Health inspection·October 12, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Interview on 10/10/23 at 2:07 PM with LVN G revealed she was Resident #85's charge nurse and was unaware Resident #85's lunch tray was still in her room. She stated it was a dignity issue for Resident #85 to be sleeping and having her hands in her plate with food on them. She stated Resident #85 required supervision with her meals and it was a potential choking hazard for resident to be asleep with her hands in her food plate. Residents Affected - Few Interview on 10/10/23 at 3:50 PM, the DON stated Resident #85 having her hands in her plate while sleeping was a dignity issue and potential choking hazard for Resident #85. Review of facility's policy Resident Rights undated reflected facility must treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life .The facility must protect and promote the rights of the resident .Respect and dignity - The resident has a right to be treated with respect and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 2 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#7) of three residents reviewed for indwelling catheter care. The facility failed to ensure Resident #7's indwelling catheter bag was maintained off the floor. This failure could place residents at risk of infection. Findings included: Record review of Resident #7's Quarterly MDS assessment, dated 09/08/23, reflected a [AGE] year-old-female admitted to the facility on [DATE]. Resident #7's diagnoses included anxiety disorder, high blood pressure, and depression. Her BIMS score was 09 revealing that resident has moderately impaired cognition. Her functional status reflected extensive assistance for bed mobility and hygiene. Bladder and bowel section of the MDS revealed that the resident has an indwelling catheter in place. Record review of Resident #7's comprehensive plan of care dated 08/07/23 reflected, Focus: Resident#7 has indwelling catheter .check tubing for kinks and maintain the drainage bag off the floor . Observation on 10/10/2023 at 10:35 AM of Resident #7 revealed CNA B and LVN A transferring resident to chair by Hoyer lift. Once Resident #7 was moved to chair, CNA A hung indwelling catheter bag underneath the chair. Surveyor observed catheter bag to be slightly folded due to sitting on the floor. Interview on 10/10/23 at 03:16 PM with LVN A revealed that the catheter bag should stay below the bladder, have no kinks, and should not be placed on the floor. LVN A stated she did not check to see where CNA B placed the catheter bag. LVN A was unaware CNA B placed the catheter bag on the floor. LVN A stated that placing the bag on the floor can cause cross contamination. Interview on 10/11/23 at 10:08 AM with CNA B revealed that catheter bags were not to be placed on the floor. CNA B stated the bag must have fallen and that was how it ended up on the floor. CNA B stated that leaving the catheter bag on the floor can cause cross contamination. Interview on 10/12/23 at 10:06 AM with the DON revealed that the catheter bags should remain below the bladder, should have no kinks, and should not be placed on the ground. The DON stated that the floor is dirty, so catheter bag should not be placed on the floor. A record review of the facility's policy Catheter Care, revised February 14th, 2007, reflected . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site . Be sure the catheter tubing and drainage bag are kept off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 3 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #52) of four residents reviewed for respiratory care. Residents Affected - Few The facility failed to replace/change the humidifer weekly or when the humidifer was empty. These failures could place residents at risk for hyperoxygenation, skin issues, and infection. Findings include: Review of Resident #52's quarterly MDS assessment, dated 09/08/2023, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #52's BIMS score was an 11 which revealed a moderately impaired cognition. Her active diagnoses included anemia, high blood pressure, and diabetes mellitus. The MDS did not have oxygen therapy checked under her specialty treatment section. Review of Resident #52's Physician orders summary dated 10/10/23 , reflected, .may use oxygen at 2-4l/m via nasal canula as needed for shortness of breath and to keep sats greater than 92% .order date 10/10/23 .start date 10/10/23 . No orders regarding humidifier. Review of Resident #52's care plan dated 10/10/23, reflected, .The resident has oxygen therapy . The resident will have no s/sx of poor oxygen absorption through the review date . An observation and interview on 10/10/23 at 10:47 AM revealed Resident #52's oxygen concentrator on and running with nasal canula sitting on the bedside table. The humidifier was empty and dated 9/17/2023. Resident #52 stated that she wore her oxygen every night. Resident #52 stated that her humidifier has been empty for a while but does not know how long. In an interview with LVN A on 10/10/23 at 03:16 PM revealed that the humidifier was to be changed when empty. LVN A stated that the humidifier and tubing should be changed regularly to prevent fungus or mold growth, dry nasal passages, and/or nose bleeds. In an interview with RN C on 10/11/23 at 09:52 AM revealed that she was the compliance review nurse. RN C revealed that she did rounds and found Resident #52 to have oxygen on and that the humidifier was empty. RN C looked further into it and realized there were no orders and called doctor for orders. RN C stated they might have standing orders, but she confirmed that the facility did not provide standing orders. RN C stated that that humidifier was to be changed weekly or when it becomes empty. In an interview with the DON on 10/12/23 at 10:06 PM revealed that orders from a doctor were required for oxygen administration. The DON stated to change humidifier as needed or every seven days. The DON stated that not having required orders could cause resident to have higher oxygen and to retain carbon dioxide. The DON stated that not replacing the humidifier could cause the resident to have dry nares. Review of the facility's policy, Oxygen Administration revised February 13th, 2007, reflected, . The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen . The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 4 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 resident will be free from infection . Open the regulator and adjust to the desired rate. Note that the water in the humidifier bubbles . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 5 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates for 1 (Medical Specialty medication room) of 2 medication rooms reviewed for medication storage. The facility failed to ensure one medication room on Medical Specialty Unit was free of expired medications. This failure could place residents at risk for increased or decreased potency of vaccination. Findings included: Observation on 10/11/23 at 01:16 PM of the Medical Specialty Unit medication room revealed, four vials of Shingrix with an expiration date of 10/6/23 in their refrigerator. Interview on 10/11/23 at 1:16 PM, LVN D stated she checks all medication rooms and carts weekly and as needed. LVN D missed that they were expired. LVN D thought they were labeled 10/30/23. LVN D stated they do dispose of expired medications due to changing the efficacy of the medication. The medication can either become more potent or weaker depending on the medication. Interview on 10/12/23 at 10:06 AM with the DON revealed, that the medication carts and rooms were checked weekly by LVN D. The DON stated the expired medications should be removed due to expired medications losing efficacy or not giving desired effect. Record review of the facility's policy titled Pharmacy Policy and Procedure Manual: Recommended Medication Storage revised 07/2012, did not reflect specific information regarding expired medications. Facility did not have any other policies regarding expired medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 6 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Cooks H and I performed hand hygiene during lunch meal preparation on 10/11/23. 3. The facility failed to ensure Dietary [NAME] I sanitized food thermometer when checking food temperatures on 10/11/23. at lunch. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations on 10/10/23 at 9:42 AM revealed the following in the refrigerator: a plastic bag open to air about 2 inches with cheese not dated or sealed. a plastic bag with turkey meat not sealed. Interview with the Dietary Manager on 10/10/23 at 9:44 AM revealed the items in the refrigerator should be dated and sealed. Observation on 10/10/23 at 9:47 AM in the walk-in freezer revealed a plastic bag open to air with chicken strips not sealed or dated. Observation and Interview on 10/10/23 at 9:49 AM with the Dietary Manager revealed the chicken strips should be sealed and was observed sealing them. He stated the weekend dietary staff had probably opened them and should have sealed it along with dating it when opened. He stated all items in refrigerator and freezer should be sealed and dated when opened. Review of the facility's policy for Food Safety dated 2012 reflected Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. 2. Observation on 10/11/23 at 11:37 AM with Dietary Aide I revealed she touched her face and nose with her hand, went to walk-in refrigerator, came out of walk-in refrigerator with tator tot bag, touched the refrigerator door to close it. At 11:39 AM she opened the tater tot bag and put them in the fryer to cook. She touched her apron with her hands and apron had visible stain and particles on it. She did not wash her hands and put on gloves. At 11:49 AM Dietary [NAME] I flipped grilled cheese sandwich using spatula and touched grilled cheese with her hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 7 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 Observation on 10/11/23 at 11:42 AM with Dietary [NAME] H revealed she touched her face with her hand and then continued stirring gravy on stove. At 11:46 AM, Dietary [NAME] H went to dry storage, got tomato soup cans, touched her face with her hand and did not wash hands. She got a clean pan, opened the cans, and poured the tomato soup cans into the pan. At 11:48 AM, Dietary [NAME] H washed her hands. She touched her face and glasses adjusting them. Dietary [NAME] H did not wash her hands. Residents Affected - Some 3. Observation on 10/11/23 at 11:52 AM with Dietary [NAME] H revealed she checked food temperature of pureed corn with a thermometer. She used a cloth to wipe the food thermometer tip. She checked the food temperature of tomato soup by placing the thermometer tip into the soup and then wiped the thermometer using the same cloth. Dietary [NAME] H checked regular diet corn temperature with food thermometer tip placed in the corn. Interview on 10/11/23 at 11:57 AM with Dietary [NAME] H revealed she did use the same cloth to wipe the food thermometer between checking food temperatures of food. She stated she usually used the alcohol sanitizing wipes when cleaning the food thermometer each time after using it to check a food temperature and before putting it in another food item to check food temperature. She stated she should have washed her hands after she touched her face or glasses before going to the next task. Interview on 10/11/23 at 11:59 AM with Dietary [NAME] I revealed she should have washed her hands when she touched her face or apron. Interview on 10/11/23 at 12:01 PM with the Dietary Manager revealed he expected dietary staff to wash hands when touching their face, apron and anytime hands get contaminated. He stated it was important for dietary staff to wash hands to prevent cross contamination of food. He stated Dietary [NAME] H should have sanitized the food thermometer with alcohol swabs between use and not to use the same cloth to clean it. He stated not sanitizing the food thermometer properly can cause cross contamination of the food. Review of Dietary [NAME] H's training reflected she completed basics of hand hygiene on 10/08/23. Review of Dietary [NAME] I's training reflected she completed hand hygiene training on 01/19/23. Review of the facility's dietary policy Handwashing dated 2012 reflected the facility will ensure proper hand washing procedures as utilized. Employees are to frequently perform hand washing . The policy did not specify when to wash hands. Review of the facility's dietary policy Equipment Sanitation dated 2012 reflected facility will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 8 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review. the facility failed to provide a safe, functional, sanitary, and comfortable environment for dining room and three of five resident halls (B hall, C hall and D hall) reviewed for physical environment. 1. The facility failed to ensure D hall hallway area was maintained with floorboards in place and intact walls to preclude the entry of insects or rodents. 2. The facility failed to ensure resident rooms on B hall, C and D hall had door protection coverings that were secure to the room entry door and not impeding resident entry and egress. 3. The facility failed to ensure a resident room on C Hall RM [ROOM NUMBER], had a shower in working order. These failures could place residents at risk for an unsanitary and unsafe environment. Findings included: 1. Observations of D Hall on 10/11/23 at 12:47 PM revealed that two areas of floorboard at the end of D hall, approximates 6 inches each had peeled away from the wall exposing the drywall beneath. It was also noted that there was an approximately a 6-inch by 5-inch area of drywall that had been knocked in, exposing the interior of the wall space in which debris and dirt. 2. Observations of B, C and D halls on 10/10/23 between 11:32 AM and 11:38 AM revealed that room [ROOM NUMBER] on B hall, room [ROOM NUMBER] on C hall and room [ROOM NUMBER] on D hall, the protective covering on the doors to the residents' rooms had peeled away from the doors, [NAME] out into the entry/exit way of the room and offering a possible impediment to residents' entry and egress into their rooms. 3. Observations of C Hall room [ROOM NUMBER] on 10/10/23 at 12:07 PM revealed that the shower in the resident's room did not have hot water available in the shower. In an interview with the Maintenance Manager on 10/11/23 at 12:50 PM, he reported that he had been made aware of the complaints by the resident on C Hall room [ROOM NUMBER] that the hot water was not functioning in that shower . He stated that he had just not been able to fix it yet. He further stated that he had seen the protective coverings on the doors to Rooms 14 on B hall, room [ROOM NUMBER] on C hall and room [ROOM NUMBER] on C Hall, had peeled away from the doors and that the material [NAME] out into the entry/exit area of the doorway could pose a snagging issue for residents with wheel chairs. He stated that he had not ordered materials for those doors yet. The Maintenance Manager revealed that he did not know about the hole in the wall at the end of D Hall but intoned that it could offer an area ingress to the facility for insects. In an interview with the DON on 10/12/23 at 10:23 AM, the DON stated that the facility staff reports maintenance issues directly to the Maintenance Manager or the facility staff also had access to a computerized maintenance reporting system. She stated that if there was a maintenance issue discovered through the Grievance process that the staff could either report it to the Maintenance Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 9 of 10 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 0921 Level of Harm - Minimal harm or potential for actual harm Directly or use the computerized reporting system. She started that the door covering material that had peeled aways from the doors for room [ROOM NUMBER] on B hall, room [ROOM NUMBER] on C hall and room [ROOM NUMBER] on D hall, could offer an impediment for residents to be able to enter and egress their rooms safely and that the material sticking out could also offer a possible mechanism for the resident to suffer a skin tear. Residents Affected - Some Review of facility's policy Environmental Services Safety Procedures implemented 01/01/23 reflected to ensure general safety procedures are followed in the course of performing housekeeping and/or laundry duties. The policy was not specific about housekeeping or maintenance requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 10 of 10