Health inspection·February 26, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that appropriate information was communicated to the receiving health care institution to include Advance Directive information for 1 of 1 (Resident #3) resident reviewed for advance directives. Resident #3's Advance Directive information was inaccurately documented on the transfer form, and a copy of the advance directive was not provided to the EMS staff or hospital staff upon transfer to the emergency room. This deficient practice could place residents at risk for not having their wishes followed according to advance care planning. The findings were:Record review of Resident #3's face sheet, dated [DATE] revealed an [AGE] year-old male admitted [DATE] and discharged [DATE] with diagnoses that included: Alzheimer's Disease (a progressive irreversible brain disease and the most common cause of dementia), Chronic Obstructive Pulmonary Disease (a progressive lung disease that causes long term breathing problems), Benign Prostatic Hyperplasia (an enlargement of the prostate gland related to a growth that squeezes the urethra), Hypertension (high blood pressure) and Hyperlipidemia (high levels of fats).Record review of Resident #3's Annual MDS dated [DATE] revealed resident was understood by others and understood what was said to him and had a BIMS Score of 8 indicating moderate cognitive impairment. Further review of the Annual MDS revealed resident required the use of a walker for mobility, was independent in bed mobility, transfers and gait and required set up assistance with eating, toileting, upper and lower body dressing.Record review of Resident #3's EMR revealed a valid Directive to Physician's and Family or Surrogates dated [DATE] that elected all treatments other than those needed to keep him comfortable be withheld, no ventilator and no feeding tube. Record review of Resident 3's physician's orders revealed an order for Full Code dated [DATE]. Record review of Resident #3's care plan revealed a focus area dated [DATE] indicating Resident is a Full Code; and Interventions to include: Initiate BLS (Basic Life Support) CPR (Cardiopulmonary Resuscitation) if the resident is without a heartbeat and Notify EMR. Record review of Resident #3's transfer form dated [DATE] revealed 6. Advance Directives, 1. Does the resident have any of the following advanced directives indicated yes for DNR in direct contradiction to his completed and valid Directive to Physicians and Family or Surrogates. During an interview on [DATE] at 1:30 p.m., LVN D confirmed she made an error of the transfer form because Resident #3 was Full Code, not DNR. LVN D stated she should have provided the EMS staff a copy of his Advance Directives to provide to the emergency room staff. LVN D stated that failure to provide correct information at time of transfer could result in the resident receiving life sustaining support that he did not desire or not obtaining treatment he did desire. During an interview on [DATE] at 5:32 p.m., the physician stated that he expected the nursing staff to relay the appropriate advance directive information on all transfers to include a hard copy of documents in order to ensure continuity of care and to ensure that the resident's wishes are honored. The physician stated Resident #3's directive did not specifically indicate DNI (Do Not Intubate) and although the Page 1 of 4 676241 676241 02/26/2026 Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documents were not sent, his wishes were not violated as he was no placed on a ventilator. During an observation on [DATE] at 8:02 a.m., Resident #3 was in bed, eyes closed, unlabored breathing with bandage to his tracheal site indicating intubation tubing had been removed. Resident #3 did not respond to verbal or tactile stimuli to complete interview. During an interview on [DATE] at 8:15 a.m., Resident #3's responsible party stated that she had been contacted by the nursing facility at time of transfer and verbalized to the discharge nurse to remember to send Resident #3's advance directive. Resident #3's responsible party stated that after discussion with the hospital physician and conversation with other family members had elected to remove the intubation tube to honor resident's wishes not to remain on life support as per his directive. During an interview on [DATE] at 3:22 p.m., the DON stated that she expected the nursing staff to provide a copy of Advance Directives to EMS staff for all hospital transfers to ensure the resident's wishes are honored. The DON stated it is important that external entities are provided with accurate information to ensure the resident's and/or responsible parties wishes are honored. The DON stated that she had completed an Inservice training for the nursing staff on accurate completion of all transfer / discharge documents. During an interview on [DATE] at 3:50 p.m., the Administrator stated the adverse effect of not providing accurate documentation on hospital transfers and all discharges could be negative outcomes for the resident if the care did not match the treatment orders. The Administrator stated she expected the nursing staff to provide accurate information on transfers and discharges and that the DON is responsible for ensuring the nursing staff are trained on the discharge process and that she as the Administrator is ultimately responsible for monitoring the accuracy of documentation for discharges. Review of facility policy titled, Self Determination End of Life Measures, undated, revealed Policy: 3. The facility will respect the wishes of the resident as outlined in the advance directive.The primary nurse will note the resuscitation status of the resident on all applicable clinical records.and also, document whether or not the resident has executed the advance directive. 676241 Page 2 of 4 676241 02/26/2026 Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455

F 0641 Ensure each resident receives an accurate assessment. 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 the assessment accurately reflected the resident's status for 2 of 2 residents (Resident #1 and Resident #2) records reviewed for Resident #1 and Resident #2's Annual MDS did not correctly assess the resident's non-invasive ventilation (Bilevel Positive Airway Pressure) therapy. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1.Record review of Resident #1's face sheet, dated 02/25/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included: Obstructive sleep apnea (a disorder where throat muscles relax excessively during sleep causing the airway to collapse and interrupt breathing), Diabetes Mellitus Type II (condition where the body resists insulin or fails to produce enough insulin causing high blood sugar), dementia (decline in memory, language, problem-solving and cognitive abilities severe enough to impact daily life), Hypertension (high blood pressure), and hyperlipidemia (high levels of fats). Record review of Resident #1's Annual MDS dated [DATE] revealed resident was understood by others and understood what said to him and had a BIMS Score of 3 indicating severe cognitive impairment. Further review of the Annual MDS revealed lower extremity range of motion impairment and use of a wheelchair for mobility, required set up assistance with eating, maximum assistance with upper body dressing, bed mobility, transfers and bathing, and total assistance in lower body dressing. Record review of Resident #1's Annual MDS, dated [DATE], revealed it was not indicated the resident utilized a non-invasive mechanical ventilator (BIPAP/CPAP) while a resident of the facility. Record review of Resident #1's care plan revealed a focus area initiated 04/02/2024 and revised 10/09/2025 revealed resident required the use of a BiPap related to sleep apnea. Record review of Resident #1's Treatment Administration Record (TAR) dated 02/01/2026 - 02/28/2026 revealed the resident had an order for : BiPAP (Bilevel Positive Airway Pressure), apply at bedtime related to Obstructive sleep apnea dated 10/09/2025. Observation and interview on 02/25/2026 at 12:20 p.m., revealed Resident #1's BiPAP was on the nightstand in the resident's room and Resident #1 stated that he used the BiPAP machine every night. 2.Record review of Resident #2's face sheet, dated 02/25/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included: sleep apnea (a disorder where throat muscles relax excessively during sleep causing the airway to collapse and interrupt breathing), Diabetes Mellitus Type II (condition where the body resists insulin or fails to produce enough insulin causing high blood sugar), End Stage Renal Disease (final state of chronic kidney disease where kidney function at less than 10-15%, necessitating dialysis), atrial fibrillation (irregular heartbeat), hypertension ( high blood pressure) and congestive heart failure (occurs when the heart pumps inefficiently causing fluid buildup in the lungs and body) and hyperlipidemia (high levels of fats). Record review of Resident #2's Annual MDS dated [DATE] revealed resident was understood by others and understood what said to him and had a BIMS Score of 15 indicating intact cognition. Further review of the Annual MDS revealed lower extremity range of motion impairment and use of a wheelchair for mobility, required set up assistance with eating, moderate assistance in bed mobility, and total assistance with toileting, bathing, upper and lower body dressing, and transfers. Record review of Resident #2's Annual MDS, dated [DATE], revealed it was not indicated the resident utilized a non-invasive mechanical ventilator (BIPAP/CPAP) while a resident of the facility. Record review of Resident #2's care plan revealed a focus area initiated 12/31/2024 and revised 01/19/2026 revealed resident required the use of a BiPap related to sleep apnea. Record review of Resident #2's Treatment Administration Record dated 02/01/2026 - 02/28/2026 revealed the resident had an order for : BiPAP (Bilevel Positive Airway Pressure) every night shift apply Residents Affected - Few 676241 Page 3 of 4 676241 02/26/2026 Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleep apnea dated 01/19/2026. Observation and interview on 02/26/2026 at 2:07 p.m., revealed Resident #2's BiPAP was on the nightstand in the resident's room and Resident #2 stated that the staff do apply the BiPap machine every night. During an interview with MDS Coordinator LVN A on 02/25/2026 at 1:14 p.m., LVN A stated that an Obstructive Sleep Apnea diagnosis should be coded on the MDS, and she believed that Resident #1 and Resident #2 utilize a BiPap. LVN A stated she does not complete the MDS Assessment and stated that the MDS should accurately reflect the resident's needs. During an interview with MDS Coordinator LVN B on 02/25/2026 at 1:48 p.m., LVN B confirmed Resident #1's Annual MDS, dated [DATE], was incorrect because the resident had been receiving non-invasive ventilation BiPap therapy since 04/02/2024 according to his care plan focus area. LVN B confirmed Resident #2's Annual MDS dated [DATE] was incorrect because the resident had been receiving non-invasive ventilation BiPap therapy since 12/31/2024 according to his care plan focus area. During an interview on 02/26/26 at 3:15 p.m., the Regional Reimbursement Nurse RN C stated the non-invasive ventilator block was not checked because the MDS nurse was unable to check the box, and she would review this with her resources to determine why this occurred. During an interview on 02/26/2026 at 3:22 p.m., the DON stated that the MDS should accurately reflect the resident's needs to ensure the care plan is properly generated. The DON stated that it is the responsibility of the MDS nurses to assess each resident and accurately record the findings on the MDS and that ultimately, it is her responsibility to ensure the data is accurate. During an interview on 02/26/2026 at 3:50 p.m., the Administrator stated that improper coding on the MDS Assessment could result in inaccurate or improper treatment plan for the residents and potentially improper billing. The Administrator stated the DON is ultimately responsible for ensuring the accuracy of the MDS Assessment and she expected the MDS information to be coded accurately. Record review of the facility policy titled, Minimum Data Set Policy, undated, indicated Purpose: to utilize the most current version of the resident assessment instrument manual to guide all IDT members on the proper procedure for coding items on the MDS assessment, completion of care area assessment, and other instructions related to MDS procedure. Record review of the MDS 3.0 Nursing Home Comprehensive Version 1.20.1 Effective 10/01/2025 revealed Section O - Special Treatments, Procedures, and Programs O0110, check all of the following treatments procedures, and programs that were performed b. While a Resident within the last 14 days, G1. Non-Invasive Mechanical Ventilator. 676241 Page 4 of 4