Health inspection·July 30, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #11's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull) with loss of consciousness of unspecified duration, injured in unspecified motor-vehicle accident, restlessness and agitation, and irritability and anger. Residents Affected - Some Record review of Resident #11's MDS tab in the EHR revealed his last completed quarterly had an ARD of 04/30/24 and he had an incomplete quarterly with ARD of 05/24/24. These quarterly MDS' were created by MDS LVN. Record review of Resident #11's quarterly MDS completed on 05/01/24 section C revealed no BIMS score as Resident #11 was rarely to never understood. The staff assessment for mental status revealed Resident #11 had severely impaired cognition. Record review of Resident #11's care plan revealed it was completed on 07/04/24. 3. Record review of Resident #18's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, non-st elevation (NSTEMI) myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blockages of the arteries), anxiety disorder, 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 suicide attempt. Record review of Resident #18's MDS tab in the EHR revealed his last completed quarterly had an ARD of 02/05/24 and he had an incomplete quarterly with ARD of 05/07/24. The complete quarterly was completed by ADON and previous DON. The incomplete quarterly was created by MDS LVN. Record review of Resident #18's quarterly MDS completed on 02/21/24 section C revealed no BIMS score as Resident #18 was rarely to never understood. The staff assessment for mental status revealed Resident #18 had moderately impaired cognition. Record review of Resident #18's care plan revealed it was completed on 07/12/24. 4. Record review of Resident #21's admission record dated 07/29/24 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 hypertension (high blood pressure). Record review of Resident #21's MDS tab in the EHR revealed her last completed quarterly had an ARD of 05/04/24 and she had an incomplete quarterly with ARD of 06/14/24. The complete quarterly was completed by previous DON. The incomplete quarterly was created by MDS LVN. Record review of Resident #21's quarterly MDS completed on 05/17/24 section C revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #21's care plan indicated it was completed on 06/18/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 2 of 16 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 07/30/2024 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 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), 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 hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's MDS tab in the EHR revealed his last completed quarterly had an ARD of 02/18/24 and he had two incomplete quarterly MDS' with ARDs of 05/20/24 and 06/14/24. The complete quarterly was completed by ADON and previous DON. The incomplete quarterlies were created by MDS LVN. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Record review of Resident #31's care plan revealed a completion date of 06/06/24. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she does not visit the facility or live in the region. During an interview on 07/29/24 at 10:31 AM MDS LVN stated she was responsible for all resident MDS'. She stated she used the RAI Manual as the policy for MDS completion. She stated she had 14 days after the ARD to complete a quarterly MDS. She stated she knew several MDS' in the facility were past the 14-day mark because she was working on finding some information to ensure she was coding correctly. She stated she was not sure of a negative outcome to residents of not completing MDS' timely. MDS LVN stated, I mean for compliance we need to try to get them done timely. She stated MDS assessments determined the funding the facility received. MDS LVN stated not having the correct funding could affect care of resident. She stated ADON did the actual interviews with residents in the facility and she (MDS LVN) used that information to complete the MDS'. During an interview on 07/29/24 at 11:20 AM ADON stated she was responsible for the MDS' in the facility for a short time, but she felt overwhelmed by doing both jobs. She stated of MDS LVN, She should look at my assessments and do MDS' from there. ADON said a possible negative outcome of not completing MDS' timely was, We won't get paid and it could affect resident care because we couldn't pay our staff. During an interview on 07/30/24 at 09:45 AM LVN A stated not completing MDS' timely would affect our funding. She stated she was not sure what impact the affected funding would have on residents. During an interview on 07/30/24 at 09:47 AM ADM stated resident care was based on the information in the care plan which was based on the information in the MDS. She asked, How do we know what care we are providing because the care plan is built off of the MDS? ADM stated the MDS' not being completed timely would also affect the funding of the facility. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11 dated October 2023 revealed the following regarding quarterly MDS': . The MDS completion date must be no later than 14 days after the ARD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 3 of 16 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 07/30/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review for 2 (Resident #5 and Resident #11) of 12 residents reviewed for PASRR. 1. The facility failed to refer Resident #5 for PASRR level II review following a diagnosis of bipolar disorder one day after he was admitted to the facility. 2. The facility failed to refer Resident #11 for PASRR level II review following a diagnosis of psychotic disorder almost 6 years after he was admitted to the facility. These failures could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: 1. Record review of Resident #5's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode mixed, bipolar disorder current episode depressed severe without psychotic features, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #5's diagnosis report dated 07/28/24 revealed the diagnoses of bipolar disorder current episode mixed, and major depressive disorder had an onset date of 07/19/23. Resident #5's diagnosis of bipolar disorder current episode depressed severe without psychotic features had an onset date of 07/20/23. Record review of Resident #5's annual MDS completed on 06/20/24 Section C revealed a BIMS score of 15 which indicated intact cognition. Section E indicated Resident #5 rejected evaluation or care 1-3 days of the look back period. Section I indicated Resident #5 had diagnoses of depression and bipolar disorder. Section N indicated Resident #5 was taking antidepressant and antipsychotic medications. Record review of Resident #5's care plan completed on 05/13/24 revealed Resident #5 had a psychosocial well-being problem r/t bipolar disorder. He was receiving trazadone, Seroquel, and lithium to treat bipolar disorder. Resident #5 was noted to have a mood problem r/t DEPRESSION. He was noted to have verbal behaviors in that, [Resident #5] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Behaviors are related to: Mental/Emotional illness. The care plan contained the following focus area initiated on 07/19/23 [Resident #5] uses psychotropic medications . related to depression, bipolar disorder. Record review of Resident #5's order report date 07/28/24 revealed the following orders: Order start date 07/19/23 Lithium (antipsychotic medication) Carbonate Oral Tablet 300 MG (Lithium Carbonate) Give 300 mg by mouth three times a day related to BIPOLAR DISORDER CURRENT EPISODE MIXED . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 4 of 16 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 07/30/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Order start date 08/09/23 SEROquel (atypical antipsychotic medication) Oral Tablet (Quetiapine Fumarate) Give 300 mg by mouth in the evening related to BIPOLAR DISORDER, CURRENT EPISODE MIXED . Order start date 01/11/24 trazodone (antidepressant medication) HCI Oral Tablet 50 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE . Record review of Resident #5's PASRR Level 1 Screening revealed it was completed on 07/19/23 by an acute care facility employee. Resident #5 was noted to have no evidence or indicator of a mental illness. 2. Record review of Resident #11's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull) with loss of consciousness of unspecified duration, injured in unspecified motor-vehicle accident, restlessness and agitation, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), irritability and anger, and psychotic disorder with hallucinations (severe mental illness including seeing things that are not there). Record review of Resident #11's diagnosis report dated 07/29/24 revealed the onset date for the diagnosis of psychotic disorder with hallucinations was 10/13/23. Record review of Resident #11's quarterly MDS completed on 05/01/24 section C revealed no BIMS score as Resident #11 was rarely to never understood. The staff assessment for mental status revealed Resident #11 had severely impaired cognition. Section E revealed no behaviors. Section I revealed active diagnoses of depression, anxiety disorder, and psychotic disorder. Section N revealed Resident #11 received antipsychotic, antianxiety, and antidepressant medications. Record review of Resident #11's care plan completed on 07/04/24 revealed Resident #11 had a behavior of sliding out of his w/c in the dining room and raising his voice for attention. Interventions listed included resident having no injuries due to behaviors and psychiatrist following behaviors. Resident #11 had sexually inappropriate behaviors r/t grabbing staff as well as physical behaviors r/t anger and poor impulse control. The care plan indicated he had psychosocial well-being and mood problems r/t anxiety and depression. Record review of Resident #11's order summary report dated 07/28/24 revealed the following orders: Order start date 10/13/23 busPIRone (antianxiety medication) HCI Tablet (Buspirone HCI) Give 10 mg by mouth three times a day related to ANXIETY DISORDER . Order start date 01/25/22 Depo-Provera Suspension (birth control used in males to control inappropriate or unwanted sexual behavior in males by lowering testosterone, reducing sex drive, discouraging sexual fantasies, and eradicating sexual obsessions) (medroxyPROGESTERone Acetate) Inject 150 mg intramuscularly one time a day every 14 day(s) related to PERSONALITY CHANGE DUE TO KNOWN PHYSIOLOGICAL CONDITION . Order start date 09/14/22 Paxil (antidepressant medication) Tablet 30 MG (PARoxetine HCl) Give 1 tablet by mouth one time a day for depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 5 of 16 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 07/30/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Order start date 03/01/22 Vortioxetine (antidepressant medication) HBr Tablet 20 MG Give 20 mg by mouth in the evening related to PERSONALITY CHANGE DUE TO KNOWN PHYSIOLOGICAL CONDITION . Record review of Resident #11's PASRR Level 1 Screening revealed it was completed on 12/01/17 by a social worker from an acute care facility. Resident #11 was noted to have no evidence or indicator of a mental illness. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for completing PASRRs. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she did not know Resident #5 had a mental illness. ADON stated, He came (to the facility) from home. We didn't know about that (bipolar disorder) until later. She stated she could not think of a negative outcome of not referring a resident for a PASRR level II when a new diagnosis of mental illness was made. During an interview on 07/30/24 at 09:45 AM LVN A stated if a resident had a new diagnosis of mental illness and was not referred for a PASRR level II the facility might not have proper care for the mental health of the resident. During an interview on 07/30/24 at 09:47 AM ADM stated not having a resident referred for a PASRR level II following a new diagnosis of mental illness could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility; . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. medication orders, including (as necessary) a medical condition or problem associated with each medication; . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 6 of 16 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 07/30/2024 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 record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 (Resident #31) of 12 residents reviewed for preadmission screenings. Residents Affected - Few The facility failed to perform a PASRR for Resident #31 until 27 days after he was admitted . This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) recurrent, and hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's diagnosis report dated 07/29/24 revealed his diagnosis of major depressive disorder had an onset date of 08/09/23. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Section E revealed Resident #31 had verbal behavioral symptoms directed toward others as well as behavior of rejecting care which occurred 1-3 days of the 7-day look back period. Section I revealed Resident #31 had a diagnosis of depression. Record review of Resident #31's care plan completed on 06/06/24 revealed Resident #31 had a diagnosis of Major Depression and was receiving two antidepressant/psychotropic medications. Record review of Resident #31's PASRR Level 1 Screening revealed it was completed by ADON on 09/05/23. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for ensuring PASRRs on new admits were completed. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she could not think of a possible negative outcome of Resident #31 being admitted prior to PASRR completion. During an interview on 07/30/24 at 09:45 AM LVN A stated if a PASRR was not completed prior to or at admission the resident might not receive proper care for mental health. During an interview on 07/30/24 at 09:47 AM ADM stated not having a PASRR completed prior to or at admission could cause harm to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 7 of 16 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 07/30/2024 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 Record review of facility policy titled admission Criteria and dated 2019 revealed the following: Level of Harm - Minimal harm or potential for actual harm . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. Residents Affected - Few Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 3 (Resident #21, Resident #22, and Resident #31) of 12 residents reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #31 until 27 days after he was admitted . This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) recurrent, and hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's diagnosis report dated 07/29/24 revealed his diagnosis of major depressive disorder had an onset date of 08/09/23. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Section E revealed Resident #31 had verbal behavioral symptoms directed toward others as well as behavior of rejecting care which occurred 1-3 days of the 7-day look back period. Section I revealed Resident #31 had a diagnosis of depression. Section N revealed Resident #31 was not receiving any antidepressant medication. Record review of Resident #31's care plan completed on 06/06/24 revealed Resident #31 had a diagnosis of Major Depression and was receiving two antidepressant/psychotropic medications. Record review of Resident #31's order summary report revealed the following orders: Order start date of 08/09/23 traZODone HCI Oral Tablet 50 MG (Trazodone HCI) Give 50 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT . Order start date of 04/23/24 Zoloft Oral Tablet 50 MG (Sertraline HCI) Give 1 tablet by mouth one time a day for depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 8 of 16 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 07/30/2024 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 #31's PASRR Level 1 Screening revealed it was completed by ADON on 09/05/23. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. Residents Affected - Few During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for ensuring PASRRs on new admits were completed. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she could not think of a possible negative outcome of Resident #31 being admitted prior to PASRR completion. During an interview on 07/30/24 at 09:45 AM LVN A stated if a PASRR was not completed prior to or at admission the resident might not receive proper care for mental health. During an interview on 07/30/24 at 09:47 AM ADM stated not having a PASRR completed prior to or at admission could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 9 of 16 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 07/30/2024 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. 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 one of one kitchen observed for food storage, preparation, and distribution. A. The DM did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: During an observation and interview on 7/28/24 at 10:55 am, the DM was observed preparing the pureed foods. The DM changed her gloves then touched various kitchen surfaces including the prep table and the blender. The DM went to the stove and used a ladle to put gravy into the blender. The DM walked back to the prep table and used her hands to remove the chicken from the bone and then placed the chicken into the blender with her gloved hands. The DM picked up the lid for the blender and began to puree the chicken. The DM did not change her gloves or wash her hands. The DM stated she just realized she did not wash her hands or change her gloves. My bad. During an observation and interview on 7/28/24 at 11:05 am, the DM washed her hands and changed her gloves and continued with the pureeing. The DM touched the prep table and picked up the blender lid, and container after it was washed. The DM took the container to the prep able. The DM carried the container to the stove and ladled the corn into the blender container. The DM carried the blender to the prep table, put the lid on the blender container and turned the blender on, The DM pureed the corn then picked up a carton of milk, took the lid off the milk and poured the milk into the corn. The DM put the lid back on the milk and set the container down on the prep table. The DM walked to the shelf and picked up a loaf of bread. The DM opened the loaf of bread and took out a piece of bread from the wrapper with her gloved hand. The DM folded the piece of bread in half with her gloved hands and put the bread into the blender with the corn. The DM did not change her gloves or wash her hands. When asked if she realized she touched the bread with her contaminated hands she stated Dadgum I did it again I should have changed my gloves. The DM stated she was not supposed to touch the food with her hands and was supposed to change gloves between tasks. She stated this could cause cross contamination. During an interview on 7/29/24 at 2:05 pm, the DM, stated she was aware she did not wash her hands between tasks. The DM stated she should have washed her hands and changed her gloves when switching tasks. The DM stated not changing gloves and washing hands could cause food borne illness. The DM stated she trained the staff in hand washing techniques. Record review of facility policy titled, Preventing Foodborne Illness, dated November 2022, revealed, in part: all employees who handle prepare serve food are trained in the practice of safe food handling and preventing food borne illness. Employees must wash hands before coming into contact with any food surfaces, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Gloves are considered single use items and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 10 of 16 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 07/30/2024 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 must be discarded after completing the task for which they are used. Gloves are removed, hands re washed and gloves are replaced. Gloves are worn when directly touching ready to eat foods. Food service employees are trained in the proper use of utensils such as tongs gloves deli paper and spatulas as tools to prevent foodborne illness. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 11 of 16 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 07/30/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #5) of 12 residents who were reviewed for accuracy of medical records. The facility failed to recognize Resident #5's PASRR level 1 was incorrect in that he was positive for mental illness due to his diagnosis of bipolar disorder. This failure could place residents at risk of harm by mentally unstable residents and/or at risk of not having their mental health needs met. Findings Included: Record review of Resident #5's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode mixed, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode depressed severe without psychotic features, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #5's diagnosis report dated 07/28/24 revealed the diagnoses of bipolar disorder current episode mixed, and major depressive disorder had an onset date of 07/19/23. Resident #5's diagnosis of bipolar disorder current episode depressed severe without psychotic features had an onset date of 07/20/23. Record review of Resident #5's annual MDS completed on 06/20/24 Section C revealed a BIMS of 15 score which indicated intact cognition. Section E indicated Resident #5 rejected evaluation or care 1-3 days of the look back period. Section I indicated Resident #5 had diagnoses of depression and bipolar disorder. Section N indicated Resident #5 was taking antidepressant and antipsychotic medications. Record review of Resident #5's care plan completed on 05/13/24 revealed Resident #5 had a psychosocial well-being problem r/t bipolar disorder. He was receiving trazadone, Seroquel, and lithium to treat bipolar disorder. Resident #5 was noted to have a mood problem r/t DEPRESSION. He was noted to have verbal behaviors in that, [Resident #5] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Behaviors are related to: Mental/Emotional illness. The care plan contained the following focus area initiated on 07/19/23 [Resident #5] uses psychotropic medications . related to depression, bipolar disorder. Record review of Resident #5's order report date 07/28/24 revealed the following order: Order start date 07/19/23 Lithium (antipsychotic medication) Carbonate Oral Tablet 300 MG (Lithium Carbonate) Give 300 mg by mouth three times a day related to BIPOLAR DISORDER CURRENT EPISODE MIXED . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 12 of 16 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 07/30/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #5's PASRR Level 1 Screening revealed it was completed on 07/19/23 by an acute care facility employee. Resident #5 was noted to have no evidence or indicator of a mental illness. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. Residents Affected - Few During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for completing PASRRs. She stated the facility did not have a PASRR level II on Resident #5. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she did not know how she missed Resident #5 had a mental illness at the time he was admitted . During an interview on 07/30/24 at 09:45 AM LVN A stated if a resident was positive for mental illness and the PASRR level I was not coded as such, resulting in the resident not receiving a PASRR level II, the facility might not provide proper care for the mental health of the resident. During an interview on 07/30/24 at 09:47 AM ADM stated not having a resident referred for a PASRR level II could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility; . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. medication orders, including (as necessary) a medical condition or problem associated with each medication; . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 13 of 16 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 07/30/2024 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 observations, interviews, 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 4 (LVN B, CNA C, CNA D, and CNA E) of 4 staff members. Residents Affected - Few -LVN B did not don PPE gown before or during performing ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA C did not don PPE gown before or during assisting ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA D did not don PPE gown before or during performing ordered Foley Catheter Care to Resident with unstageable pressure ulcer to sacral area on Resident #187. -CNA E did not don PPE gown before or during observation of Foley Catheter Care to Resident with unstageable pressure ulcer to sacral area on Resident #187. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, and communicable diseases. Findings included: Record review of Resident #187's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to facility on 7/9/24 with diagnoses of essential (primary) hypertension, diabetes mellitus due to underlying condition without complications, retention of urine, unspecified, type 2 diabetes mellitus with diabetic neuropathy, unspecified, hyperlipidemia, unspecified, single subsegmental pulmonary embolism without acute cor pulmonale (a pulmonary embolism occurs when a clump of material, most often a blood clot, gets stuck in an artery in the lungs, blocking the flow of blood.), pressure ulcer of sacral region, unstageable. Record review of Resident #187's Care Plan revealed that it stated Resident #187 needed x1 person assist with ADL's. Resident has a Foley Catheter for urine drainage and wears a Depends for bowel movements. Receives daily wound care to unstageable sacral pressure ulcer. Record review of Resident #187's active order summary report dated 07/29/24 revealed the following orders: Order start date 07/21/24 Cleanse wound to coccyx with [brand name wound cleanser], pack with [brand name wound cleanser] soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. Every shift related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . Order start date 07/29/24 Cleanse wound to coccyx with wound cleanser, pack with wound cleanser soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. every 1 hours as needed related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 14 of 16 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 07/30/2024 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 - Few Order start date 07/29/24 Cleanse wound to coccyx with wound cleanser, pack with wound cleanser soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. every shift related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . Order start date 07/11/24 Protein Oral Liquid (Protein) Give 30 ml by mouth one time a day for wound healing. Order start date 07/10/24 Vitamin C Oral Tablet (Ascorbic Acid) Give 500 mg by mouth two times a day for wound healing. Order start date 07/11/24 Zinc Oral Tablet (Zinc) Give 220 mg by mouth one time a day for wound healing. Order start date 07/09/24 Foley care q shift every shift Foley catheter care each shift. Order start date 07/09/24 Foley catheter: ensure Foley catheter is anchored to resident's leg so as to prevent injury every shift. Order start date 08/09/24 Foley Catheter: Insert 16 French catheter with 30 cc balloon. Every day shift starting on the 9th and ending on the 10th every month Foley Catheter: Insert 16 French catheter with 30 cc bulb to closed bedside drainage. Change monthly on the 9th. Observation on 7/28/24 at 11:35 AM revealed LVN B and CNA C did not don a PPE gown before or during performing wound care to an unstageable pressure ulcer to the sacral area of Resident #187. The PPE gown was not present inside the room or in the hallway outside the door of Resident #187's room. Observation on 7/29/24 at 9:58AM revealed CNA D and CNA E did not don a PPE gown before or during performing ordered Foley Catheter care to Resident #187 who had an unstageable pressure ulcer to his sacral area. The PPE gown was not present inside the room or in the hallway outside the door of Resident #187's room. In an interview on 7/29/24 at 10:06AM with CNA D she stated she had never been told to wear a gown as part of PPE when giving Foley Catheter care. She did not know what Enhanced Barrier Precautions (EBP) were. When asked what a negative outcome could be from not donning a PPE gown she stated, You could get something on patient like bacteria. In an interview on 7/29/24 at 10:11AM with CNA E he stated he hand never heard of EBP. He had never been told to wear gown while doing any type of care to Residents. When asked what a negative outcome could be from not donning a PPE gown he stated, Could cause cross contamination. In an interview on 7/29/29 at 10:28AM with LVN A, facilities Infection Preventionist, she stated she had never heard of Enhanced Barrier Precautions (EBP). When asked what a negative outcome could be from not donning a PPE gown she stated, I haven't taught anyone about this. We didn't know. A negative outcome could be cross contamination. In an interview on 7/29/24 at 10:32AM with the ADON she stated she hadn't heard of Enhanced Barrier Precautions (EBP) until today. When asked what a negative outcome could be from not donning a PPE gown she stated, Carrying germs from one resident to another. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 15 of 16 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 07/30/2024 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 - Few In an interview on 7/29/24 at 10:44 AM with the ADM she stated she had never heard of Enhanced Barrier Precautions (EPB). She stated, Our best practice act person has been here twice and didn't tell us about it. When asked what a negative outcome could be from not donning a PPE gown she stated, Infection control. Getting germs on you and contaminate another resident. In an interview on 7/29/24 at 11:31AM with CNA C by phone, she stated she had never been told to wear a gown when performing any kind of personal care to residents. She stated she was never told about Enhanced Barrier Precautions (EBP.) When asked what a negative outcome could be from not donning a PPE gown she said, It could spread infection or germs. In an interview on 7/29/24 at 5:29PM with LVN B by phone, she stated no one told her to wear a gown when giving care to residents and had not been informed of Enhanced Barrier Precautions (EPB). When asked what a negative outcome could be from not donning a PPE gown she stated, Giving an infection to a resident. Record review of CMS QSO-24-08-NH dated 03/20/24 revealed the following, . In July 2022, the CDC released updated EBP recommendations for 'Implementation of PPE Use in nursing homes to prevent spread of MDROs,' and therefore, CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. Record review of facility provided policies and procedures for Infection Prevention and Control Program dated 12/2023 states: Policy Interpretation and Implementation .2. The program is based on accepted nation infection prevention and control standards. 4. Policies and procedures are reviewed and revised as necessary: a. When changes in regulations or professional standards of practice necessitate revisions: 7. Prevention of Infection a. 3. educating staff and ensuring that they adhere to proper techniques and procedures; 7. implementing appropriate enhanced barrier and transmission-based precautions . Record review of facility provided policies for Infection Preventionist dated 9/2022 states: .Responsibilities; 3. The infection preventionist monitors, changes in infection prevention and control guidelines and regulations to ensure that policies, practices, and protocols remain current and aid in preventing and controlling the spread of infection . No In-services on Enhanced Barrier Protection (EPH) were done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455641 If continuation sheet Page 16 of 16