Health inspection·August 24, 2023

F 0657 Give 5 mg by mouth two times a day related to PULMONARY EMBOLISM (I26) dated 8/23/2023 Level of Harm - Minimal harm or potential for actual harm - Monitor for blood in stools or urine, bleeding gums, or excess bleeding with minor injuries, check if any signs or symptoms present, notify MD immediately and document dated 7/12/2023 Residents Affected - Few Interview on 8/24/2023 at 2:57pm DON stated, anticoagulants such as Plavix should be care planned as it was person-centered and direct care staff need to be able to identify any adverse effects of anticoagulants. Interview on 8/24/2023 at 3:15pm MDS Coordinator stated, Plavix should be care planned and must have missed it by mistake. MDS Coordinator stated it is important to care plan anticoagulants so nurses and staff are aware R #1 is on this type of medication so they can be looking for signs and symptoms of bruising, bleeding, or complications, especially since R #1 had fractures. MDS Coordinator stated he would update R #1's care plan immediately. Record review of Care Plan, Comprehensive Person-Centered Policy dated December 2016 stated; A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; m. aide in preventing or reducing decline in the resident's functional status and/or functional levels; o. Reflect currently recognized standards of practice for problem areas and conditions. 12. The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455455 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care of Alice 218 219 N King St Alice, TX 78332 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 help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 1 resident, Resident #1 (#R1) of 5 staff members who were observed for infection control, in that; Residents Affected - Few 1.)CNA in training did not perform hand hygiene for at least 20 seconds. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings include: Record review of R #1's Face Sheet revealed a [AGE] year-old female, with an original admission date of 10/11/2016. Diagnosis included, Type 2 diabetes ( insufficient production of insulin in the body), Dysphasia (difficulty swallowing), Alzheimer's Disease (neurodegenerative disease that affects a person's cognitive in daily activities including memory, thought control, and language), Heart Failure, Pulmonary Embolism (blockage of an artery in the lungs), Fracture of Lower Leg, including Ankle, TIA (transient ischemic attack, similar to a stroke), and Cerebral Infarction (type of stroke caused by impaired blood flow to the brain). Record review of R #1's Quarterly Minimum Data Set, dated [DATE] revealed R #2 has a BIMS (Brief Interview Mental Status) of 10 (Moderately Impairment) and requires Extensive Assistance with, bed mobility, transfers, Dressing, Toilet use and Personal Hygiene. Record review of R #1's Care Plan dated 7/14/2023 revealed R #1 was at risk for infection r/t (related to) Covid-19 due to Advanced age, Immunosuppressed, Heart Disease and Lung Disease. Observation on 8/24/2023 at 2:38pm. R #1 was in need of personal care (brief change and bed sheet change). CNA in training completed brief change for R #1 and removed gloves and washed hands for approximately 10 seconds. CNA in training put on new gloves and assisted with changing soiled bed sheets. Once completed, CNA in training removed gloves, began assisting R #1 with moving personal items such as drinks and bedside table closer to R #1, lowered R #1's bed, and covered R #1 with blankets. CNA in training then proceeded to wash hands for approximately 8 seconds. Interview with CNA in training on 8/24/2023 at 2:50pm stated, she has been working at the facility for approximately 3 months and hands should be washed for at least 20 seconds to prevent cross contamination and possible infections to residents. CNA in training stated she was nervous and thought she washed hands for about 20 seconds but realized she may have rushed her hand washing while she sang Old McDonald song in her head. CNA in training stated she does not know why she sang that song as she was taught to sing the Happy Birthday song twice. CNA in training stated that hand hygiene and infection control in-services are conducted almost weekly. Interview with DON on 8/24/2023 at 3:05pm, stated it is important to perform proper hand hygiene as to prevent the spread of infections to residents and staff/visitors. DON stated, while performing hand hygiene with soap and water, it should be done for at least 20 seconds or greater and routine hand hygiene in-services are conducted frequently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455455 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care of Alice 218 219 N King St Alice, TX 78332 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 Record Review of Handwashing and Hand Hygiene Policy dated August 2015 stated; Level of Harm - Minimal harm or potential for actual harm Washing Hands Procedure Residents Affected - Few 1.Vigorously lather hands with soap and water and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455455 If continuation sheet Page 4 of 4