Health inspection·November 20, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eating, oral and personal hygiene. It also revealed that Resident #1 required substantial/maximal assistance with toileting hygiene, shower/bath, upper body dressing and lower body dressing. In Section GG0170 revealed that Resident #1 required substantial/maximal assistance with rolling left and right and sit to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfer. In Section H0100 revealed that Resident #1 had bowel and urinary incontinence. In Section I0020 revealed that Resident #1 had diagnoses of Dementia, anxiety and depression, and presence of cardiac pacemaker. In Section O0400 revealed that Resident #1 was receiving physical and speech therapy. Record review of Resident #1's physician orders revealed that physical therapy was ordered on 10/12/2023 and speech therapy was ordered on 10/13/2023. Physician orders dated 11/17/2023 revealed Resident #1 had a prescription for Buspirone HCL oral tablet 15 mg three times a day for dementia. Record review of Resident #1's nursing notes dated 11/11/2023 revealed resident was taking Buspirone HCL oral tablet 10 mg by mouth three times a day related to dementia. Nursing notes dated 11/17/2023 revealed that the physician increased Buspirone from 10mg to 15 mg three times a day. Record review of Resident #1's care plan dated 10/30/2023 revealed no evidence of documentation related to self-care activities which required partial/moderate and substantial assistance, no evidence of documentation of Resident #1's diagnoses of depression, anxiety or dementia, no evidence of documentation of Resident #1's diagnosis of presence of cardiac pacemaker, no evidence of documentation of physical or speech therapy and no evidence of documentation of Resident #1's urinary and bowel incontinence. During an interview and observation on 11/20/2023 at 9:54 AM, Resident #1 was sitting in his room eating his breakfast. His appearance was clean and his room was homelike. Resident #1 stated he had no concerns about his care at the facility and his needs were being met. During an interview and observation on 11/20/2023 at 2:25 PM, ADON reviewed Resident #1's care plan and MDS Assessment via EHR. ADON stated that she was sorry that the care plan was not completed and that she was going to fix the care plan immediately. During an interview on 11/20/2023 at 2:35 PM, DON stated she was responsible for completing Resident #1's care plan. When asked about the negative outcome for an incomplete or inaccurate care plan, DON stated that holes in communication in care can cause the resident's needs not to be met. DON stated a verbal report is given at each shift and that is how they keep track of what each resident needs and the care plan is just a paper trail. During an interview on 11/20/2023 at 2:39 PM, LVN A stated that she is familiar with all her residents, so she is aware of their needs, LVN A said she is given a verbal report at each shift on any changes with the residents. When asked about a possible negative outcome for a missed or inaccurate verbal report, LVN A stated that a resident could get hurt. During an interview and observation on 11/20/2023 at 2:53 PM, ADM reviewed Resident #1's care plan via EHR and acknowledged that Resident #1's care plan was not completed . When asked about inaccuracies or incomplete care plans, ADM stated that it was a problem and that she couldn't argue that it was not filled out accurately. Record Review of Care plan policy(no date) revealed .It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 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 455641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete will contain information about the physical, emotional, psychological, psychosocial, spiritual, education and environmental needs as appropriate. It is the purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care . Event ID: Facility ID: 455641 If continuation sheet Page 3 of 3