed call light fixed. During an interview on 06/18/25 at 12:03 P.M., Maintenance Supervisor G said he changed the damaged call light cord in Resident #40's room. He said staff were supposed to be doing champion rounds to find those type of issues. He said soon as LVN L was aware of the damaged cord she notified me. He said the call light cord was damaged and it was not high in voltage, but it should have been changed prior to surveyor intervention. During an interview on 06/19/25 at 9:31 A.M., LVN C said maintenance was responsible for ensuring the call light were safe and replaced if damaged or frayed. She said it was all staff responsibility to let maintenance know about a damaged call light. She said negative effect of a frayed call light was someone could get electrocuted. During an interview on 06/19/25 10:02 A.M., Maintenance Supervisor G said he changed the call light when they were damaged in the facility. He said champion rounds were performed by department heads and nurses and they should be checking for those types of issues. He said a negative effect of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 9 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 - Minimal harm or potential for actual harm Residents Affected - Some resident with a frayed call light was a resident could not get the care they needed due to the call light may not work properly. During an interview on 06/19/25 at 10:52 A.M., the DON said maintenance were responsible for replacing frayed call lights. She said staff were supposed to be doing angel rounds every morning and if they see the call lights were frayed, they need to report it to myself or maintenance. She said a negative effect of a frayed call light could be a fire. During an interview on 06/19/25 at 11:14 A.M., the ADM said we make champion rounds in the mornings before the morning meetings. She said maintenance were responsible for replacing the frayed call lights. She said a negative effect of a frayed call light was it could electrocute someone and if the call light is not working properly the resident could not get the help they need. Record review of facility's admission packet form titled Items not allowed in resident rooms revised on 4/1/2022 indicated .Medications (includes all prescription and over-the-counter drugs, except emergency items like nitroglycerin, which must be ordered by the doctor through the Health Care Center) .rubbing alcohol or any liniments .the resident is deemed safe to self-medicate the above listed items must be secured in a locked box in the resident's room. Note: A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled Keep out of reach of children or carries any typer of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. May of out residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. Special note .Always check before bringing in food or any item which might be detrimental to the care of any of our residents; this includes items that may be detrimental to residents on special diets. If you have any questions regarding items are not allowed, please check with the administrator or director of nursing. Record review of the facility's policy, Resident Rights, undated, indicated: . Safe environment- The resident has a right a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide belongings to the extent possible . a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does pose a safety risk . b. The facility shall exercise reasonable care for the protection of the resident's property from loss or theft . 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains free of accidents hazards as possible and provide supervision to prevent accidents for 3 of 20 residents reviewed for accidents. (Resident #40, Resident #48, and Resident #55) 1. The facility failed to ensure prohibited items, witch hazel and hand sanitizer, were out of Resident #48's room. 2. The facility failed to ensure prohibited item, alcohol, was out of Resident #55's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 10 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 3. Level of Harm - Minimal harm or potential for actual harm The facility failed to replace a frayed call light prior to surveyor intervention in Resident #40's room. These failures could place residents at risk for injury or harm. Residents Affected - Some Findings included: 1. Record review of Resident #48's face sheet dated 6/17/2025 indicated he was a [AGE] year-old male readmitted to the facility on [DATE]. Some of his diagnoses included Type II Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), Glaucoma (a group pf eye diseases that can lead to damage to the optic nerve; left untreated, glaucoma can lead to permanent vision loss or blindness), and Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wear down over time leading to joint pain, stiffness, and inflammation). Record review of Resident #48's Quarterly MDS dated [DATE] indicated he was able to make self-understood and understood others. The MDS indicated Resident #48's vision was highly impaired and required corrective lenses. Resident #48 had a BIMS of 14 indicating he was cognitively intact. Record review of Resident #48's care plan dated revised on 4/5/2022 indicated the resident had potential for injuries related to being legally blind with interventions to announce self when entering an area where resident is located, explain all procedures to resident before initiating them, involve resident in auditory activities, music, parties and exercise, keep environment free from clutter, keep items off the floor, and reorient if furniture is moved or there is a change in environment. The care plan revised on 11/9/2024 also indicated Resident #48 has ADL self-care performance deficits which included an intervention for staff to assist with personal hygiene as required: hair, shaving, oral care as needed. During an observation on 6/16/2025 at 9:33 AM, Resident #48 observed to have a bottle of witch hazel on top of his mini refrigerator located on the nightstand next to his bed. During an observation and interview on 6/17/2025 at 8:22 AM, Resident #48 had a bottle of witch hazel and hand sanitizer located on top of his mini refrigerator. Resident #48 said the witch hazel was used as his aftershave. 2. Record review of Resident #55's face sheet dated 6/17/2025 indicated he was a [AGE] year-old female admitted to the facility on [DATE]. Some of his diagnoses included Dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), cognitive communication deficit (communication difficulties that arise from cognitive impairment rather than primary language or speech issues), hypertension (the force of blood pushing against the artery walls is consistently too high) and pain. Record review of Resident #55's Quarterly MDS dated [DATE] indicated her vision was impaired and able to see large print and wore corrected lenses. Resident #55 was able to make self-understood and understood others. She had a BIMS score of 12 indicating she was moderately impaired. Record review of Resident #55's care plan dated revised on 4/5/2022 indicated the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 11 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 - Minimal harm or potential for actual harm impaired cognitive function related to dementia with impaired thought processes. Interventions included engaging the resident in simple, structured activities that avoid overly demanding task, keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Resident #55's care plan indicated she had impaired visual function and had glasses but did not wear them. Interventions included to arrange room to her needs. Residents Affected - Some During an observation on 06/16/25 at 11:13 a.m., Resident #55 was lying in bed. On a small, black table near Resident #55's head was a bottle of 90% rubbing alcohol. During an observation on 06/17/25 at 09:07 a.m., Resident #55 was lying in bed asleep. On a small, black table near Resident #55's head was a bottle of 90% rubbing alcohol. During an observation on 06/17/25 at 1:54 p.m., Resident #55 was lying in bed asleep. On a small, black table near Resident #55's head was a bottle of 90% rubbing alcohol. During an interview on 6/19/2025 at 9:04 AM, LVN C said the CNAs are the ones who check the rooms for items the residents are not supposed to have. LVN C said the CNAs would bring items to her. LVN C said Resident were not allowed to have alcohol or witch hazel in their rooms. LVN C said she never goes through a resident's stuff. LVN C said Resident #48 should not have alcohol products unless it was part of their treatment. LVN C said personal items like hand sanitizers and witch hazel were put in a drawer or a closet. LVN C said Resident #48 could not see, so he depends on staff. LVN C said if another resident wandered into his room, they could drink the alcohol, witch hazel, or improperly use if in the wrong hands. She said it could cause an allergic reaction or kill them if taken incorrectly. During an interview on 6/19/2025 at 9:13 AM, CNA A said all the staff were responsible for checking resident's rooms to ensure the resident did not have unapproved items in their room. She said the facility had a closet to store witch hazel, alcohol, aftershaves, and other personal care items. The CNA A said Resident #48 should not have witch hazel or hand sanitizer at his bedside. CNA A said another resident could get it in their eyes, try to eat or drink it causing them harm. CNA A said if those products dropped, it could cause a slip and fall or cause a resident to get sick. CNA A said Resident #48's family member brought the resident things from home. CNA A said Resident #48 did not shave himself and she used witch hazel for his aftershave. CNA A said a resident should not have alcohol-based products, mouth washes, or razors in their room. She said she would notify the nurse when she identified those items. During an interview on 6/19/2025 at 11:14 AM, the DON said Resident #48 should not have witch hazel or hand sanitizer in his room. She said alcohol products should not be stored in a resident's room and would be stored at the nurse's station. She said a resident could have those items for their treatment and care. The DON said another resident could drink the sanitizer, alcohol or witch hazel making them sick. The DON said she expected the staff to keep those items store at the nurse's station. During an interview on 6/19/2025 at 11:32 AM, the ADM said residents should not have alcohol products in their room. She said nursing was responsible for ensuring items were properly stored on the medication cart. The ADM said the CNA should remove or notify the nurse if an item was identified. The ADM said it could be hazardous if another resident drank or spilled it causing a fall or if consumed, could cause a resident to become sick if consumed. The ADM said staff should inventory personal items brought to the facility and/or send home if the item was not appropriate to have in resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 12 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 room. 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: 676241 If continuation sheet Page 13 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 6 residents (Resident #14 and Resident #51) reviewed for respiratory care and services. Residents Affected - Few 1.The facility failed to cover the nasal cannula tubing with a bag on an oxygen concentrator machine that was not in use for Resident #14. 2.The facility failed to cover the bi pap mask with a bag that was not in use for Resident #51. These failures could place residents at risk for developing respiratory complications. Findings included: 1.Record review of Resident #14's face sheet, dated 06/17/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dyspnea (labored breathing) and dependence on supplemental oxygen. Record review of Resident #14's quarterly MDS assessment dated [DATE] indicated Resident #14 understood and understood others. Resident #14's BIMS score of 15 which indicated cognition was intact. Resident #14 required set-up assistance with toileting and eating. Resident #14 required supervision with upper dressing and personal hygiene. Record review of Resident #14's order summary report dated 06/17/25 indicated Resident #14: Order: May use oxygen at 2 liter per minute via nasal cannula every shift related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dated 03/07/25. Order: 02 at 2-4 liter per minute as needed for shortness of breath, dated 04/14/25. Record review of Resident #14's care plan dated 03/12/25 indicated the resident has oxygen therapy. Interventions indicate encourage or assist with ambulation as indicated, monitor for signs and symptoms of respiratory distress and report to medical director as needed: respirations, pulse, oximetry, increased breathing, diaphoresis, and restlessness. 2.Record review of Resident #51's face sheet, dated 06/19/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included wheezing (a high-pitched whistling sound made while breathing), obstructive sleep apnea (intermittent airflow blockage during sleep), altered mental status (an altered level of consciousness) and multi-system degeneration of the autonomic nervous system (progressive neurodegenerative disorder that affects the autonomic nervous system and other areas of the brain). Record review of Resident #51's MDS assessment dated [DATE] indicated Resident #51 was understood. Resident #51's BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #51's order summary report dated 06/19/25 indicated Resident #51: Order: bi pap on at bedtime setting Ipap 13cm Epap 6cm at bedtime for obstructive sleep apnea (intermittent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 14 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 airflow blockage during sleep), dated 05/28/25. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/16/25 at 11:24 A.M. Resident #51's bi-pap mask was sitting on top of the nightstand and not covered with a plastic bag. Residents Affected - Few During an observation on 06/16/25 at 11:37 A.M. Resident #14's nasal cannula was laying over her concentrator and not covered with a plastic bag. During an observation and interview on 06/16/25 at 1:29 P.M. Resident #14's nasal cannula was thrown over her concentrator and not covered with a plastic bag. Resident #14 said she usually wore oxygen every night and sometimes during the day. During an observation on 06/16/25 at 1:38 P.M. Resident #51's bi pap mask was sitting on top of nightstand and not covered with a plastic bag. During an observation on 06/17/25 at 12:44 P.M. Resident #14's nasal cannula tubing was on oxygen concentrator without being secured in a bag. During an observation on 06/17/25 at 12:45 P.M. Resident #51's bi pap machine face mask was stored in nightstand and not in a plastic a bag. During observation on 06/17/25 at 2:40 P.M. Resident #14's nasal cannula on concentrator was not in a bag. During observation and interview 06/17/25 at 2:45 P.M. Resident #51 said she wore her bi pap machine at night and when she got up in the morning the nurse took the mask off. She said when the nurses took her mask off, they normally put the mask over on her nightstand. During an interview on 06/17/25 at 3:07 P.M., LVN L said Resident #14's nasal cannula tubing should absolutely be in a bag. She said the tubing and humidifier bottles should be changed weekly. She said she would change the tubing and apply a bag to the tubing. She said the nurses takes off Resident #51's bi pap mask. She said the nurses should have bagged the face mask when they got Resident #51 up this morning. She said not bagging the nasal cannula and bi pap face mask could expose the residents to infections and they were stored improperly. During an interview on 06/19/25 at 9:31 A.M., LVN C said all staff should make sure that the nasal cannulas and bi pap mask are in bags when not in use. She said the nasal cannula and humidifier bottles were supposed to be changed out on Sunday nights by the night nurse. She said the night nurses were also responsible for ensuring the bags were placed on the concentrators and on the bi pap machines. She said a negative effect of not ensuring these devices were bagged could expose the residents to bacteria in the devices. During an interview on 06/19/25 at 10:52 A.M., the DON said the charge nurses and CNA's were responsible for ensuring that the nasal cannulas and bi pap face mask were in a bag when not in use. She said the humidifier bottles and nasal cannula tubing should be changed every Sunday night by night nurse. She said she was responsible for ensuring that the nurses were doing it. She said she made rounds to ensure that tasks were done. She said a negative effect of improper storage of the nasal cannula and bi pap face mask could cause infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 15 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 06/19/25 at 11:14 A.M. The ADM said the nurses were responsible for ensuring that the nasal cannulas and bi pap mask were in a bag when not in use. She said the DON was responsible for monitoring the nurses on a weekly basis and during champion rounds. She said a negative effective of improper storage of nasal cannulas and bi pap face mask could be a risk for infection. Record review of the facility's policy, Respiratory Policies and Procedures, revised on June 1, 2006, indicated: .Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Humidification of oxygen is used for a flow rate of four liters per minute or greater, or if requested by a patient. Oxygen is set up., delivered, and monitored by a licensed nurse or respiratory therapist . To provide oxygen concentrations at flow rates from1/2 liter per minute to 8 liters per minute .15. Replace entire set-up every seven days. Date and store in treatment bag when not in use . Event ID: Facility ID: 676241 If continuation sheet Page 16 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who require dialysis services receive such services consistent with professional standards of practice for 1 of 2 residents reviewed for dialysis services. (Resident #41) Residents Affected - Some The facility failed to ensure the dialysis communication forms for Residents #41 were received back from the dialysis center after returning from dialysis treatment. The facility failed to ensure the post-dialysis assessments were completed and documented on Resident #41's dialysis communication forms on 02/17/25, 03/05/25. 04/16/25, and 06/04/25. The facility failed to ensure the post (after)-dialysis vital signs (are measurements of the body's most basic functions) were documented in Resident #41's EMR on 06/02/25, 06/11/25, 06/13/25, and 06/16/25. These failures could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #41's face sheet dated 06/17/25 indicated Resident #41 was a 53-years-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses including chronic kidney disease, stage 4 (severe) (means that your kidneys are moderately or severely damaged and are not properly filtering waste from your blood), disorder of kidney and ureter (the tube that carries urine from the kidney to the bladder), presence of cardiac and vascular implant and graft (is a surgical procedure that redirects blood flow from one area of the body to another by reconnecting the blood vessels), and dependence on renal dialysis (is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). Special Instructions: Dialysis, Monday-Wednesday-Friday, 12pm-4pm. Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated Resident #41 was understood and had the ability to understand others. Resident #41 had severely impaired vision. Resident #41 had a BIMS score of 14 which indicated intact cognition. Resident #41 received dialysis. Record review of Resident #41's care plan dated 03/29/23 indicated Resident #41 needed dialysis type hemodialysis (is a medical procedure that filters a patient's blood to remove waste products and excess fluid, acting as a replacement for kidney function when the kidneys are unable to do so) related to renal failure (occurs when the kidneys are unable to adequately filter waste and excess fluids from the blood). Intervention included obtain vital signs and weight per protocol. Record review of Resident #41's consolidated physician order dated 08/22/23 indicated: *May receive dialysis on Mondays-Wednesdays-Fridays and as needed. Please complete dialysis nursing report sheet and send with resident to dialysis center one time a day every Monday, Wednesday, Friday for dialysis. *Assess dialysis device: Location left forearm, positive bruit and thrill every shift for dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 17 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0698 monitoring. Level of Harm - Minimal harm or potential for actual harm *Monitor for infection, pain, bleeding. Apply pressure to dressing for 15 minutes. Notify Medical Doctor, if continues to bleed call 911 every shift related to dependence on renal dialysis. Residents Affected - Some Resident #41's consolidated physician orders did not reflect post-dialysis vital signs or assessments until surveyor intervention on 06/19/25. Record review of Resident #41's Uploaded Dialysis Communication Form for January 2025-June 2025 accessed on 06/18/25 indicated: *06/04/25 *04/16/25 *03/05/25 *02/17/25 *02/12/25 *02/05/25 *02/03/25 *01/31/25 *01/24/25 These were the only uploaded Dialysis Communication forms noted in Resident #41's EMR for January 2025-June 2025. Resident #41's EMR did not reflect January 2025 dialysis communication forms for 12 out of the 14 dialysis days. Resident #41's EMR did not reflect February 2025 dialysis communication forms for 7 out of the 11 dialysis days. Resident #41's EMR did not reflect March 2025 dialysis communication forms for 11 out of the 12 dialysis days. Resident #41's EMR did not reflect April 2025 dialysis communication forms for 11 out of the 12 dialysis days. Resident #41's EMR did not reflect May 2025 dialysis communication forms for 13 out of the 13 dialysis days. Resident #41's EMR did not reflect June 2025 dialysis communication forms for 6 out of the 7 dialysis days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 18 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0698 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #41's Dialysis Center Communication Form dated 02/17/25 indicated pre-dialysis and dialysis information completed. The post-dialysis section was blank. Record review of Resident #41's Dialysis Center Communication Form dated 03/05/25 indicated pre-dialysis and dialysis information completed. The post-dialysis section was blank. Residents Affected - Some Record review of Resident #41's Dialysis Center Communication Form dated 04/16/25 indicated pre-dialysis and dialysis information completed. The post-dialysis section was blank. Record review of Resident #41's Dialysis Center Communication Form dated 06/04/25 indicated pre-dialysis and dialysis information completed. The post-dialysis section was blank. Record review of Resident #41's Pulse (a type of vital sign) Summary for June 2025 accessed on 06/18/25 indicated: *06/02/25 at 9:31 a.m. 67 beats per minute *06/11/25 at 8:14 a.m. 77 beats per minute *06/13/25 at 9:26 a.m. 80 beats per minute *06/16/25 at 8:15 a.m. 82 beats per minute Resident #41's EMR did not reflect post-dialysis (after 4pm) Pulse (Hear Rate) for the listed days. Record review of Resident #41's Blood Pressure (a type of vital sign) for June 2025 accessed on 06/18/25 indicated: *06/02/25 at 9:31 a.m. 99/58 *06/11/25 at 8:14 a.m. 98/75 *06/13/25 at 9:26 a.m. 130/70 *06/16/25 at 8:15 a.m. 132/59 Resident #41's EMR did not reflect post-dialysis (after 4pm) Blood Pressure for the listed days. During an interview on 06/17/25 at 9:09 a.m., Resident #41 was in his room performing exercises. Resident #41 said he did not have any complaints about the facility related to dialysis. He said the facility used to make him take a form with him to his appointment but he stopped doing it. He said now the facility faxed it to dialysis. He said when he returned from dialysis, he was really tired. He said the facility did not check his vital signs or site when he returned from dialysis. He said he normally took off his own dressing from his site after dialysis. During an interview on 06/18/25 at 2:05 p.m., LVN J said Resident #41 had dialysis on Mondays, Wednesdays, and Fridays. She said Resident #41 left around 10am and arrived back to the facility around 4-5pm. She said the facility did the pre-dialysis section and the dialysis center did the dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 19 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and post dialysis section on the communication form. She said the dialysis center was supposed to send the communication form back to the facility at the end of day. She said the dialysis center was supposed to fax the completed communication form to the front office fax number. She said if the dialysis center did not fax the communication form, then the charge nurse for Resident #41 should call the dialysis center. She said when the communication forms were returned from the dialysis center, they were given to medical record to be scanned into the resident's chart. She said when Resident #41 returned from dialysis, she checked his bandage for bleeding and vital signs. She said she documented the post-dialysis vital signs in Resident #41's EMR. She said the communication form was important because it contained how much fluid was taken off Resident #41 during dialysis, post dialysis information, and if his vital signs were stable. She said when the facility did not receive the communication form, the resident could get sick or had too much fluid pulled which could cause the resident's blood pressure to drop. During an interview on 06/19/25 at 10:11 a.m., a nurse from Resident #41's dialysis center said Resident #41 used to bring the communication form with him to his appointments. She said now, the facility faxed the communication form to the dialysis center and they sent it back. She said the dialysis center was responsible for the Dialysis section. She said the dialysis center was not supposed to do the post-dialysis section. She said the facility had never informed the dialysis center they were expected to complete the post-dialysis section. She said the dialysis center normally put the post dialysis weight and amount taken off on the dialysis communication form. She said the dialysis center put their post-dialysis vital signs in their own system. During an interview on 06/19/25 at 11:46 a.m., the DON said, she had been in her position since September 2023. She said the facility was responsible for ensuring the dialysis center sent the communication forms back. She said it was important to get the communication form back to know how the dialysis went. She said it was also a form of communication between the dialysis center and the facility. She said when the facility did not get the forms back, the facility may not know the post dialysis information. She said the facility did call the dialysis center after Resident #41 returned from dialysis, to get information on him. She said the nursing staff documented post dialysis vital signs and an assessment in the facility's charting system. She said the assessment of the bruit (is a whooshing sound heard with a stethoscope) and thrill (is a palpable vibration or buzzing sensation felt over the fistula (is a surgically created connection between an artery and a vein, typically in the arm, used for hemodialysis access in patients with kidney failure)) was documented on the treatment administration record. She said the vital signs were documented under the vital sign tab at the time of the resident's return. She said post dialysis vital signs and an assessment was important to make sure the resident was stable when they returned. She said the DON and the nursing administration were responsible for ensuring the nurses were documenting post dialysis vital signs and an assessment. During an interview on 06/19/25 at 12:19 p.m., the ADM with the ADO and RCN present said, she said the nursing staff were responsible for the dialysis communication forms and post-dialysis vital signs and an assessment. She said the DON should be ensuring the nursing staff were completing vital signs and an assessment. The RCN said the nursing staff should be completing the post-dialysis section on the dialysis communication form not the dialysis center. The ADM said the DON should be completing chart audit to monitoring the uploaded dialysis communication forms and post-dialysis vital signs and the assessment. She said the medical record was responsible for uploading the dialysis communication forms into the resident's medical record. Record review of a facility's Dialysis policy revised on 11/2013 indicated, .The facility will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 20 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0698 Level of Harm - Minimal harm or potential for actual harm monitor departures and returns from the dialysis center . The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed . The resident's clinical record will be documented with this information . The date and time of the resident's return to the facility will be recorded by the nurse . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 21 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 3 (Medication Cart #3) reviewed for medication storage: The facility failed to ensure Medication Cart #3 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to harm or drug diversions. Findings included: An observation on 6/19/2025 beginning at 10:04AM, revealed, Medication Cart #3 was unlocked and unattended with no nurse or medication aide at cart for 5 minutes. The staff member responsible for the medication cart returned to the unit at 10:06 AM. All other drawers could be opened, and medication and supplies could be easily accessed. The cart was observed to have prescribed medication blister packs, over counter medications, as well as a locked narcotic box. A resident was observed seated in a wheelchair with back of chair near the medication cart, 3 additional residents were sitting in their wheelchairs approximately 10 feet from the medication cart near the nurse's station, 2 staff members walking down the hallway going into resident rooms, and 1 visitor walking on the unit. RN D returned to the unit and went directly to his medication cart and locked it. He was holding a cup of orange juice and said he would be right back. During an interview on 6/19/2025 at 10:06 AM, RN D said his medication cart was unlocked because he got distracted after a CNA requested him to get a resident orange juice for another resident. RN D said he took off to get the orange juice. RN D said someone could have gotten in his medication cart and got medications out and they could have taken them making them sick. He said a confused resident could get have opened his medication cart and take medications that were not prescribed to them. He said medications not prescribed could cause an allergic reaction or make them sick. RN D said he was off the unit for approximately 5 minutes. RN D said the staff member assigned with the keys to the medication cart was responsible for ensuring the medication cart was locked. During an interview on 6/19/2025 at 11:00 AM, CMA B said whoever was assigned to the medication cart was responsible for keeping the cart locked. She said the medication cart should only be unlocked while administering medications. She said the medication cart could be unlocked if the staff responsible was within sight of the cart. CMA B said a visitor or resident could steal medication and cause them to get sick or die. During an interview on 6/19/2025 at 11:19 AM, the DON said she expected the nurses to keep the medication carts locked. The DON said the medication carts could be unlocked while administering medication and if the medication cart was in eyesight. She said another resident passing could get medication out of cart and take a medication not prescribed to them making them sick. During an interview on 6/19/2025 at 11:32 AM, the ADM said the nurse was responsible for ensuring the medication cart were locked. She said a medication cart could be unlocked while administering medications. The ADM said a visitor, or another resident could steal medication or take medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 22 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that were not prescribed to them. She said it could cause an allergic reaction, they could become sick and could include death. Review of the facility's policy titled Medication Storage in the Facility last revised 3/2025 indicated .Policy statement .Medications and biologicals are stored safely, securely, and properly following manufactures' recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedure .2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Event ID: Facility ID: 676241 If continuation sheet Page 23 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. The Facility failed to label and date all food items in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observation in the kitchen refrigerator 1 of 3 on 06/16/25 at 8:49 a.m., the following was observed with the Dietary Manager: - (2) separate bags of lettuce had a open date of 6/13/25 and no expiration date. -(1) bag of shredded cheese had a open date of 6/13/25 and no expiration date. During observation in the kitchen refrigerator 2 of 3 on 06/16/25 at 8:55 a.m., the following was observed with the Dietary Manager: -(1) cooked bacon and breakfast sausage had a prep date of 6//16/25 and no expiration date. -(1) leftover cooked breakfast eggs had a prep date of 6/16/25 and no expiration date. During a phone interview on 6/19/25 at 9:10 am the Dietary Manager stated she had been employed at the facility since August of 2021. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manager stated all food items in the refrigerator were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated all staff had completed in-services on labeling, dating and discarding expired food items two weeks ago. The Dietary Manager stated she conducted walk throughs in the kitchen daily. The Dietary Manager stated the Administrator tried to conduct walk throughs daily but did complete walk throughs in the kitchen every other day. The Dietary Manager stated it was important to ensure all food items were labeled, dated, and expired food was discarded because food that went bad could have bacteria growth on it and it was not safe for the residents to eat. During an interview on 6/19/25 at 9:19 am the Administrator stated she had been employed since December of 2023. The Administrator stated she oversaw the Dietary Manager. The Administrator stated all all-food items in the refrigerator were to be labeled, dated with receive date, open date and expiration date. The Administrator stated staff had completed in services on labeling, dating, and discarding expired food items on March 31, 2025, for mock survey. The Administrator stated she conducted walk throughs in the kitchen daily. The Administrator stated she was not made aware of the expired food items found in the kitchen, food items not labeled and dated. The Administrator stated she did expect the Dietary Manager to report issues found in the kitchen to her. The Administrator stated it was important to ensure staff were labeling, dating, and discarding expired food items because if the food was out of date the residents could get sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 24 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 Record Review of food storage and supplies dated 2012, indicated (6.) When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before _ it 1s used. Any product with a stamped expiration date will be discarded once that date passes. (7.) According to the USDA fact sheet on Food Product dating, www. fsis.usd a.gov/wps/portal/f sis/topics/food-safety-education/get-answers/food-safety-fact. (10) Frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within 7 days. Some items that are nearing expiration may be frozen prior to expiration to preserve food safety and should be dated when removed from freezer to maintain proper time frame for food safety. Some items such as health shakes do not have an expiration date since they are received frozen and are good for 14 days once removed from the freezer. If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging. Any frozen food more than one year old will be inspected for food quality and freezer bum before being used. Some frozen battered, breaded, or fry-ready products are packaged with small slits in the interior bags to prevent ice crystal formation and do not need to be sealed in an air-proof packaging while frozen. Event ID: Facility ID: 676241 If continuation sheet Page 25 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 1 of 4 residents reviewed for enhanced barrier precautions (Resident #1) infection control practices. Residents Affected - Few 1. The facility failed to ensure LVN J donned a gown prior to administering feeding to Resident #1 via g-tube. Resident #1 was on enhanced barrier precautions. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #1's face sheet dated 06/17/25, indicated she was a [AGE] year-old female that admitted [DATE] with diagnoses that included: epilepsy (a disorder in which nerve cell activity in the brain disturbed, causing seizures), gastrostomy status (opening allows for a tube to be inserted, providing a direct route for administering food) and nutritional deficiency (occurs when the body doesn't get enough of the essential nutrient it needs). Record review of Resident #1's physician's orders indicated: 3/12/25 enteral feed orders every 4 hours Jevity 1.5 1/2 carton (118ml) bolus feed 6 times daily. Flush with 50cc water before and after feeding and med pass. Order: 3/13/25 enhanced barrier precautions due to g-tube every shift for infection prevention. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 rarely understood others and was rarely understood by others. No BIMS score indicated. Cognitive skills for decision making (severely impaired). She was dependent with ADL's. Record review of the care plan dated 10/05/22 indicated Resident #1 requires tube feeding related to swallowing problem, potential for weight loss. During observation of med pass to Resident #1 on 6/17/25 at 11:33 AM LVN J checked for g-tube placement and administered Jevity 118ml via g-tube without donning (to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure) a gown. Resident #1 was on enhancement barrier precautions due to a g-tube. Outside of Resident #1's door was a sign posted which stated, Multidrug-resistant organisms (MDROs) are a threat to our residents .Enhanced Barrier Precautions (EBP) Steps .wear gown .wear gloves .use EBP during high contact care activities for resident with .indwelling medical devices .e.g. feeding tube . During an interview on 6/17/25 at 11:45 A.M., LVN J said she just wore gloves when she gave Resident #1 her feedings. She said she thought enhanced barrier precautions was for catheters, wounds and during incontinent care PPE should be worn. She said she was not aware that she was supposed to use enhanced barrier precautions with peg or g-tubes. She said she had not worn PPE while giving Resident #1 her feedings before. She said she saw the enhanced barrier precaution sign outside Resident #1's room. She said enhanced barrier precautions protects the residents and staff from germs and cross (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 26 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/19/25 at 9:18 A.M., CNA M said staff should be wearing PPE with residents on enhanced barrier precautions, and they were residents with tubes, catheters, and wounds. She said the residents had signs outside their doors. She said enhanced barrier precautions were to protect the staff and the residents from cross contamination. Residents Affected - Few During an interview on 6/19/25 at 9:31 A.M., LVN C said in point click care it tells the nurse in the resident's orders if the resident was on EBP and why the resident was on EBP. She said it was important for staff to wear the PPE for residents on EBP, because they do not want to give what they have to someone else, because the next person system may not be strong enough to handle it. She said staff should also use EBP to prevent spreading infection. During an interview on 6/19/25 at 10:52 A.M., the DON said she monitored the nurses and the ADON's monitored the nurses with PPE on for EBP residents. She said she goes down the hallways to ensure the nurses were wearing their PPE. She said the ADM and herself were the infection preventionist. She said the nurses had been in serviced on EBP. She said resident that were on EBP had signs on their doors that gave the staff instructions on what PPE to wear and which residents the staff had to wear the PPE for. She said it was important for the staff to follow EBP to prevent infection. During an interview on 6/19/25 at 11:14 A.M., the ADM said she expect the staff to follow policy and wear their PPE when they were supposed to. She said a negative effect of not wearing PPE on enhanced barrier precaution residents would spread germs. Record review of the facility's policy, Enhanced Barrier Precautions, undated, indicated: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient . EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines, urinary catheters, feeding tubes PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. For example, staff entering the resident's room to answer a call light, converse with a resident, or provide medications who do not engage in a high-contact resident care activity would likely not need to employ EBP while interacting with the resident . Communication to Staff The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 27 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 20 residents (Resident #71) reviewed for resident call system. Residents Affected - Few The facility failed to ensure Resident #71 had a call light that was functional. Resident #71's call light did not turn on when the button was pressed on 06/17/25. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #71's face sheet dated 06/17/25 indicated Resident #71 was an 80-years-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #71 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), obesity, nontraumatic subacute subdural hemorrhage (is a collection of blood in the space between the brain and its outer membrane (dura mater) that develops gradually without a recent head injury), and atrial fibrillation (is a common heart condition where the heart's upper chambers (atria) beat irregularly and sometimes rapidly). Record review of Resident #71's quarterly MDS assessment dated [DATE] indicated Resident #71 was usually understood and usually had the ability to understand others. Resident #71 had a BIMS score of 5 which indicated severe cognitive impairment. Resident #71 required supervision for oral and personal hygiene, partial/moderate assistance for upper body dressing, and dependent for toilet hygiene and shower/bathe self. Resident #71 was always incontinent of urine and frequently incontinent of bowel. Record review of Resident #71's care plan dated 02/21/25 indicated Resident #71 had an ADL self-care performance deficit. Intervention included encourage the resident to use bell to call for assistance. Record review of Resident #71's care plan revised on 03/12/25 indicated Resident #71 had an actual fall. Intervention included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 06/17/25 at 8:48 a.m., Resident #71 was lying in bed with tremors noted to her hands. Resident #71 was partially disrobed with her nasal cannula on her face but not in her nose. Resident #71's call light was clipped to her gown and in her hand. I asked Resident #71 if she needed assistance and her reply was mumbled. Resident #71 pushed her call light and a clicking noise was heard but the light in the room nor outside came on. I asked Resident #71 to try pushing the button again. Resident #71 pushed her call light again and a clicking noise was heard but the light in the room nor outside came on. I also pushed Resident #71's call light at 8:55 a.m. and 8:58 a.m., a clicking noise was heard but the light in the room nor outside came on. Resident #71 said she did not know how long she had been pushing the call light button. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 28 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 Level of Harm - Minimal harm or potential for actual harm During an interview and observation on 06/17/25 at 9:01 a.m., the Unit Manager H arrived in Resident #71's room. Unit Manager H pushed Resident #71's call light button and a clicking noise was heard but the light in the room nor outside came on. She said Resident #71 had just got back from the hospital and had been in the room for a couple of days. Unit Manager H swapped the cord from the B bed to Resident #71's side. The light came on with the new cord when Unit Manager H pushed the call light button. Residents Affected - Few During an interview on 06/18/25 at 1:03 p.m., the Maintenance Supervisor G said he did not know Resident #71's call light button was not working. He said he checked resident's call light once a week. He said he documented the call light checks on paper. He said after he found out Resident #71's call light was not working. The facility did a call light audit on all the resident's rooms. He said Resident #71's call light was the only one not working. He said Resident #71's call light button was worn out. He said it was important for a resident to have a working call light for emergencies, their wellness, to report physical pain or for bathroom assistance. He said the residents could fall or not be able to get help when their call light button did not work. A copy of the call light maintenance checks was requested. During an interview on 06/18/25 at 2:00 p.m., the Unit Manager H said, the maintenance supervisor was responsible for functional call lights. She said the residents did not get the care they needed when the call lights did not work. She said the residents could fall, not get changed, and try to get out of bed without assistance when call light were not functional. During an interview on 06/18/25 at 2:05 p.m., LVN J said the call light was important so the resident could call for assistance. She said everyone should ensure the call lights were working. She said when the call lights were not working, it placed the resident at risk for falls. She said it also placed the residents at risk for not getting to the bathroom, and not getting help in an emergency like choking or chest pain. She said if a call light was not working, the staff should notify maintenance, DON, and the ADM. She said when the resident's call light did not work, their needs may not get met. During an interview on 06/18/25 at 2:53 p.m., CNA K said maintenance was responsible for ensuring the resident's call lights worked. She said the call lights were important because they let the staff know what the residents needed. She said when the call lights did not work, the residents could be sick or have issues and could not get help. She said it placed the residents at risk for falls. During an interview on 06/19/25 at 11:46 a.m., the DON said, she had been in her position since September 2023. She said all staff should make sure the call lights worked. She said when the staff noticed a call light not working, they needed to notify maintenance. She said the call light was important because it was needed for everything and emergencies. She said when the call lights did not work, the staff would not know the resident's needs or get their needs met. During an interview on 06/19/25 at 12:19 p.m., the ADM with the ADO and RCN present said, the maintenance supervisor was responsible for ensuring the resident's call lights worked. She said when the resident's call light did not work, they could not get help. She said it placed the resident at risk for not getting assistance. She said the maintenance should be monitoring the working of the resident's call lights by doing rounds. She said the facility also had champion rounds that the assigned staff members were supposed to check if the call light was working and in place. She said if during champion rounds, a call light was not working, it was supposed to be reported to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676241 If continuation sheet Page 29 of 30 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 676241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of Call Light Checks dated 02/12/25-06/17/25 provided by Maintenance Supervisor G on 06/18/25 did not reflect room [ROOM NUMBER], the room Resident #71 resided, had been checked. The call light checks list reflected three random rooms, weekly were checked. Record review of the facility's policy, Resident Rights, undated, indicated: . Safe environment- The resident has a right a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide belongings to the extent possible . a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does pose a safety risk . b. The facility shall exercise reasonable care for the protection of the resident's property from loss or theft . 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Event ID: Facility ID: 676241 If continuation sheet Page 30 of 30