Health inspection·February 9, 2023

F 0656 Review of Resident #1' Order Summary dated 2/8/23 revealed the following orders: Level of Harm - Minimal harm or potential for actual harm Change O2 tubing and humidifier bottle every night shift every Thursday for oxygen use ensure that tubing is dated when changed (order date 12/05/22, start date 12/08/22). Residents Affected - Some Monitor O2 saturation. Notify physician if SpO2 falls below 90% every shift (order date 12/05/22, start date 12/05/22). O2 @ 3LPM via NC. Monitor O2 saturation and notify MD if SpO2 falls below 90% as needed for low oxygen blood saturations/wheezing (order date 12/05/22, start date 12/05/22). Record Review of Resident #1's care plan dated 11/08/2022 did not address the use of oxygen. Review of Resident #1's Care Plan, last revised 11/8/22, revealed (in part): Focus - Resident is at risk for respiratory compromise secondary to dx of COPD; Goal - Resident will maintain her current respiratory status during the next 90 days; Interventions - Monitor Resident for SOB, cyanosis, fatigue. Monitor respiratory rate, lung sounds PRN. Resident #9 Review of Resident #9's admission Record dated 2/9/23 revealed: She was an [AGE] year-old female admitted to the facility 10/05/22 with diagnoses which included vascular dementia, hypertension, cerebral ischemia, pressure ulcer of the sacral region stage 3, pressure ulcer of left heel stage 4, neuralgia and neuritis. Review of Resident #9's Quarterly MDS assessment dated [DATE] revealed: She scored 3 out of 15 on her mental status exam indicating severe cognitive impairment. She had 3 falls reported since the last assessment. Daily use of bed alarm and chair alarm were documented on the quarterly MDS assessment. Review of Resident #9's Order Summary dated 2/9/23 revealed the following orders: Alarming pressure mat to bed to alert staff of attempted unassisted transfers every shift for poor safety awareness related to vascular dementia (order date 2/8/23, start date 2/8/23). Record Review of Resident #9's care plan dated 02/06/2023 did not address bed alarm as an intervention. Resident #13 Review of Resident #13's admission Record dated 2/9/23 revealed: She was a [AGE] year-old female admitted to the facility 6/28/22 with diagnoses which included dementia, peripheral vascular disease, hypertension, aphasia, Alzheimer's Disease with late onset, major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 2 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 depressive disorder, and insomnia. Level of Harm - Minimal harm or potential for actual harm Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed: She scored 3 out of 15 on her mental status exam indicating severe cognitive impairment. Residents Affected - Some She had no reported falls since the last assessment. Daily use of bed alarm and chair alarm were documented in quarterly MDS assessment. Review of Resident #13's Order Summary dated 2/9/23 revealed the following orders: Alarm to wheelchair to alert staff if resident attempts to get up without assistance d/t lack of safety awareness every shift related to dementia (order date 2/8/23, start date 2/9/23). LAL mattress with bolsters to bed set on comfort setting 1 every shift for skin protection (order date 6/28/22, start date 6/28/22). Low bed with mat every shift (order date 6/28/22, start date 6/28/22). Pressure alarm to bed to alert staff of attempts to transfer unassisted every shift for fall prevention (order date 2/8/23, start date 2/9/23). Record Review of Resident #13's care plan dated 01/17/2023 did not address bed alarm as an intervention. Resident #24 Review of Resident #24's admission Record dated 2/9/23 revealed: He was an [AGE] year-old male originally admitted to the facility 8/7/20 with the most recent admission date of 1/13/23. He had diagnoses which included dementia, Type 2 Diabetes Mellitus, non-pressure chronic ulcer of the right foot, benign prostatic hyperplasia, repeated falls, major depressive disorder, hypertension, history of heart attack, and chronic kidney disease stage 3. Review of Resident #24's Quarterly MDS assessment dated [DATE] revealed: He scored 3 out of 15 on his mental status exam indicating sever cognitive impairment. He was a high risk for developing pressure ulcers. He had no unhealed pressure ulcers at the time of the assessment. He had a diabetic foot ulcer at the time of the assessment. He used pressure reducing devices for his chair and bed, and application of ointment /medication for skin and ulcer treatment. Daily use of a bed alarm was documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 3 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Use of a chair alarm was not documented. Level of Harm - Minimal harm or potential for actual harm Review of Resident #24's Order Summary dated 2/9/23 revealed: Residents Affected - Some Admit to this nursing facility under care of Dr. X for wound care, dementia, and atherosclerotic heart disease (order date1/13/23). Alarming pressure mat to bed every shift to alert staff to unassisted transfers poor safety awareness related to dementia, check for function and placement Q shift (order date 1/13/23, start date 1/13/23). Pressure alarm to wheelchair to alert staff of attempts to transfer unassisted due to poor safety awareness ensure proper placement and function every shift for resident safety related to dementia (order date 2/8/23, start date 2/9/23). Prevalon boot to right foot when up to aid in wound healing every shift for wound healing (order date 1/13/23, start date 1/13/23). Tx to right foot ulcer: cleanse wound, and peri wound with normal saline. Apply wound dressing of honey gel, apply secondary wound dressing on silicone bordered foam every dayshift for right foot ulcer (order date 1/13/23, start date 1/13/23). Record Review of Resident #24's care plan dated 01/26/2023 did not address the care of the ulcer/wound on his right foot and Resident #24's care plan dated 01/26/2023 did not address bed alarm as an intervention. Interview on 2/9/23 at 11:35 AM with the Administrator, the DON and Regional Compliance RN, the Administrator stated that MDS nurse was responsible for starting care plans. Regional Compliance RN stated that corporate policy was that the comprehensive care plan was initiated based on the CAAs triggered from the MDS assessment completed by the MDS nurse but once the care plan was started, all clinical staff had access to it in the EMR and was able to update interventions as needed. When asked what should be included on a care plan, the DON stated fall risk, psychotropic medications, diagnoses, pressure ulcer or skin risk, code status, ADLs and interventions for all of the care plan areas. The Regional Compliance RN described fall interventions as things put in place to prevent additional fall occurrences such as bed or chair alarms, fall mats, appropriate footwear. The Administrator stated that falls were part of the facility's quality measures and the missing care plans should have been addressed. The Administrator stated the MDS nurse had been working the night shift to help with staffing shortages and she was unavailable to be interviewed. The DON stated that she was unaware that oxygen use required a care plan of its own, and that having it listed as an intervention for a disease process was sufficient. When asked how staff without access to resident charts knew how to care for resident's oxygen, DON stated they used the [NAME] which was populated by the care plan. The DON stated that if the information regarding oxygen parameters and maintenance was not on the care plan it would not be on the [NAME], she then stated she understood that meant the staff would not know how to properly care for the resident. Review of the facility policy Care Plans and CAA (Care Area Assessments) revision date 5/16/2016 revealed in part: Purpose: The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 4 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident. The policy contained no information on what should be included in each resident's care plan and the facility provided no other policies regarding care plans prior to exit. Event ID: Facility ID: 675038 If continuation sheet Page 5 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 40 residents (Resident #12), 1 of 1 treatment carts and 1 of 1 crash carts reviewed for pharmacy services. 1. The facility failed to ensure the Treatment Cart #1 did not include an opened and expired tube of Aspercreme (creme used for joint pain) for Resident #12. 2. There was an opened and expired bottle of Hibiclens (used for cleansing skin of bacteria) and opened and expired bottle of olive oil. (Used for all residents, as needed). 3. The facility failed to ensure the crash cart #1 did not have expired Sodium Chloride. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Review of Resident #12's face sheet dated 2/9/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Myocardial Infarction (heart attack), Hypertension (high blood pressure), restless leg syndrome (uncomfortable sensation in legs), Polyneuropathy (peripheral nerve damage). Review of Resident #12's care plan dated 01/13/23 stated goal for Resident #12 was that Resident #12 will not have severe pain through the review date, interventions- administer pain medications per MD order. Review of Resident #12's MDS dated [DATE] revealed nothing on pain. Review of Resident #12's physician's orders dated 01/31/22 revealed, Aspercreme Original Crème 10%, to be applied to affected joints topically, as needed for pain. Observation on 02/09/2023 at 08:30 AM, inventory of the treatment cart #1 with the DON revealed one tube of Aspercreme Original Crème 10%-1.25 ounce (expiration date 11/9/22) with Resident #12's name on RX label. Observation on 02/09/2023 at 08:30 AM also revealed the following expired medications (for all residents -standing orders): one 8-ounce bottle of Hibeclens (expiration date 05/22) and a 250ml bottle of olive oil (expiration date 1/23/23). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 6 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/09/2023 at 09:30 AM revealed four disposable vials of Sodium Chloride on Crash Cart #1 (expired 2022). Interview on 02/09/2023 at 11:30 AM with the DON and ADON, The DON stated that night shift was responsible of checking medication cart for expired/discontinued medications. The ADON stated that she usually does spot checks weekly. The ADON stated that she just checked it last week but failed to look at expiration dates. The DON stated that it was important to check expiration dates because the medications can lose potency and therefore resident does not receive desired effect. The DON stated that expired/discontinued medications are to be removed from medication/treatment carts and placed in the locked closet in her office until the pharmacist comes to facility to destroy. Record review of the facility policy titled Medication Storage dated January 20, 2021, reads in part: Medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 7 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 observation, interview, and record review, the facility failed to maintain medical records that are complete and accurately documented for 1 of 3 residents (Resident #240) who were reviewed for documentation of indwelling catheter care. RN A did not document Foley Catheter change for R#240 as required by policy This failure could affect residents who receive catheter care and put them at risk for urinary tract infections. Findings included: Review of Resident #240's electronic face sheet dated 2/09/2023 revealed resident was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses of Hemiplegia (paralysis of one side of body) and Hemiparesis (muscle weakness to one side of body) following Cerebral Infarction (stoke)-affecting left non-Dominant side, Obstructive and Reflux Uropathy (urine cannot drain through the urinary tract) and Kidney Failure. Review of Resident #240's admission MDS dated [DATE] revealed a BIMS of 12 making him moderately cognitively intact. He could understand and be understood. He had no other behavior issues, no rejection to care, required one person assistance with ADLs, and admitted with indwelling catheter. Review of Resident #240's comprehensive plan of care dated 01/12/2023 revealed he had an indwelling urinary catheter related to his obstructive uropathy with urine retention, and under interventions .change urinary catheter per routine schedule as ordered by the physician. Review of Resident #240's physician orders dated 01/19/2023 revealed, Change Foley catheter every 5th day of the month and PRN. During an interview on 02/09/2023 at 9:32 AM, Resident #240 stated that his catheter had not been changed since January 5th when he was residing at another SNF. Resident #240 stated that his catheter should have been changed on February 05, 2023, but this had not occurred. Resident #240 stated that he was not experiencing any pelvic pain at this time and stated that yesterday he observed blood-tinged urine draining through catheter tubing into collection bag. Observation on 02/09/2023 at 9:40 AM of Resident #240's Foley catheter system revealed amber colored urine in tubing and collection bag, excessive sediment observed within the drainage tubing, anti-reflux valve (flap that prevents urine back flow into the drainage tubing) and collection bag. Record review for Resident #240 revealed that on 01/05/2023 RN A entered initials on the facility TAR's (Treatment Administration Record) but did not document changing Resident #240's catheter in the Nursing Progress Notes or the Daily Skilled Notes, per facility policy (Foley Catheter Guideline). Review of RN A's nursing progress notes and Daily Skilled Nursing Note (for Resident #240) dated, 02/03/2023 at 11:19 AM, read in part, Resident has catheter Foley catheter patent and draining amber urine Physician was not contacted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 8 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 Review of RN A's nursing progress notes and Daily Skilled Nursing Note (for Resident #240) dated, 02/05/2023 at 10:44 AM, revealed in part, Resident has catheter Foley catheter is patent and draining yellow cloudy urine with sediment noticeable. During an interview on 02/09/2023 at 10:48 AM, the DON stated that RN A or any nurse working the weekend day shift was to review the TAR's to review for treatments due during their shift. The DON stated that the Med-Aide reviews the MAR's (Medication Administration Record) for medications due during their shift. The DON stated that on 02/05/2023 the RN A was working and was responsible for reviewing the TAR's. The DON stated that there was a Med-Aide working on 02/05/2023 who would be responsible for medication administration. The DON stated that it was her expectation that documentation should be entered into the Nursing Progress Notes and Daily Skilled Notes if a resident has a treatment done (including catheter changes), per facility policy ((Foley Catheter Guideline). The DON stated that this should be completed along with initialing on the TAR's. During an interview on 02/09/2023 at 11:00 AM, RN A stated that he was not able to recall which residents had catheter changes on 02/05/2023. RN A stated that he would have to review the TAR's to see who had catheter changes. During an interview on 02/09/2023 at 11:28 AM, RN A stated that after reviewing TAR's, he determined that two residents were scheduled to have Foley Catheter changes on 02/05/2023. RN A stated that Resident #8 was scheduled to have catheter changed but this had been completed on 02/03/2023, so he did not perform the catheter change. RN A stated that Resident #240 was scheduled for Foley catheter change and stated that he changed Resident #240's Foley catheter. RN stated that he initialed this on the TAR's but did not document in Daily Skilled Note or Nursing Progress Note. RN A asked if he was supposed to document catheter changes in progress notes. Interview on 02/08/23 at 4:09 PM, the Administrator stated that his expectations were that all staff follow facility policies and procedures. Record review of facility policy, Foley Catheter Guideline revised 02/2016, revealed in part, The intent of this policy is to provide guidance for staff caring for residents with urinary catheters and to assist in the prevention of catheter-associated urinary tract infections (CAUTI) The clinical indication for inserting a urinary catheter should be documented in the patient's medical record Catheter care should be provided daily and as necessary Evaluate the color of urine and for urine leaks around the catheter, tubing, or drainage bag Documentation- Physician Orders, Treatment Administration Record, Nurses Progress Notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 9 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 maintain an infection prevention 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 (Resident #16) of 2 residents reviewed for wound care, in that: Residents Affected - Few RN B failed to perform sanitary wound care for Resident #16, per facility policy. This failure could place residents with wounds or pressure ulcers at risk for cross contamination and infection. Findings included: Record review of Resident #16's face sheet, dated 02/09/2023, revealed that she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16's diagnoses included Dementia (Loss of Memory and Intellectual Functioning), Heart Failure, Colostomy (artificial opening in abdominal wall to allow fecal matter to be removed), Protein-Calorie Malnutrition (Inadequate intake of Proteins/Calories), Contracture of Upper Right Arm (Shortening and Hardening of Muscles, Tendons, or other tissue), Kidney Disease, Contractures of bilateral lower extremities and Muscle Wasting. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 3, indicating she had severe cognitive impairment. Resident #16 required total dependence of staff for her activities of daily living. Resident #16 was frequently incontinent of bladder and had a colostomy. Resident #16 had one unstageable pressure injuries presenting as deep tissue injury with pressure reducing device in place for wheelchair and bed. Record review of Resident #16's care plan, dated 01/03/23, revealed in part: Resident #16 has an ADL Self-care deficit due to functional limitations in range of motion and decreased mobility. Resident #16 has a terminal illness and is receiving hospice or palliative care. Resident #16 has the potential for development of a pressure ulcer related to urinary incontinence and impaired mobility with interventions of administer analgesics as needed for discomfort or pain, if necessary to provide pain management prior to dressing changes and repositioning, check frequently for wetness, every two hours and provide incontinence care as needed, weekly skin checks to monitor for redness, pressure sores, open areas, and other changes to skin integrity, pressure reducing devices on bed/chair, including heel pressure reducing device. Record review of Resident #16's physician orders, dated 02/03/23 revealed in part: Apply skin prep to great toe and second toe on Right foot. Cleanse Left lower lateral leg wound with wound cleanser, pat dry, apply Xeroform (Medicated gauze), apply ADB pad (Abdominal Pad used for absorption of discharge from a wound) and wrap with Kerlix (Rolled gauze) every day for wound healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 10 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 Cleanse Right heel with wound cleanser, pat dry, apply Triad cream to affected area and cover with padded dressing. Cleanse right lower coccyx (stage 2 pressure ulcer) with wound cleanser, pat dry, apply barrier cream and cover with foam sacral (Area of the first and second vertebrae-lowest part of spine near buttock) dressing. Residents Affected - Few Observation on 02/07/23 at 2:30 PM revealed Resident #16's door had a sign posted Enhanced Barrier Precautions which stated everyone entering room must: Clean hands (including before entering and when leaving room) Wear gloves and gown with High-Contact Care Activities (dressings, bathing, transferring, changing linens, providing hygiene, assisting with toileting, providing care with central lines/urinary catheters/feeding tubes/trach. Put on gloves before entering and discard before exiting room. Put on gown before entering and discard before exiting room. Observation of boxes of gloves and clean disposable gowns hanging on Resident #16's door (under sign). Observation and interview on 02/07/23 at 2:40 PM revealed RN B applied disposable gown and gloves before entering Resident #16's room. No observation (by surveyor) of RN B washing hands or using hand sanitizer prior to applying gloves. RN B placed wound care supplies on Resident # 16's dresser and, placed red bio-hazard trash bag on Resident #16's mattress (at the foot of bed). RN B used scissors to remove old bandage to Resident #16's Left lower lateral leg and placed scissors on top of the red biohazard trash bag (within the interior of bag). RN B then placed dressing (removed from leg) in the red bio-hazard trash bag. RN B changed gloves without washing hands or using hand sanitizer. RN B sprayed wound cleanser on wound and used gauze to wipe off excess exudate/drainage from wound and placed gauze in the red bio-hazard trash bag. RN B opened Xeroform and placed it on Resident #16's leg wound and stated that she did not bring enough Xeroform to cover wound. RN B removed her gloves and left the resident's room to get more Xeroform. RN B did not wash hands, use hand sanitizer and RN B did not remove the disposable gown when exiting the room. RN B returned to Resident #16's room without changing gown and applied a new pair of gloves before entering room without washing hands or using hand sanitizer. RN B applied Xeroform and followed wound care orders. RN B took gloves off and placed them in the red bio-hazard trash bag and applied new pair of gloves without washing hands or using hand sanitizer. RN B took scissors out of the red bio-hazard trash bag and used scissors to remove bandage from Resident 16's Right heel without sanitizing the scissors. RN B placed scissors on Resident #16's blanket (beside red bio-hazard trash bag), removed dressing from the Right heel and placed it in red bio-hazard bag. RN B removed gloves, placed it in red bio-hazard trash bag, and applied a new pair of gloves without washing hands or using hand sanitizer. RN B sprayed wound cleanser on the Right heel, patted dry with gauze and placed gauze in the red bio-hazard trash bag. RN B applied Triad cream to wound of heel and covered wound with padded dressing. RN B removed gloves, placed it in red bio-hazard trash bag, and applied a new pair of gloves without washing hands or using hand sanitizer. RN B removed dressing from right lower coccyx and performed wound care without changing gloves. Resident #16 was repositioned by aide that assisted RN B during wound care. RN B removed gloves and applied new pair of gloves without washing hands or using hand sanitizer and wiped scissors and supplies to be taken out of room with disinfecting wipes. RN B exited room, placed supplies on treatment cart (located by Resident #16's door) and removed disposable gown and gloves and disposed of them in bin (located in hall by Resident #16's door). RN B then documented treatment in computer without observation of hand washing or use of hand sanitizer. RN B pushed treatment cart to next resident's room to perform wound care. RN B used hand sanitizer prior to entering the next resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 11 of 12 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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 room and wound care was observed with no issues observed regarding infection control. Level of Harm - Minimal harm or potential for actual harm Interview on 02/08/23 at 11:23 AM, the DON stated that RN B informed DON that she did not perform wound care per policy/procedure (on 02/07/23 prior to ending her shift) and stated this occurred because she was nervous with state staff watching her. The DON stated that her expectations were that all staff should follow facility policies and procedures with all treatments. The DON stated that hands should be washed (or hand sanitizer used) between glove changes. The DON stated she had done hand hygiene, wound care, and infection control in-services with RN B, when they spoke. Residents Affected - Few Interview on 02/08/23 at 11:51 AM, RN C stated that the facility corporate office had put Enhanced Barrier Precautions into effect with all of their facilities to use due to CDC guidance, as a precaution designed to reduce transmission of multidrug-resistant organisms (MDRO's) in nursing homes. Interview on 02/08/23 at 4:09 PM, the Administrator stated that his expectations were that all staff follow facility policies and procedures. Record review of facility policy, Infection Prevention and Control Program revised 10/27/2022, revealed in part: This facility has established and maintains 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 as per accepted national standards and guidelines Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures All staff shall use personal protective equipment (PPE) according to established facility policy. Record review of facility policy, Hand Hygiene revised 02/11/2022, revealed in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 12 of 12