Inspection·April 25, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm give 250 ml via G-Tube one time a day related to encounter for attention to gastrostomy **Hold for residual >200ml** with 100 ml water at 1:00 PM. Start date: 02/23/22 Record review of Resident #1's TAR tube feeding was missed on 3/6/23 at 1300 (1:00pm) and was given at 1730 (5:30 PM). Residents Affected - Few During an interview on 04/25/23 at 11:40 AM with the DON, when asked if the DON failed to give Resident #1 her tube feeding on 3/6/23 at 1:00 pm, she stated, I failed to see it (order for tube feeding). The DON stated this was her first time taking care of Resident #1 and she was new to the facility. The DON stated I was brand new and needed to be trained on the floor, unfortunately that's what happened. The DON stated a negative outcome to the resident could have been weight loss and skin issues. The DON stated I'll admit I made a mistake. Resident #1 failed to receive her tube feeding at 1:00pm on 3/6/23. The facility ensured she got her calories for the day. During an interview on 4/25/23 at 2:37 PM with the ADON when asked how did the DON know she missed the tube feeding at 1:00pm on 3/6/23, she stated I was the one that found the error and notified the DON immediately. The ADON stated she noticed the tube feeding was to be delivered at 1:00 PM and discovered around shift change that the tube feeding had not been given to Resident #1, which was around 5:00 PM. She notified the MD and received an order to give Resident #1 an additional feeding. The ADON stated the resident did receive all her calories for the day, it was just later in the day and into the evening when she received all her caloric intake. Resident #1 receives all caloric intake via gastrostomy tube. Record review of the facility's, undated, policy titled Enteral Nutrition revealed the following: Policy .Adequate nutrition support through enteral nutrition is provided to residents as ordered . Policy Interpretation and Implementation . 4.) Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary . 10.) Enteral feedings are scheduled to try to optimize resident independence whenever possible (for example., at night or during hours that do not interfere with the resident's ability to participate in facility activities.) 11.) The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. Enteral nutrition product . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 2 of 5 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 04/25/2023 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 0693 d. Level of Harm - Minimal harm or potential for actual harm Administration method . 13) Residents Affected - Few Staff caring for resident with feeding tubes are trained on potential adverse effects of tube feeding . 17) Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 3 of 5 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 04/25/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and 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 1 of 1 (Resident #1) resident reviewed for infection control. Residents Affected - Few CNA B failed to use proper hand hygiene techniques when providing incontinence care for Resident #1. This failure could place residents at risk of being exposed to the spread of viral infections, secondary infections, tissue breakdown, communicable disease and feelings of isolation related to poor hygiene. Findings include: Record Review of Resident # 1's face sheet, dated 4/25/23, revealed a [AGE] year-old female who was admitted to facility on 2/23/22 with diagnoses which included, but were not limited to, Cerebral palsy (group of disorders that affect movement and muscle tone or posture), gastrostomy tube (feeding tube), intermittent explosive disorder (explosive eruptions occur, suddenly with little or no warning), urinary tract infection, muscle weakness, developmental disorder of speech and language and constipation (infrequent, irregular or difficult evacuation of the bowels). Record Review of Resident #1 quarterly MDS, dated [DATE], revealed a BIMS of 99 which indicated severely impaired cognition. The MDS revealed the resident required extensive assistance with 2 persons assistance with all ADL's. Record review of Resident #1 care plan, last reviewed 2/22/23, revealed Resident #1 had bladder and bowel incontinence. Interventions include, but not included: ACTIVITIES: notify nursing if incontinent during activities. INCONTINENT care frequently and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, Monitor/document/report to MD PRN if possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects. Check resident frequently and assist with toileting as needed. Provide peri care after each incontinent episode. Report any skin change to the nurse immediately. During an observation on 4/25/23 at 1:30 PM, CNA A and CNA B assisted Resident #1 with incontinence care. CNA A placed all supplies on the bedside table. CNA A closed the curtains and door for privacy. CNA A and CNA B washed their hands and placed gloves on their hands. CNA B picked up Resident #1, in a scoop lift technique, and placed Resident #1 onto the bed. CNA A and CNA B turned Resident #1 onto each side to remove pants and placed a blanket over her peri-area for privacy. CNA B performed peri-care using wipes from front to back. CNA B took gloves off and placed them into a receptacle. CNA B rolled Resident #1 onto her side and cleaned her anal area from front to back. CNA B removed the dirty brief and threw it away into a receptacle. CNA B picked up gloves and went to place them on and one glove broke. CNA B took the glove off and threw it away. CNA B picked up a new gloves and placed on hands. CNA B did not wash hands or use ABHR prior to applying new gloves. CNA B placed a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 4 of 5 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 04/25/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brief onto Resident #1 and rolled Resident #1. CNA A and CNA B rolled Resident #1 to each side to pull her pants back into place. CNA B picked up Resident #1 in a scoop lift technique and placed Resident #1 back into her wheelchair. CNA's A and B left Resident #1 in a comfortable position. During an interview on 4/25/23 at 2:31 PM, CNA B stated she did a horrible job with incontinence care. She stated she felt she did 'everything' wrong. CNA B stated I did not sanitize my hands when I changed my gloves. I should have stopped and said I need to stop and sanitize my hands. During an interview on 4/25/23 at 3:04 PM, CNA A stated this was not our best incontinence care. We were always asked to show the state how good we were. CNA A stated she felt like they missed a lot. CNA A stated CNA B did not sanitize her hands when she changed her gloves. Record review of the facility's undated, Nurse Aide Incontinence Care Proficiency Assessment competency revealed Place in employee's personnel file when complete . Washes hands/Changes gloves Record review of the facility's Infection Control Plan: Overview, dated 10/2022, stated .Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infection and prevent cross-contamination FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675016 If continuation sheet Page 5 of 5