Health inspection·February 24, 2023

F 0578 Active Orders as of 2-23-2023 with the following order: Level of Harm - Minimal harm or potential for actual harm Order Summary-DNR Active 10-19-2022 Residents Affected - Few Record review of the clinical record for Resident #39's revealed a DNR (dated 10-29-2022 by the qualified relative) in the miscellaneous section under the Advanced Directives. In the section for the Physicians Statement the physician's signature, printed name, and license number was present but there was no date of when the physician signed the document. Record review of the clinical record for Resident #39 revealed under the miscellaneous section under Hospice Intake was a DNR (dated 10-29-2022 by the qualified relative). This DNR also had no date of when the physician signed the document. During an interview on 02-24-2023 at 08:49 AM LVN A reported that if Resident #39 coded she would first assess the resident to confirm that he had coded and since he was a DNR she would notify the hospice nurse and follow her instructions, that she would not code him, she would not initiate CPR. LVN A reported that she would verify his code status in his hospice book, the facility DNR book, or on the computer system. LVN A checked Resident #39's in the facility's DNR book and found Resident #39's DNR. LVN A reviewed the DNR and reported that it was valid. When asked when the physician signed the DNR LVN A reviewed the DNR again and stated, Oh, it does not have a date of when the doctor signed it. LVN A then reported that Resident #39 did not have a valid DNR and that if Resident #39 coded at this time she would get the crash cart and start CPR. During an interview on 02-24-2023 at 10:06 AM LVN A reported that if a DNR was incorrect then a residents or family's wishes may not be followed, and it could result in a lawsuit. During an interview on 02-24-2023 at 09:21 AM the DON verified that Resident #39 was on hospice and was a DNR. The DON reviewed Resident #39's DNR and reported that it was not valid due to not having a date when the physician signed the DNR. The DON reported that they would get it corrected immediately. The DON reported that an invalid DNR can cause issued if the doctor. did not recognize it as valid DNR once activated, the family could say it was not valid if activated, and it could cause issues with the residents wishes. The DON reported that the part time Social Worker was responsible for reviewing all DNR's for correctness. During an interview by phone on 02-24-2023 at 09:05 AM the Social Worker verified that she was the part time Social Worker for the facility. The Social Worker verified that she would review all DNR's for the facility and that she usually reviews each form line by line and that Resident #39 was one of many and she just missed that the physician did not date the form. The Social Worker reported that an incorrect DNR can result in the resident or family not having their wishes followed. Record review of facility provided policy titled Do Not Resuscitate Order, with the date of revision 10-12-2013, revealed the following: Out of Hospital DNR Form: The Out of Hospital DNR form was designed [NAME] the Texas Department of Human Services to comply with the requirements as set forth in the Health and Safety Code for the purposes of instructing Emergency Medical personnel and other health care professionals for forgo resuscitation attempts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 2 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 11. All validly executed DNR order will be honored by the facility Level of Harm - Minimal harm or potential for actual harm 13. For completion of the form, see attached instructions of the out of hospital DNR form the TAHC Residents Affected - Few Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 3 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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. Based on observation, interview, and record review; it was determined the facility failed to ensure medications were stored in accordance with currently accepted professional principles on 1 (100/500 Hall Medication cart) of 3 medication carts reviewed for medication storage. 5 loose medications were observed in the bottom of the second drawer of the 100/500 Hall medication cart The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could place residents receiving medication at risk for administration of medication incorrectly or missing doses of medications that could result in ineffective treatment and/or exacerbation of the disease process. Findings include: During an observation on 02-23-2023 at 09:41 AM of the 100/500 Hall medication cart 5 loose pills were noted in the bottom of the second drawer. The observation was completed with LVN A present. LVN A was asked by this surveyor to gather all 5 loose pills and have them identified. On 02-23-2023 at 09:57 AM LVN A reported that the 5 loose pills had been identified as Allopurinol (used to treat Gout/high uric acid), Lisinopril (used to treat high blood pressure), Ropinirole (used to treat Parkinson's-a disorder of the central nervous system that affects movement, often including tremors), Carbamazepine (anticonvulsant-used to prevent or reduce the severity of epileptic fits of other convulsions), and Furosemide (Diuretic-used to treat fluid retention). During an interview on 02-23-2023 at 10:02 AM LVN A (the nurse responsible for the 100/500 Hall medication cart this shift) reported that the 5 loose pills were an issue because residents could have a bad reaction to the medications meaning that they could receive the wrong medications if the nurses would not check the back of the pill cards for loose pills that stick and do not get administered. LVN A feels that residents could miss doses of medications and that it could affect their condition. LVN A reported that the nurses are supposed to check their carts every shift, but she got busy this shift and did not have time to check the cart. During an interview on 02-23-2023 at 10:13 AM ADON B verified that she was responsible for checking the carts daily, that she checked them Monday and they were good, that the facility had a call-in Tuesday, and she did not have time due to working the floor, and with the survey she had been busy and did not get to check the carts. ADON B reported that usually she would not find any issues and the five loose pills were abnormal. ADON B did feel that 5 loose pills were an issue and was not acceptable. ADON B reported that the facility would not be aware if the residents received their needed medications. ADON B reported that if a resident did not receive one medication dose it would probably not affect their treatment or care but that the residents do need their medications. ADON B reported that the facility would address the issue of the loose pills. During an interview on 02-24-2023 at 10:08 AM the DON reported that the facility had the night shift check each cart each shift for cleanliness and loose medications and the ADON does an audit of each cart on Mondays and that due to this process this facility does not have any issues with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 4 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 missing any medications, that the five loose pills were a onetime occurrence and that the residents did not miss any doses of medications. The DON reported that this facility has never had any residents report any missed medications and that if the resident's medication were short and needed to be filled early that the facility would pay for the refill but that has not occurred. The DON felt that there were no negative consequences from the loose medications. Residents Affected - Few During an interview on 02-24-2023 at 12:52 PM the DON reported that they only had the one med storage policy that she had provided to this surveyor and did not have any other polices on medication cart safety/care. Record review of the facility provided policy titled Recommended Medication Storage revised 7-2012 revealed no information related to this deficiency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 5 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 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, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Residents Affected - Many A. Ensure stored food was properly labeled, dated and stored B. Ensure that all expired food is discarded after 7 days. C. Ensure staff followed proper hand hygiene processes. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation in the facility kitchen on 02/22/2023 at 9:23 AM, revealed: 02/22/23 09:22AM Entered into kitchen area, observed flat of eggs on grill of stove. Heat coming from stove/oven area. 02/22/23 09:23AM observed scrambled, poached eggs left out on roller cart at room temperature. There is also pork sausage stored on same cart at room temperature. Dry cereal in bowls left on counter uncovered. 02/22/23 09:24AM Observed tomato juice in a juice cup with lid with no date, tub that juice was in was labeled with a date of 02/05/2023. 02/22/02/22/23 09:28AM observed cereal in zip lock bag with a date 11/14 (No year noted on bag) 02/22/23 11:23AM observed expired food in freezer with an expiration date of 05/09/2022. 02/22/23 11:30am observed a bottle scrubber, rag that appeared to be dirty, and a used glove leaning against what appeared to be clean pitchers on a lower shelf in the kitchen. There also appeared to be a mask, and employee personal cup on the top shelf of this unit of shelving. 02/22/23 11:44AM Observed what appeared to be a pork chop in a zip-lock bag lying on a cart at room temperature. Unaware of how long product had been there. 02/22/23 11:45AM observed cherry cobblers prepared and uncovered on serving trays. Cherry cobblers still uncovered. During an observation of kitchen on 02/22/23 09:32am hand washing sink with roll of unused trash bags in the sink as well as on the back of the sink area. This was the only hand washing sink in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 6 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 kitchen Level of Harm - Minimal harm or potential for actual harm During an observation on 02/22/23 12:23 PM CNA D wiped brow and played with the miniblind cord. No hand washing or sanitation was performed between the passing of trays. CNA D did not wash or sanitize throughout the delivery of lunch trays. Residents Affected - Many During observation on 02/22/23 12:28 PM CNA D assisting resident with eating and did not wash or sanitize hands before assisting resident with eating. CNA D then turned to resident behind her, adjusted clothing protector under residents' hair. CNA D then returned to original resident and did not wash or sanitize hands before assisting resident to eat. During an interview on 02/22/23 01:04 PM CNA D stated that we are supposed to sanitize our hands in between each resident's tray. Asked why this was not performed. CNA D stated, I was nervous because you guys were watching us. CAN D was asked what a negative outcome could be from not performing this task, her response was infection or cross contamination. During an interview on 02/22/23 02:43pm interviewed Dietary Aide D regarding the warm up of the dishwashing machine. Dietary Aide D stated that it does take some time for the machine to be ready to wash dishes. Dietary Aide D stated that she runs the machine a couple of times before washing any dishes. During an interview on 02/22/2023 at 3:27 PM, [NAME] C was asked how long food is to be stored in the refrigerators and freezers once they have been opened, she stated that it was to be only 7 days from the date written on the packaging. Also asked if plates and bowls of food were to be set out on trays without coverings, [NAME] C stated no they should be covered once the plates or bowls are made. When asked why this wasn't done with the dessert [NAME] C stated that the Dietary Aide D does not normally work with her, and she is not sure why they were not covered. During an interview on 02/23/2023 at 3:38pm, ADM was asked about the hiring of a Dietary Manager. ADM stated that a new one had been hired and was starting the following week. Was unable to interview department manager due to facility not having one. Record review of the facility's policy titled Food Safety with a date of 2012, documented: 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained. 8. Do not keep potentially hazardous food in refrigerator past the labeled expiration date. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 7 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Record review of facility policy dated 2012 titled Hand Washing revealed the following: Residents Affected - Many We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispenser, and paper towels, and should have a sign posted conspicuously near or above wash basin. 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. c. Wet hands d. Deliver soap in palm e. Lather up soap f. Cup the fingertips within the palms of the hands and rub vigorously g. Interlock fingers and work them back and forth and side to side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 8 of 9 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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 h. Level of Harm - Minimal harm or potential for actual harm Scrub back of hands, wrists or lower arms. i. Residents Affected - Many Rinse hands, wrists, and lower arms thoroughly 3. Dry hand sand arms with paper towel, then turnoff the faucets with the paper towel 4. Discard used paper towels in trash receptacle 5. Food preparation sinks are not to be used for hand washing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 9 of 9