Health inspection·June 20, 2023

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some restroom that morning. Resident #3 said Resident #2 had also seen insects and that she was out of the room eating in the dining area. Eleven small live roaches were crawling on the restroom floor and wall including two roaches that crawled into the floor drain. The wall below the hand sink had damage from plumbing penetrations into wall that were not sealed, and two pink basins were located below plumbing that appeared dirty. Left pink basin had one dead roach and right pink basin had one live spider. The wall appeared damaged next to hand sink were not sealed at damaged openings or at plumbing penetrations leading to interior walls in resident room. During an observation on 06/15/23 at 12:03 a.m., one dead wasp was on the floor near the nurse station. During an observation on 06/15/2023 at 12:07 p.m., one fly landed on the dining table near Resident #5. During an interview on 06/15/23 at 12:34 p.m., Resident #6 who resided on 400 hall said roaches crawled on her floor all the time. During an interview on 06/15/2023 at 2:57 p.m., the Hospitality Aide said she had seen large roaches on the floor in hallways. The Hospitality Aide said that she reported any pest control concerns to Human Resources. During an interview on 06/15/23 at 3:15 p.m., CNA A said Resident #19 reported that he had seen roaches crawling on the floor within the last couple of weeks. The CNA A said roaches were often observed throughout the facility and can promote the spread of infection. During an interview on 06/15/2023 at 3:48 p.m., CNA B said large sized roaches were in resident rooms. CNA B said that she reported pest control concerns to any nurse and did not remember who she last reported to. CNA B said pest control concerns were kept in a book at the nurse station for written maintenance requests. During an interview on 06/20/23 at 2:38 p.m., LVN A said roaches water bugs were observed near nurse station and that she reported concerns to the Maintenance Director. LVN A said a log was provided at the nurse station to report any pest control concerns. During an interview on 06/20/2023 at 2:54 p.m., the Administrator said there were no pest control concerns since 6/15/2023 visit and the pest control service provider was targeting pests by putting out granules, spraying, and building a bigger barrier at exterior. The Administrator said the presence of pests did not pose infection control concerns and were a risk to residents by being a nuisance and decreasing cleanliness. The Administrator said that the pest control servicer provider visited the facility anytime they were needed and that written recommendations on remediation were not provided by the pest control service. The Administrator said verbal recommendations to improve pest control concerns included building a larger barrier at the exterior of facility and sealing any potential entry/exit points. During an observation on 06/20/23 at 3:10 p.m., one dead roach was observed in the activity room on the floor. During a record review and interview on 06/20/2023 at 3:13 p.m., the Maintenance Director said he worked at the facility for four years and that he was responsible for carrying out pest control in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 2 of 3 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some collaboration with the pest control service provider and the Administrator. The Maintenance Director said he provided the maintenance log for pest control concerns for staff or residents. The maintenance log contained no entry concerning pests for the prior 6 months. The Maintenance Director said he had noticed the larger sized roaches throughout the building and that pest control services were provided monthly and as requested. The Maintenance Director said he believed pest control services were effective and that granules were put at plumbing penetrations to target roaches and walls were sealed as he sees them. The Maintenance Director said that the pest control service provider provides verbal recommendations to assist with pest eradication to include a barrier and sealing and potential entry and exit areas. The Maintenance Director said that the presence of roaches and other insects in the facility can pose a risk to residents by promoting the spread of infection and a decreased quality of life from an unsanitary environment. During an interview on 06/20/23 at 3:54 p.m., the DON said larger sized roaches were water bugs seen when it rains that were both live and dead in different areas of the facility. During an observation and interview on 06/20/23 at 4:49 p.m., there were four flies in the kitchen area that landed on staff and, food prep surfaces, and dishware. Two flies were in the dining area and landed on the ice cooler. Multiple trash bags of waste were stored outside of dumpster on the ground. Multiple empty food container boxes were stored on the ground outside near kitchen exit door. Dietary Aide A and Dietary Aide B said the dietary manager was not working and that they did not know why there were multiple bags of waste stored on the ground near dumpster. Dietary Aide A and Dietary Aide B said there were flies in the kitchen and that were previously reported to the Administrator. Dietary Aide B said he thought the garbage was not picked up on Monday due to the holiday. Dietary Aide A and Dietary Aide B said they were not sure what was being done to address the flies in the kitchen and were not aware of any pest control services provided for flies. During an interview on 06/20/23 at 5:09 p.m., the Environmental Services Manager said roaches on the 200 hall were the main pest control concern. During an interview on 06/20/23 at 5:58 p.m., the Administrator said the trash bags of waste were to be removed tomorrow by garbage collector and their pest control provider were good about coming out when requested. Record review of Grievance, dated 5/22/23, revealed Resident #4 had discharged and reported large brown roaches crawled through her room. Action taken included fly treatment and barrier for water bugs. The Administrator noted the grievance as resolved on 5/26/23 with a description to include granular bait and barrier spray applied by technician. Review of facility's policy Pest Control Program implemented 1/10/2020 reflected this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 3 of 3