Inspection·August 9, 2023

F 0607 score. The MDS assessment indicated that Resident #1 was not coded for any behaviors. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #1 care plan, revision date of 6/09/23, indicated that Resident #1 was resistance to care related to pinching, scratching, hitting, periods of disorientations and spitting at staff when approaching during care. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause and document behaviors and interventions in behavior log. Residents Affected - Few Record Review of Resident #2 face sheet, dated on 8/14/23, indicated that Resident #2 was a [AGE] year-old female, admitted to the facility on the original administration date of 11/17/22 with a primary diagnose of dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions). Record Review of Resident #2 discharge MDS assessment dated on 6/26/23 indicated that Resident #2 was not coded for any behaviors. The assessment indicated Resident #2 was moderately cognitively impaired with a BIMS score of 9. Record Review of Resident #2 care plan, revision date of 7/03/23, indicated that resident #2 had a behavior problem as related to been bossy to other residents, staff and guest; wants to touch others while she was talking to them, cursing, attention seeking, condescending tone of voice, and packing room belongings. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved and situations and document behavior and interventions in behavior log. Record Review of the progress note, dated on 6/26/23, indicated that Resident #2 was transferred to a different facility on 6/26/23. Record Review indicated that in services were completed for all staff on abuse on 4/2/2023. Record Review of a written statement dated 4/2/23 signed by the Administrator, indicated that the Administrator interviewed LVN B regarding the resident-to-resident incident that occurred on 4/1/23. The administrator stated, in a signed written statement, that she were informed by LVN B of the skin tear injury and bruise on resident #1. The Administrator stated in the written statement that she questioned LVN B if other marks were found on resident #1 and LVN B stated that she did not find no other marks or injuries. During phone interview on 8/08/23 at 11:03 a.m., the family member of Resident #2 stated that the facility informed him about the resident-to-resident alteration that occurred on 4/1/23. The family member of Resident #2 stated that since Resident #2 was diagnosed with dementia, that her activities with dealing with physical aggression had increased. The family member of Resident #2 stated that the facility would normally move her to a room by herself as an intervention. During a phone interview on 8/08/2023 at 02:25 p.m., the Hospitality aide stated that as she were picking up meal trays on the hall on 4/1/23, that she overheard Resident #1 and Resident #2 hollering. The Hospitality aide stated Resident #1 and Resident #2 were roommates. Hospitality aide stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 2 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that when she entered the room she saw both residents, Resident #1 and Resident #2 holding each other by the arms and yelling at each other. The Hospitality aide stated that she yelled down the hall for help and LVN B ran down the hall to assist her. The Hospitality aide stated that she noticed immediately that both residents had bright red blood on their clothing. The Hospitality aide stated that she transferred resident #2 to her wheelchair. The Hospitality aide stated that she noticed a skin tear on Resident #1 right arm. The hospitality aide stated that Resident #2 was immediately moved to a different room. The Hospitality aide stated that she does not know why this happened. The hospitality aide stated that to her knowledge, this was the first incident between Resident #1 and Resident #2. The Hospitality aide stated that this incident was report to the DON and the Administrator on the same day. During a phone interview on 8/08/2023 at 2:33 p.m., LVN B stated that she ran down the hall to assist the Hospitality Aide who was yelling for help. LVN B stated that upon entering Resident #1 and Resident #2 room that she saw both residents, Resident #1 and Resident #2 holding each other by the arms, yelling out loud. LVN B stated that she immediately separated Resident #1 and Resident #2. LVN B stated that she assisted resident #2 to her wheelchair then moved Resident #2 to a different room across the hall. LVN B stated that upon assessing Resident #1, she immediately noticed that Resident #1 had a significant skin tear on her right arm that was bleeding and bruising on right hand that appeared purple in color. LVN B stated that upon assessing Resident #2 that she noticed that Resident #2 had a skin tear underneath her arm that appeared to be an old skin tear with dried edges and had no new injuries. LVN B stated there were not any aggressions in the past between Resident #1 and Resident #2. LVN B stated she does not know why this happened. LVN B stated that this incident was reported to the DON and Administrator on the same day of the incident. During a phone interview on 8/09/2023 at 11:55 p.m., the DON stated the different types of abuse were physical, verbal, emotional and sexual. The DON stated that the Administrator was the abuse coordinator. The DON stated that resident to resident altercations was considered abuse. The DON stated that abuse should be reported immediately within 2 hours. The DON stated that she was not fully informed of the full details of this incident, which was why she did not report it timely. The DON stated that the staff were aware that they should report directly to the Administrator and then report to her as secondary. The DON stated that she were made aware of this incident on 4/1/23 while at home recovering from COVID. The DON stated that she did not follow up with the Administrator regarding this incident. The DON stated that reporting was important to ensure that the resident was safe. An attempted interview on 8/9/23 at 12:32 p.m. and on 8/9/23 at 1:02 p.m., the Administrator was not reachable by telephone for interviewing purposes after 2 unsuccessful calls with call back requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 3 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 (Resident #1 and Resident #2) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 24 hours of being notified of resident to resident altercation for Resident #1 and resident #2. This failure to report could place the residents at risk for abuse. Findings included: Record Review of the Policy and Procedures for Abuse, Neglect and Exploitation dated 2/01/2021 indicated that (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any responsible suspicion of a crime against an individual who is a resident of or is receiving care from the facility (B) Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Record Review of the Provider Investigation Report dated on 4/06/23 indicated a resident-to-resident incident between Resident #1 and Resident #2 occurred on 04/1/2023 at 6:00 p.m. The report indicated the hospitality aide and charge nurse found Resident #1 and Resident #2 holding each other by the arms and yelling at each other, both residents appeared to have had blood on their clothing. The report indicated Resident #1 was assessed by the charge nurse and found to have had a skin tear on her right arm and a bruise on her right hand. Resident #2 was assessed by the charge nurse found an old skin tear with dried edges, no signs of drainage and no bruises following this incident. The incident was reported to the state agency on 04/3/2023 at 5:32 p.m. Record Review of Resident #1 face sheet, dated on 8/14/23, indicated that Resident #1 was a [AGE] year-old female, admitted to the facility on the original administration date of 9/09/22 with a primary diagnosis of dementia which included (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), hypotension (low blood pressure) and Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements). Record Review of Resident #1 quarterly MDS assessment, dated on 6/21/23, indicated that Resident # 1 was usually understood others and made herself understood. The MDS assessment indicated that resident #1 was unable to complete the interview. The MDS assessment was not coded with a BIMS summary score. The MDS assessment indicated that Resident #1 was not coded for any behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 4 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 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 0609 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #1 care plan, revision date of 6/09/23, indicated that Resident #1 was resistance to care related to pinching, scratching, hitting, periods of disorientations and spitting at staff when approaching during care. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause and document behaviors and interventions in behavior log. Residents Affected - Few Record Review of Resident #2 face sheet, dated on 8/14/23, indicated that Resident #2 was a [AGE] year-old female, admitted to the facility on the original administration date of 11/17/22 with a primary diagnose of dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions). Record Review of Resident #2 discharge MDS assessment dated on 6/26/23 indicated that Resident #2 was not coded for any behaviors. The assessment indicated Resident #2 was moderately cognitively impaired with a BIMS score of 9. Record Review of Resident #2 care plan, revision date of 7/03/23, indicated that resident #2 had a behavior problem as related to been bossy to other residents, staff and guest; wants to touch others while she was talking to them, cursing, attention seeking, condescending tone of voice, and packing room belongings. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved and situations and document behavior and interventions in behavior log. Record Review of the progress note, dated on 6/26/23, indicated that Resident #2 was transferred to a different facility on 6/26/23. Record Review indicated that in services were completed for all staff on abuse on 4/2/2023. Record Review of a written statement dated 4/2/23 signed by the Administrator, indicated that the Administrator interviewed LVN B regarding the resident-to-resident incident that occurred on 4/1/23. The administrator stated, in a signed written statement, that she were informed by LVN B of the skin tear injury and bruise on resident #1. The Administrator stated in the written statement that she questioned LVN B if other marks were found on resident #1 and LVN B stated that she did not find no other marks or injuries. During phone interview on 8/08/23 at 11:03 a.m., The family member of Resident #2 stated that the facility informed him about the resident-to-resident alteration that occurred on 4/1/23. The family member of Resident #2 stated that since Resident #2 was diagnosed with dementia, that her activities with dealing with physical aggression had increased. The family member of Resident #2 stated that the facility would normally move her to a room by herself as an intervention. During a phone interview on 8/08/2023 at 02:25 p.m., the Hospitality aide stated that as she were picking up meal trays on the hall on 4/1/23, that she overheard Resident #1 and Resident #2 hollering. The Hospitality aide stated Resident #1 and Resident #2 were roommates. Hospitality aide stated that when she entered the room she saw both residents, Resident #1 and Resident #2 holding each other by the arms and yelling at each other. The Hospitality aide stated that she yelled down the hall for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 5 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few help and LVN B ran down the hall to assist her. The Hospitality aide stated that she noticed immediately that both residents had bright red blood on their clothing. The Hospitality aide stated that she transferred resident #2 to her wheelchair. The Hospitality aide stated that she noticed a skin tear on Resident #1 right arm. The hospitality aide stated that Resident #2 was immediately moved to a different room. The Hospitality aide stated that she does not know why this happened. The hospitality aide stated that to her knowledge, this was the first incident between Resident #1 and Resident #2. The Hospitality aide stated that this incident was report to the DON and the Administrator on the same day. During a phone interview on 8/08/2023 at 2:33 p.m., LVN B stated that she ran down the hall to assist the Hospitality Aide who was yelling for help. LVN B stated that upon entering Resident #1 and Resident #2 room that she saw both residents, Resident #1 and Resident #2 holding each other by the arms, yelling out loud. LVN B stated that she immediately separated Resident #1 and Resident #2. LVN B stated that she assisted resident #2 to her wheelchair then moved Resident #2 to a different room across the hall. LVN B stated that upon assessing Resident #1, she immediately noticed that Resident #1 had a significant skin tear on her right arm that was bleeding and bruising on right hand that appeared purple in color. LVN B stated that upon assessing Resident #2 that she noticed that Resident #2 had a skin tear underneath her arm that appeared to be an old skin tear with dried edges and had no new injuries. LVN B stated there were not any aggressions in the past between Resident #1 and Resident #2. LVN B stated she does not know why this happened. LVN B stated that this incident was reported to the DON and Administrator on the same day of the incident. During a phone interview on 8/09/2023 at 11:55 p.m., the DON stated the different types of abuse were physical, verbal, emotional and sexual. The DON stated that the Administrator was the abuse coordinator. The DON stated that resident to resident altercations was considered abuse. The DON stated that abuse should be reported immediately within 2 hours. The DON stated that she was not fully informed of the full details of this incident, which was why she did not report it timely. The DON stated that the staff were aware that they should report directly to the Administrator and then report to her as secondary. The DON stated that she were made aware of this incident on 4/1/23 while at home recovering from COVID. The DON stated that she did not follow up with the Administrator regarding this incident. The DON stated that reporting was important to ensure that the resident was safe. An attempted interview on 8/9/23 at 12:32 p.m. and on 8/9/23 at 1:02 p.m., the Administrator was not reachable by telephone for interviewing purposes after 2 unsuccessful calls with call back requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 6 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 1 (Resident #3) residents reviewed for medication storage. 1. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #3 had a medication cup with 4 tablets and 1 capsule sitting on top of her dresser. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: During an observation on 8/8/2023 at 10:20 AM revealed Resident #3 had a clear plastic medication cup with 4 tablets and 1 capsule sitting by a clear plastic cup of water on top of her dresser. Resident #3 stated the medication belonged to her roommate however, records indicated resident # 3 didn't have a roommate. Record review of face sheet, dated 10/12/2022, revealed Resident #3 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.), Alzheimer's disease with late onset (Alzheimer's disease was a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. Alzheimer's disease that develops when someone was 65 or older was late onset, generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life), and essential (primary) hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). Record review of Resident # 3's care plan, dated 1/13/2022, did not address medications left at bedside. Record review of the MDS assessment, dated 6/10/2023, revealed Resident #3 had a BIMS score of 9 (moderately impaired cognition). The assessment indicated Resident #3 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of the MAR, dated 8/1/2023, indicated Resident #3 was ordered to receive Amlodipine 5mg 1 tablet in the morning with instructions to hold medication if systolic blood pressure was less than 100 mmhg and diastolic was below 60 mmhg. Losartan 10mg 1 tablet in the morning with instructions to hold medication if systolic blood pressure was less than 100 mmhg and diastolic was below 60 mmhg. Gabapentin 300mg 1 tablet by mouth two times a day. Namenda 10 mg 1 tablet by mouth two times a day. During an interview on 8/9/2023 at 10:47 a.m., LVN A stated there were no residents on hall 300 with the ability to self-administer medications. LVN A stated the requirement for a resident to be able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 7 of 8 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 455985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarksville Nursing Home 300 E Baker St Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to self-administer medications was that they must know what medications they take, the strength of the medication, what the medication was for, and how to take the medication. LVN A stated people who were unable to self-administer medications should not have them at bedside. LVN A stated after 14 years she has never left medications at bedside. LVN A stated she had observed Resident #3 put the cup with the medication to her mouth and had the cup of water in the other hand. LVN A stated she observed the pills going into Resident #3's mouth, and LVN A stated she was called out into the hall. LVN A stated she left the room as the pills were going into Resident #3's mouth. LVN A stated if she had seen medications left at the bedside she would collect the medication, assess the resident, notified charge nurse, notify the doctor, monitor the resident, get labs if ordered by the doctor, and notify the family. LVN A stated it was important to not keep medication at the bedside in case of overdose. LVN A stated if another resident was to take the medication or if a child comes into the facility and take the medication. LVN A stated it was for community safety. During an interview on 8/9/2023 at 11:30 a.m., the DON stated to ensure medications were not left at bedside different department heads would make rounds. The DON stated the department heads made rounds at 9:00 a.m., yesterday. The DON stated after the medication was found at bedside, she did a Qapi and in-service. The DON stated she expects staff to ensure medications aren't left at bedside. The DON stated department heads would monitor that medications were not left sitting at bedside by making rounds in the morning. The DON stated each department head will take a hall after every med pass to ensure no medication was left. Record review of the 'Medication - treatment Administration and Documentation Guidelines policy, revised date 2/2/2014, revealed verify and provide medication or treatment focused assessment i.e. BP. P wound measurement as indicate by manufactures guidelines or physician orders. Administer the medication according to the physician order. Document initials and/or signature for medication administration on the MAR or TAR immediately following administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455985 If continuation sheet Page 8 of 8