Health inspection·June 1, 2023

F 0578 legally appointed guardian's wishes. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #22's physician's orders revealed an active order for DNR with a revision date of [DATE]. Residents Affected - Some Record review of Resident #22's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician printed name, or date in the section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no signature of one of the witnesses in the section; the line was left blank. 2. Record review of Resident #31's face sheet, dated [DATE], revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), hyperlipidemia (high cholesterol), presence of cardiac pacemaker, personal history of malignant neoplasm of breast (breast cancer), and hypertension (high blood pressure). Resident #31's face sheet revealed an advance directive of DNR. Record review of Resident #31's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #31's care plan, dated [DATE] revealed, in part: [Resident #31] has physician's orders that include a status of full code .[Resident #31]/legally appointed guardian's wishes will be followed daily and ongoing. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Resident #31's care plan did not mention DNR. Record review of Resident #31's physician's orders revealed an active order for DNR with a revision date of [DATE]. Record review of Resident #31's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no date in the section; the line was left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date or signature of one of the witnesses in the section; the lines were left blank. 3. Record review of Resident #32's face sheet dated, [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), other stimulant dependence, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and insomnia Resident #32's face sheet revealed an advance directive of DNR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 2 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #32's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #32's care plan, dated [DATE] revealed, in part: Resident has physician's orders that include an order for DNR. Do not resuscitate orders will be honored per resident or legally appointed guardian's wishes. Record review of Resident #32's physician's orders revealed an order for DNR with a discontinued date of [DATE] and an original revision date of [DATE]. The order was discontinued following an interview with ADM regarding the validity of the OOH-DNR form on [DATE]. Record review of Resident #32's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 3 WITNESSES: . We have witnessed all of the above signatures there was no date next to the second witness' signature; the line was left blank. Section 4 of the document revealed PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician printed name, or date in the section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date in the section; the line was left blank. During an observation and interview on [DATE] at 08:27 AM RN A stated nurses could carry forth orders and put them in the EHR if it is a new order for DNR. She pointed out on the EHR where a resident is listed as DNR or full code. RN A retrieved a binder from the nurses' station and explained that the binder contained a plastic page protector for each resident with their face sheet. RN A explained if the resident was DNR, a copy of the DNR was in the back side of their plastic page protector. If they were full code, there was nothing in the back side. Observation revealed the residents were in the binder in alphabetical order. During an observation and interview on [DATE] at 08:32 AM the ADM was shown the OOH-DNR forms for Resident #31 and Resident #32. She was unable to identify what was wrong with the forms. She took the forms into the ADON/DON's office and asked who was responsible for DNR forms. The DON raised her hand. During an interview on [DATE] at 09:11 AM the ADON and the DON were asked for a possible negative outcome of having an incorrectly filled out OOH-DNR. They stated they would have assumed the DNR's for Resident #31, Resident #32, and Resident #22 were filled out correctly. The ADON stated they could be in legal danger even resulting in jail time if they did not render life-saving aid and the family decided to get upset about that. During an interview on [DATE] at 09:13 AM RN A stated a possible negative outcome of a an incorrectly filled out OOH-DNR was, We would assume they are DNR and there would be all kinds of legal ramifications from that. The patient's wishes might not be followed. Record review of a portion of the facility's admission packet titled, Advance Directives revealed the following: .What is an Out-of-Hospital Do Not Resuscitate Order (OOHDNR)? This form is for use when you are not in the hospital. It lets you tell health care workers, including Emergency Medical Services (EMS) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 3 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 0578 Level of Harm - Minimal harm or potential for actual harm workers, NOT to do some things if you stop breathing or your heart stops. If you don't have one of these forms filled out, EMS workers will ALWAYS give you CPR or advanced life support even if your advance care planning forms say not to. You should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if you don't want CPR. Residents Affected - Some Record review of a document titled, Out-of-Hospital DNR instructions revealed the following: .The form must be signed and dated by two witnesses .The original standard Texas Out-of-Hospital must be completed and properly executed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 4 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 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 complete an assessment that accurately reflected the resident's status for 1 of 12 residents (Resident #4) reviewed for accuracy of MDS assessments. Residents Affected - Few The facility failed to identify Resident #4's administration of Humalog Solution (insulin lispro) injections on his annual MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk and could result in residents not receiving correct care and services. Findings include: Record review of Resident #4's face sheet on May 31, 2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, chronic pain, covid-19, encounter for immunization, hypoosmolality(electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia(low levels of sodium in blood), anemia, mild cognitive impairment of uncertain etiology, Parkinson's disease, unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing, unspecified fracture of upper end of right humerus, subsequent encounter for fracture with delayed healing, other abnormalities of gait and mobility, repeated falls, cognitive communication deficit, other osteoporosis with current pathological fracture(broken bone spread by disease), muscle weakness, age-related osteoporosis without current pathological fracture, need for assistance with personal care, unspecified nondisplaced fracture of surgical neck of left humerus, subsequent encounter for fracture with routine healing, low back pain, major depressive disorder, vitamin D Deficiency, gastro-esophageal reflux disease without esophagitis, vitamin efficiency, overactive bladder, hyperlipidemia, hypothyroidism, essential hypertension, type 2 diabetes, tremors, drug induced subacute dyskinesia(condition affecting the nervous system), schizoaffective disorder, and depressive type. Record review of Resident #4's physician's orders revealed active orders dated 08/23/2022 to administer Humalog Solution (insulin lispro) on a sliding scale. Record review of Resident #4's Medication Administration Record for the month of March 2023 revealed that 2 units of Humalog Solution was administered on 03/16/2023 at 8 PM, on 03/18/2023 at 7:30 AM, and on 03/21/2023 at 4:30 PM. Record review of Resident #4's MDS assessment dated [DATE] revealed the resident had a BIMS(brief interview for mental status) score of 9 out of 15. The MDS also indicated in Section N0300 (Injections) that Resident #4 received 0 Humalog Solution (insulin lispro) injections from the 7 days during the MDS look back period to check for medications administered to the resident. Record review of Resident #4's Care plan dated 04/03/2023 indicated a focus on diabetes as the resident was at risk for unstable blood sugars related to Type II Diabetes with interventions to administer diabetes medication as ordered by the physician. During an interview with Resident #4 on 05/30/2023 at 2:45 PM, the resident was identified as a Type II diabetic. Resident #4 stated he was checked by staff twice a day and was given insulin when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 5 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 0641 needed. Level of Harm - Minimal harm or potential for actual harm During an interview with the MDS Coordinator on 05/31/2023 at 10:26 AM, the MDS Coordinator stated the look back period for medication was 7 days for the MDS Assessment. The MDS Coordinator also said he looked to the Resident Assessment Instrument when he has questions regarding MDS Assessments. When asked about policies regarding MDS Assessments, the MDS Coordinator showed surveyor the MDS Coordinator Manual. Residents Affected - Few During an observation and interview with the MDS Coordinator on 05/31/2023 at 2:00 PM, the MDS Coordinator reviewed Resident #4's MDS assessment dated [DATE] and observed that there was no indication of any insulin injections given to resident in section N0300 (Injections). The MDS Coordinator also reviewed the Medication Administration Record for Resident #4 and observed 2 units of Humalog Solution was administered on 03/16/2023 at 8:00 PM, 03/18/2023 at 7:30 AM and 03/21/2023 at 4:30 PM. After reviewing the MDS Assessment and the MAR the MDS Coordinator said, I made a mistake. It is not accurate and I will correct it now. When asked about the negative outcome for inaccurate MDS Assessments the MDS Coordinator did not provide an answer. During an interview with LVN B on 06/01/2023 at 9:56 AM concerning Resident #4 and the process of checking Resident #4's blood sugar, LVN B stated Resident #4's blood sugar was checked in the mornings, before meals and in the evenings. Record review of Resident Assessment Instrument dated October 2023 via the CMS website revealed the Steps for MDS Assessment were as follows: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care locations where the resident may have received injections while a resident of the nursing home (e.g., flu vaccine in a physician's office, in the emergency room - as long as the resident was not admitted ). 3. Determine if any medications were received by the resident via injection. If received, determine the number of days during the look-back period they were received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 6 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 that each resident was screened for a mental disorder or intellectual disability prior to admission for 3 of 12 residents (Residents #15, #22, and #29) reviewed for PASRR compliance. Residents Affected - Some The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #15 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #22 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #29 prior to admission to the facility. These failures could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings Included: 1. Record review of Resident #15's face sheet, dated 05/31/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and psychotic disorder with delusions (a condition of the mind that results in difficulties determining what is real and what is not real accompanied by an unshakable belief in something that is untrue). Record review of Resident #15's MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated severe cognitive impairment. Record review of Resident #15's care plan, dated 04/17/23, revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #15's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 12/26/22, 97 days after she was admitted to the facility. 2. Record review of Resident #22's face sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and a need for assistance with personal care. Record review of Resident #22's MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 7 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 0645 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #22's care plan, dated 05/05/23 revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #22's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 08/24/22, 14 days after she was admitted to the facility. Residents Affected - Some 3. Record review of Resident #29's face sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cirrhosis of the liver (impaired liver function caused by the formation of scar tissue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #29's MDS, dated [DATE], revealed a BIMS score of out of 12 out of 15 which indicated moderate cognitive impairment. Record review of Resident #29's care plan, dated 05/26/23, revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #29's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 02/15/23, two days after she was admitted to the facility. Record review of a document from Resident #29's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 02/27/23, 14 days after she was admitted to the facility. During an interview on 05/31/23 at 04:17 PM the MDS Coordinator stated PASRR level 1 screenings were done within 24 hours of admission of a resident. He stated he was responsible for ensuring the PASRR level 1 screening were completed on or before the day of admission. He stated a possible negative outcome of completing the PASRR level 1 screenings after admission was residents who were PASRR positive would not get the specialized services they needed. When asked why Resident #15's PASRR level 1 screening was completed 97 days after her admission to the facility, the MDS Coordinator stated he did not know why as he was not employed at that time. When asked why Resident #22's PASRR level 1 screening was completed 14 days after her admission to the facility he stated, She came from home or something. I'm not sure. When asked why Resident #29's PASRR level 1 screening was completed either 2 or 14 days after her admission to the facility he stated, She came from home too. When asked why Resident #29 had two PASRR level 1 screenings in her EHR he stated he did not know. When asked who was responsible for completing PASRR level 1 screenings when a resident is admitted to the facility from home, the MDS Coordinator stated he was. On 06/01/23 a policy governing PASRR was requested from, but not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 8 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Some 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, interview, and record review, facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 5 of 12 residents (Residents #19, #22, #31, #32, #33) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to complete goals related to smoking for Residents #22, #32, #33 2. Failure to create goals of services being provided such as hospice care for Resident #31 3. Failure to reflect accurate advance directives in care plan Resident #31 These failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as fall preventions and smoking. Findings included: Resident #22 Record review of Resident #22's face sheet on 05/30/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to congestive heart failure, major depressive disorder, hypokalemia, retention of urine, anemia in chronic kidney disease, hypercholesterolemia, other idiopathic peripheral autonomic neuropathy, hypertension, chronic kidney disease stage 1-4, old myocardial infarction, abnormalities of gait and mobility, repeated falls, reduced mobility, assistance with personal care, long term use of anticoagulants, history of other venous thrombosis and embolism, and obstructive and reflux uropathy. Resident has a brief mental status interview of 15 labeled as cognitively intact. Record review of the facility's smokers list (no date) provided by ADM revealed that Resident #22 was a smoker. Record review of Resident #22's care plan dated 5/5/23 indicated no focused goal for smoking. Resident #32 Record review of Resident #32's face sheet 05/31/23 dated revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 9 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Some of thinking and social symptoms that interferes with daily functioning), other stimulant dependence, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and insomnia. Record review of Resident #32's evaluations revealed Resident #32's smoking assessment dated [DATE] was completed. No additional smoking assessments were completed after admission. Record review of the facility's smoker's list (no date provided) provided by ADM mentions Resident #32 as a smoker. Record review of Resident #32's care plan dated 4/3/23 indicated resident did not have a focus goal related to smoking. Resident #33 Record review of Resident #33's face sheet dated 5/31/23, revealed [AGE] year-old female admitted to the facility on [DATE] with a brief mental interview status of 02. Resident #33's current diagnoses included but were not limited to: Anxiety, hyperlipidemia (high cholesterol), polycythemia (blood cancer), nicotine dependence, sever protein-calorie malnutrition, essential hypertension (high blood pressure), acute ischemic heart disease, heart failure, gastro-esophageal reflux disease without esophagitis (inflammation of the esophagus due to stomach acid), osteoporosis (bone weakness), and moderate dementia. Record review of Resident #33's evaluation assessments face sheet (no date) revealed no smoking assessment completed upon admission. The smoking assessment was not completed until 5/30/2023 with no prior assessments completed since admission. Record review of the facility's smokers list (no date) provided by ADM indicated that Resident #33 is a smoker with occasional written in parentheses beside resident's name. Record review of Resident #33 care plan initiated on 01/06/2023 revealed that no goal was identified for smoking. Interview on 05/31/23 at 02:23 PM with LVN B revealed if someone was a smoker, should it be included in the goals/care plan? LVN B responded with, Yes. Asked LVN B indicated that smoking assessment should be with goals/care plan. LVN B indicated RN should be responsible for completing assessments and should be on the initial intake. LVN B stated a negative outcome could be as far as to the resident, may not be mentally capable of smoking, burn themselves, burn others, burn the house down. If they go out and smoke, some of them you have to go out there with. LVN indicates that they (pointing to ADON) do assessments more often but unaware of timeline. Interview on 05/31/23 at 02:31 PM with the DON revealed if someone is smoker, they (the resident) should they have something in their care plan as well as a smoking assessment. DON confirmed that MDS coordinator was responsible for completing the smoking assessment. DON stated that a negative outcome would be oxygen could not be monitored and if symptoms were present then knowledge of smoking has to be documented. DON also stated that smoking assessments are done every month when care plans are done and every resident is assessed for smoking. Record review of Resident #31's face sheet, dated 05/30/23, revealed an [AGE] year-old female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 10 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Some admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), hyperlipidemia (high cholesterol), presence of cardiac pacemaker, personal history of malignant neoplasm of breast (breast cancer), and hypertension (high blood pressure). Resident #31's face sheet revealed an advance directive of DNR. Record review of Resident #31's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #31's care plan, dated 04/17/23 revealed, in part: [Resident #31] has physician's orders that include a status of full code .[Resident #31]/legally appointed guardian's wishes will be followed daily and ongoing. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Resident #31's care plan did not mention DNR. Record review of Resident #31's physician's orders revealed an active order for DNR with a revision date of 03/06/23. Record review of Resident #31's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated 03/03/23, which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no date in the section; the line was left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date or signature of one of the witnesses in the section; the lines were left blank. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care plan revealed that the care plan will contain information about the physical, emotional/psychosocial, spiritual, educational, and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with the individualized, goal-directed care, which is reasonable, measurable, and based on resident's needs. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care Plan, under section Developing Care Plan: Line 2- The services provide or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. Line 3 (c) Each planned intervention will be specific and include parameters for frequency and time schedule. Line 4-Each discipline will check or add expected outcomes and goals. Expected outcomes describe the realistic short-range goals to be achieved by the resident within a specific time frame. Line 5-These activities will be completed for each patient problem. Line 6- The care plan will be maintained in the care plan section of the resident medial record. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care Plan under section Updating Care Plans reveals: Line (1) Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. Line 3 (a) significant change in the resident's condition. Line 5- Revisions involving the care of other disciplines are done through consultative and collaborative efforts and documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 11 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Few 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** Based on observation, interview, and record review, the facility failed to keep resident environment free of accidents and hazards and assistance devices to prevent accidents for 1 of 12 residents (Resident #19) reviewed. The facility failed to provide a fall mat for Resident #19. This failure can increase the risk of injury for residents requiring assistance due to history of falls. Findings include: Record review of Resident #19's face sheet dated 05/30/23 revealed he is a [AGE] year-old male originally admitted to the facility on [DATE] with a readmission on [DATE]. Resident #19 has diagnoses including non-st elevation (NSTEMI), myocardial infarction (Heart attack), aphagia (inability or refusal to swallow), anxiety disorder, iron deficiency anemia, unspecified, other abnormalities of gait and mobility, heart failure, Pneumonia, unspecified organism, insomnia, dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbance, major depressive disorder, recurrent severe without psychotic, hyperlipidemia, unspecified, gastro- esophageal reflux disease without esophagitis (irritation of the esophagus caused by stomach acid, muscle weakness (generalized), ataxic gait (unsteady or uncoordinated walk), cognitive communication deficit, aphasia (language disorder, other reduced mobility, need for assistance with personal care, problem related to care provider dependency, unspecified, moderate protein calorie malnutrition, essential (primary) hypertension (high blood pressure), chronic atrial fibrillation (fast heart beat), unspecified, other malaise, traumatic hemorrhage of cerebrum (stroke), unspecified with loss of consciousness of unspecified duration, sequela (conditions or diseases that follow another, suicide attempt (sequela). Record review of Resident #19's care plan revealed Resident #19 had a goal of potential for falls related to cognitive impairment with initiation date of 7/20/22 and a revision date of 4/24/23. Intervention associated with goal reflected Floor mat while in bed. Resident #19's care plan reflected the resident had a recent fall on 4/22/23. Record review of Resident #19 MDS (no date) indicated a BIMS of 01. On 05/31/23 at 3:44 PM, observation revealed Resident #19 in bed with no fall mat located next to resident's bed. On 6/1/23 at 8:35 AM, observation revealed Resident #19 was in bed with no fall mat on floor next to resident bed. An interview on 5/31/23 at 2:55 PM with CNA F revealed charge nurse oversees assistive devices and CNA F was not sure how often the residents were assessed. CNA F indicated that going to nurses or therapy would provide assistive devices and types of assistive devices included hi-lo beds, fall mats, and rails. CNA F stated that if assistive devices are ordered, orders would be in the charting system of each person's chart. CNA F identified negative outcomes as the resident would fall and hurt themselves if resident fell with no fall mat or had a hi-lo bed that was not to the ground. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 12 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Few An interview on 5/31/23 at 3:02 PM with CNA G revealed: Who is responsible for fall assessments and assistive devices? Nurse of physical therapy. Go to nurse first if you have a fall. How often are residents assessed? CNA G stated, I don't know that. Where would you go if any assistive devices are needed? CNA G indicated, First nursing or go to therapy. What assistive devices are used for fall prevention? CNA G responded, Fall mats, beds lowered all the way to the ground, no cords or wires, walkers, canes, wheelchair. When would you get a new assessment for assistive device orders? CNA G indicated, Through our nurse of the ADON would if is like a big need or we go get them. Is there a certain area that you would need to go get the assistive devices? CNA G stated, A lot of the times we keep fall mats in the shower room to sanitize and in our clean utility room. What is a negative outcome if fall preventions are not place such as a floor mat not being in place? CNA G responded, Them falling and breaking a hip and hurting themselves. On 5/31/23 at 3:44 PM, interview with RN A revealed: Who is responsible for fall assessments and assistive devices? RN A advised that a licensed nurse should do the fall assessment. This should go into the care plan when the pop up on the screen and need an evaluation. RN A advised that administration should be asked about timelines of assessments as they (RN A) was new to the facility. RN A identified that fall prevention devices included walkers, wheelchairs, fall mats and beds in lowest position. RN A identified a negative outcome of if fall mat is on a care plan and not in place it could be a possible injury and a tag if not following care plans On 5/31/23 at 3:53 PM, an interview with the ADON revealed that nurses do the fall assessments if there is a fall, but they are assessed during QOL. It is discussed if they need something new and it can be the DON, the MDS Coordinator, or whoever I can catch. ADON revealed that residents are always assessed if a fall occurs and any assistive devices go through ADON and ADM to put assistive device in place. ADON stated that hi-lo bed, assisted rails, fall mats are all assistive devices but unsure if the facility has any right now. ADON stated that a negative outcome would be an injury to the resident and the team is responsible for assistive devices being in place. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care plan revealed that the care plan will contain information about the physical, emotional/psychosocial, spiritual, educational, and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with the individualized, goal-directed care, which is reasonable, measurable, and based on resident's needs. Record review revealed that in-service training was provided for Fall Prevention completed on 2/21/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 13 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 and 1 of 1 kitchen storage room reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure foods were sealed properly. 3. The facility failed to properly sanitize thermometer to check food temperatures. 4. The facility failed to ensure proper thawing procedures. 5. The facility failed to ensure proper infection control measures. 6. The facility failed to check expiration dates on foods. 7. The facility failed to properly cover/seal foods. These deficient practices could expose residents who consume food prepared in the facility's kitchen to food-borne illnesses. Findings Include : Observation of the dry storage area on 5/30/23 at 8:41 AM revealed the following: 1. 2- 5-pound tubs of potato granules with no lid. lid on the third tub had written in black marker Do not throw away lid with a date of 5/9. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 14 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 1 gallon of vegetable oil sealed with a piece of tin foil. There was no date and labeled in black marker around the edge Do not throw away. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Many Fancy [NAME] Mousse package -not dated. 4. 7 1-pound packages of Instant Pudding Mix not dated 5. 3 clear containers with condiment packages of (1) mustard (2) mixture of condiment packages (3) mayonnaise- no label or date 6. 2 18-ounce packages of Strawberry Presweetened soft drink mix- no dates 7. Gallon size zip top bag labeled Fruit Loops dated 5/28 with no expiration date. 8. A gallon size zip top bag labeled Corn Flakes dated 5/20 with no expiration date. 9. A box of opened 16-ounce lasagna located in a bigger brown box- opened, not properly sealed, and not dated with an open date. 10. A brown box containing 8 boxes of 16-ounce boxes of lasagna noodles- not dated 11. A gallon size zip top bag with a cream of wheat box with no expiration date. 12. Small Jelly packets - not labeled with a received date 13. Clear Liquid Fry Shortening 35 pounds - No date opened- No use by date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 15 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 14. Level of Harm - Minimal harm or potential for actual harm 40 7.25 oz individual [NAME] Chicken Noodle Soup - No received date 15. Residents Affected - Many 7 individual glass Agues Fresca Powder Strawberry with no received date 16. Oatmeal in zip top bag- No expiration date 17. Graham cracker crust- No expiration date 18. Light corn syrup bottle 16oz- no open date 19. 7 2.5 oz Ms. Dash Original seasonings- no received/open date 20. 5 pound pancake mix - No expiration date 21. 9 cherry gelatins with no received date 22. 5 pound seasoning salt that was not in a secured container open to air Observation of small refrigerator/freezer on 5/30/23 at 8:56 AM revealed the following: 1. 2 blocks of margarine-wrapped with no dates 2. Gallon jug in Red Diamond container with a brown substance and black markings that reflected, Do not throw away. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 16 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 16-ounce lemon juice opened on 3/2 with no expiration date Level of Harm - Minimal harm or potential for actual harm 4. 4.5 fluid ounce of Trappey's Peppers opened 4/19- no expiration date or use by date Residents Affected - Many 5. Italian Dressing bottle- opened- no date open 6. 22-ounce Nesquik chocolate syrup- opened with no date 7. 8-ounce [NAME] turkey breast in gallon size plastic bag- not labeled and not dated- no expiration date or use by date 8. A storage container box of oranges in a juice substance- no open date/ no expiration date 9. Small margarine cups in a plastic container- open date- no expiration date. 10. 12.75 oz Heinz Mustard that expired on 1-29-23 11. Sausage Patties in a bag-o expiration date 12. A 1 liter bottle with a label indicating Dr. Pepper. in the freezer- not labeled or dated. 13. 2 12fl oz canisters of concentrated apple juice- no received date Observation of the shelving unit on 5/30/23 at 9:05 AM revealed the following: 1. Nixtamal Corn Tortillas that were not refrigerated indicated to refrigerate after opening and opened with no open date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 17 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 2. Level of Harm - Minimal harm or potential for actual harm Tender Crust [NAME] Bread- opened with no open date and no received date 3. Residents Affected - Many 2.12-ounce spice jar labeled Nutmeg dated 11/7/21- no use by date or expiration date 4. 3.12-ounce spice jar labeled Garlic Powder- not dated 5. 6.50-ounce plastic jar labeled [NAME] on lid- opened 2/28 with no expiration date 6. 1 pound box of baking soda- no open date 7. 12-ounce [NAME] baking powder - opened 2/9 - expired 9/4/22 8. 17 oz Restaurant Pride oil exposed to air opened 4/28 9. 1 pound 2-ounce plastic container labeled Light Chili Powder and labeled on the back side with a post it note that reflected SALT written in black marker 10. 7 fluid ounces plastic container of Dawn Dish soap located on the bottom shelf stored with food items 11. [NAME] Homestyle Beef Flavored Base- no expiration date- no received date- no open date 12. 2.5 oz Ms. Dash Original spice - opened with no open date 13. A 0.4 oz organic cilantro - opened with no open date- expired 10-30-21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 18 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 14. Level of Harm - Minimal harm or potential for actual harm 8 fl oz imitation vanilla flavor - expired 4/2023 15. Residents Affected - Many 16 oz cornstarch- no expiration date on the bag 16. 13 oz oregano- expired 4-4-2023 17. Light chili powder- no expiration date 18. Silver canister shaker with a powdery white substance- no label/no date Observation on 5/30/23 at 9:15 AM revealed a frozen ham in a metal pan on the counter located in the middle of the kitchen. Observation of freezer in kitchen storage room the left side of room at 9:23 AM revealed the following: 1. 5 frozen drink cups- no label 2. 2 2 lblb. bags containing frozen okra 2lb - no use by date 3. 6 frozen coconut cream Pies - no use by date 4. 6 16 oz classic jumbo frank hot dogs- no receive date 5. A clear bag containing frozen items- no use by date and not labeled 6. A white bag unopened- no label (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 19 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 7. Level of Harm - Minimal harm or potential for actual harm 6 12 oz frozen peas - no receive date 8. Residents Affected - Many 4 vegetable stir fry- expired 5/2/2023 9. A clear bag containing egg rolls in a cylinder shape- no label- no expiration date 10. A clear bag containing a shredded substance- no label and no dates 11. Frozen Diced Chicken- no use by date Observation of the refrigerator in room [ROOM NUMBER] on the left side of room at 5/30/23 at 9:25 AM revealed the following: 1. A green plastic tub labeled Potato Salad dated 5/29- no use by or expiration date 2. 4 bags labeled Nestle Tollhouse semi-sweet chocolate chips- no date 3. A gallon size bag holding two pieces of cut meat labeled Ham with no dates 4. 2 pints of Food Club Heavy Whipping Cream- no dates 5. 1 gallon Best Made pickles- opened 5/9 no expiration date 6. 19- 1-pound units of individually wrapped margarine- not dated 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 20 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 1 gallon of Kikkoman Teriyaki marinade- opened 9/27- expired 1/15/23 Level of Harm - Minimal harm or potential for actual harm 8. 12-ounce plastic container of cottage cheese- dated 5/19 Residents Affected - Many 9. A plastic bag containing 6 green bell peppers not labeled, not dated, and located in a box that contained and was labeled tomatoes Observation of the freezer in room [ROOM NUMBER] on the right side of room on 5/30/23 at 9:35 AM revealed the following: 1. 9 bags of Flour tortillas 24 count Frozen - expired 5/16/23- no receive date An observation on 5/30/23 at 12:08 PM revealed DM H did not follow proper protocol with sanitizing the food thermometer between food items. DM H did not sanitize temperature thermometer prior to taking temperatures. DM H placed the thermometer in cooked ham. DM H placed the thermometer in ice and moved the thermometer around. DM H removed the thermometer from the ice and placed the thermometer in mashed potatoes. DM H removed thermometer from mashed potatoes, placed thermometer in ice and moved thermometer around. DM H removed thermometer from ice and placed thermometer in Brussels sprouts. DM H removed thermometer from Brussels sprouts, placed thermometer in ice and moved thermometer around. DM H removed thermometer from ice and placed thermometer in mechanical (finely chopped) ham. DM H removed thermometer from mechanical ham, placed thermometer in ice, and moved around. DM H removed thermometer from ice and placed thermometer in mechanical corn. DM H removed thermometer from mechanical corn, placed in ice and moved thermometer around. DM H removed thermometer from ice and then placed thermometer in pureed ham. DM H removed thermometer from pureed ham and placed in ice. DM H removed thermometer from ice and placed in pureed corn. DM H removed thermometer from pureed corn, placed in ice and moved thermometer around in ice. DM H removed thermometer from ice and placed thermometer in coconut cream pie. An observation on 5/30/23 at 12:32 PM revealed DM H did not wash her hands prior to putting on gloves. DM H continued to wear same gloves when touching the refrigerator, a thick container (powder substance to make liquids thick), a sink handle for water, plastic wrap, and meal card tickets prior to the meal service. DM H then began preparing plates for residents and assembling trays without hand hygiene and changing gloves. An interview with DM H on 5/30/23 at 3:24PM, DM H stated she had been employed at the facility for 15 years. DM H stated she supervised 5 staff. DM H said that her RD trained her on policy and procedures. DM H stated the date received should be written on each food item when it is received. DM H said that they check-in the trucks and are responsible for writing the date received on the food that they get. DM H stated the date open should be written on each food item when it is opened. DM H said the expiration policy for expired foods is 3 days to throw it away. DM H said their handwashing policy is to sing happy birthday and to wash their hands upon entering and exiting the kitchen. DM H stated staff are trained on policy and procedures every 3 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 21 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Many An interview with [NAME] J on 5/30/23 at 3:17 PM revealed that [NAME] J had been employed at the facility since November 2022. [NAME] J stated training is from videos and DM H. [NAME] J stated the date and name should be on all food when it is received. [NAME] J said when a product is opened that the date it is opened should be written on it. [NAME] J said that the expiration policy is 3 days. [NAME] J stated the handwashing policy is to wash their hands every time staff enters the kitchen from the outside. [NAME] J stated that food is thawed by putting food in the fridge the day before to thaw. An interview with [NAME] K on 5/30/23 at 3:14 PM, [NAME] K stated that [NAME] K had been employed with the facility since April. [NAME] K said DM H trains staff on policies and procedures. [NAME] K stated food should have the date received written on it when it is received. [NAME] K stated when a product is opened that the date should be written on the outside of the item. [NAME] K said the facility's expiration policy is 3 days. [NAME] K stated the handwashing policy is for staff to wash hands when entering the kitchen and before gloves are put on. [NAME] K said meat and food are thawed in the fridge the night before. Record review of the Policy of Storage of Dry Food and Supplies, origination 4/2017; review date 7/2018 revealed, under Procedure headline, line (5)- Chemicals will be kept separate from food and paper . (In a separate storeroom or mop closet) Do not intermingle food and paper supplies, keep in separate areas of the storeroom. Line (6)- Use FIFO (First In, First Out). All foods will be dated on the day of deliver and rotated so that the oldest product is to the front for the first use. Line (7)- For products that will be removed from their original container, use metal or plastic food grade safe plastic containers with tight fitting lids. Label both top and sides of containers. Plastic food grade storage bags may also be used, must be sealed tight and clearly labeled. Line (8)- Use only National Safety Foundation (NSF) approved containers and food grade storage bags for food storage. Line (10)-All opened product will be resealed effectively. Product from open bags, boxes, etc. that cannot be resealed are placed in an appropriate container, labeled, and dated. Record review of the policy Food Safety and Sanitation Plan, origination 4/2015; review date 4/2018, revealed, under line (13) Personal Hygiene Practiced (a) thorough hand washing is required (but not limited to) the following situations: (b) starting the work shift and (e) After coughing, sneezing, or touching hair or face. Record review of the policy Food Safety and Sanitation Plan, origination 4/2015; review date 4/2018, revealed, under Procedure, line (4) Potentially hazardous foods shall be kept at safe temperatures, line (b) Under potable running water at temperature of 70 degrees F below, with sufficient water velocity to agitate and float off loose food particles. Record review of the Policy of Food Inventory, Ordering, Receiving and Stocking, originated 4/2015; review date 4/2018, revealed, under heading of Stock Rotation to date stock with date of delivery (other systems for stock rotation visibility may be used if approved by consultant dietician) place your procedure in this manual. Record review of the policy Storage of Frozen and Refrigerated Food, originated 8/29/2005; review date 10/2017, revealed under the heading Procedure: line (8) Thaw potentially hazardous food on a try on the bottom shelf of the refrigerator. Label to date removed from the freezer, use by date. (7 days from the date removed form the freezer.) This includes meats, fish, poultry, vegetables, and frozen shakes, and all thawing potentially hazardous foods. Line (9) Refrigerate foods in shallow containers to speed the cooling process. Label to date placed in the refrigerator, time, expiration or use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 22 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 - Many by date. Once a product has been opened the date opened shall be written on the product and use by date is 3 days from the date opened. Food prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 3 days from the date prepared. Line (11) Items to be stored in the refrigerator upon delivery are to be dated to delivery date and expiration date- 7 days following delivery date. The only exception to expiration dating is items containing an expiration date form the manufacturer, ex. Milk, sour cream, cottage cheese, etc. Line (12) Manufactured refrigerated items such as cooked eggs, cheese, lunch meat, when opened are to be placed in a sealed container, labeled to opened date and use by date (7days). Line (14) All refrigerated and Frozen items will contain proper labeling of at least the common name of the product and dated as noted above. Record review of the Dietary Policy Hand Washing origination date: 4/2017; review date 9/2018, revealed, under the heading Fundamental Information- Dietary employees will wash their hands before starting work and after or in-between the following activities: (3) Touching the hair, face, or body; (11) Before donning gloves for working with food. Under heading Procedure: (3) Wet hands and forearms with warm water . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 23 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 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 3 (CNA D, RN A and CNA E) of 3 staff observed for infection control practices. Residents Affected - Some -CNA D failed to use proper hand hygiene techniques when providing incontinent care to Resident #30. -RN A failed to use proper hand hygiene when delivering meals in dining area. -CNA E failed to use proper hand hygiene when assisting resident with meal tray in resident room. This failure may place resident at an increased risk for transmissible diseases. Findings include: Record review of Resident #30 face sheet dated 5/30/23 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, traumatic brain injury with loss of consciousness (violent bow or jolt to the head or body), intermittent explosive disorder (repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts), local infection of the skin and subcutaneous tissue (any type of microorganism, bacterial, viral or fungal that enters any break in the skin), anxiety disorder (persistent feeling of anxiety or dread which can interfere with daily life), candidiasis (fungal infection caused by a yeast called Candida), major depressive disorder (causes persistent feeling of sadness and loss of interest), extrapyramidal and movement disorder (variety of movement disorders) , alcohol dependence, essential hypertension (high blood pressure), stage 4 pressure ulcer of sacral region (full-thickness skin loss extending through the fascia with considerable tissue loss, this might involve muscle, bone, tendon or joint), dysphagia (swallowing difficulties), ataxic gait (awkward, uncoordinated walking), and pedestrian injured in traffic accident. Record review of Resident #30's last quarterly MDS dated [DATE] revealed a BIMS score of 00 out of 15 which indicated he was severely impaired. Resident #30 required extensive assist with 2 persons assist with all ADL's. Resident #30 utilized a wheelchair for ambulation with limited assist with 1 person assist. Record review of Resident #30's care plan dated 5/8/23, revealed in part: Problem: Resident has mixed bladder incontinence r/t loss of peritoneal tone Goal: Resident will decrease frequency of urinary incontinence through next review date. Interventions: Check frequently for wetness and soiling every two hours and change as needed. Briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinent episodes. Assist to toilet as needed. Monitor for and report MD signs/symptoms urinary tract infections: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency foul smelling urine, fever, chills, altered mental status, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 24 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 Level of Harm - Minimal harm or potential for actual harm change in behavior, change in eating patterns. Weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns, Report any new skin conditions to the physician. Registered dietician to evaluate resident's nutritional status as needed. Problem: Resident has bowel incontinence related to immobility, medications. Residents Affected - Some Goal: Resident will have less than two episodes of incontinence per day through the review date. Intervention: Check resident every two hours and assist with toileting as needed. Observe pattern of incontinence and initiate toileting schedule if indicated. Provide bedpan/bedside commode. Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode. Take resident to toilet at same time each day resident usually has bowel movement. During an observation on 5/30/23 at 09:25 AM of incontinence care for Resident #30 revealed CNA C and CNA D entered the room and introduced selves to Resident #30. The door to resident #30 room was closed and the privacy curtain was closed. All supplies were assembled before the procedure. CNA C explained to Resident #30 they were going to change his brief. Both CNA C and CNA D washed their hands with soap and water prior to starting care. Both CNA C and CNA D placed gloves on and completed the incontinent care. CNA C changed her gloves and utilized ABHR throughout incontinent care with each removal of wipes and wiping from dirty to clean. CNA C applied ABHR and changed gloves with each cleaning of Resident #30 and grabbing a new wipe. CNA C and CNA D turned Resident #30 over and cleaned the anal region. CNA D removed the dirty brief, did not remove her gloves, and did not wash her hands. CNA C changed her gloves, applied ABHR and applied new gloves, placed a new brief on Resident #30 and CNA D grabbed the new brief assisting with applying the new brief without changing her gloves or washing her hands. An observation on 05/30/23 at 12:40PM, revealed RN A was observed at the pick-up window by the kitchen placing hands on face and near mouth. RN A then obtained a tray to deliver to resident. RN A then handled residents' silverware without proper hand hygiene. RN A proceeded to take a napkin and pen out of her pocket, wrote on the napkin, and delivered a drink to a resident by taking the cellophane off top of glass. No hand hygiene was practiced prior to delivering the drink. An observation on 05/31/23 at 07:54 AM, observed CNA E serving Resident #3 a tray of food in Resident #3's room. CNA E placed the tray on the table, took off the lid, asked the resident if they would like for the bed to be raised, touch the bed buttons on the right lower side of the bed to elevate head area. CNA E asked the resident if they would like for the toast to have jam on it, grabbed a kitchen utensil and then picked up the resident's toast (2 pieces). CNA E grabbed the resident's drink, removed the cellophane and grabbed the top of the cup with 3 fingers around the edge of the glass. No hand hygiene was practiced during observation. During an interview on 5/30/23 at 09:55 AM with CNA D, when asked about removing the dirty brief and not changing her gloves after, CNA D stated she should have changed her gloves, washed her hands, and placed new gloves on. When asked what a negative outcome could be for not changing her gloves and washing her hands, CNA D stated cross-contamination. An interview on 05/31/23 at 01:26 PM, RN A was asked about proper hand hygiene when delivering meals. RN A stated, Know now that for nursing but wash hands before donning gloves. Wash after taking after gloves. During sterile dressings. Change between patients and wash hands. Gloves before administering glucose checks or ointments. Don't touch food with bare hands. If something happens should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 25 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wash. Should use alcohol when delivering trays. Forgot to do it during mealtime. RN A was asked what a negative outcome could be if hand hygiene was not practiced correctly when delivering meals. RN A stated, It can make residents sick if not doing hand hygiene. In an interview on 05/31/23 at 01:30 PM, CNA G was asked what the handwashing policy was. CNA G stated, Wash hands as soon as you enter the room. All the way up to wrists. Dining room sanitize hands between each tray while serving. An interview on 06/01/23 at 09:53 AM with the DON, it was asked what is the hand washing policy for dining room and delivering food to residents? During dining we are to gel when they get to the window to grab the tray. They delivery the tray then gel again after completing the delivery. Cross contamination can be a negative outcome of not doing hand hygiene during meal delivery services. Record review of facility policy titled, Handwashing/Hand Hygiene revised April 2012, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . n. Before and after assisting a resident with toileting (hand washing with soap and water) . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: f. Before moving from a contaminated body site to a clean body site during resident care . g. After contact with a resident's intact skin . Record review of facility policy titled Peri care Competency, undated, revealed the following: 4: Washes hands: -Before donning gloves -After removing gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 26 of 27 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Duro Nursing Home 405 S Collins St Claude, TX 79019 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 -Between cleaning the front and back Level of Harm - Minimal harm or potential for actual harm -When heavily soiled . 7. Always washes clean to dirty . Residents Affected - Some Record review of the Food Code through the Food and Drug Administration, dated January 18th, 2023 indicates code 2-301.14 When to Wash that food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single use and single-use articlesp and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 27 of 27