Health inspection·May 22, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's electronic face sheet, dated 5/22/23 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include Folliculitis, Cellulitis, and Muscle Wasting. During an interview on 5/19/2023 at 2:25PM Resident #2 stated she is extremely itchy. She stated her back is the worst part. She stated the itching gets much worse after showering or when she gets hot. During an observation on 5/19/23 at 2:25 PM Resident #2 arms had several small bumps and itch marks. Legs had small bumps and itch marks and back has small bumps. Record review of Resident #3's electronic face sheet, dated 5/22/2023 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include Cellulitis, Hypertension, and Muscle Weakness. During an interview on 5/19/2023 at 2:45PM Resident #3 stated the itching is bad. She stated she really is not sure what it is. She stated her back is bad. She stated whatever they are doing is not working. She stated that she has been treated by the facility for skin lice out of precaution, but that did nothing for her. She stated she has never been put on isolation because she was told that her rash was associated to her Cellulitis. She stated the rash has been around for a while. She stated it gets bad at night and when she takes her shower. During an observation on 5/19/23 at 2:45 PM Resident #3 skin has bumps and bites down the right arm, a few of the spots were bleeding. Record review of Resident #4's electronic face sheet, dated 5/22/23 revealed she was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Epilepsy, Muscle Weakness, and Muscle wasting. During an interview on 5/19/2023 at 3:15 PM Resident #4 stated she had a rash on her arms and legs. She stated she has no idea how she got it. She stated it does it but not to bad. She stated it get much worse when she gets hot or goes to get her shower. During an interview on 5/19/23 at 2:00 PM DON stated that about 9:30 AM on 5/18/23 she called the hospital and the hospital stated that Resident #1 did have scabies confirmed through the biopsy done on 5/15/23. She stated that somehow the hospital had the results of the biopsy, but she did not. She stated she did not call the medical director or any of the other physicians that have residents in the facility. She stated she did not put up any isolation carts or signage for any other residents. She stated that Resident #1 had isolation up due to being immunocompromised, the isolation was not up due to scabies. She stated the facility was not sure what the resident had, she stated that he was diagnosed with eczema and dermatitis. She stated that there were a few other residents that did have unknown rashes on them in the facility, but she did not think they needed to be isolated because the facility did not believe they were scabies. During an interview on 5/19/2023 at 3:05 PM MD-A stated he never received a call yesterday, 5/18/23 from facility confirming the scabies diagnosis. He stated that with the confirming diagnosis he would have suggested to do a skin assessment of all residents and any resident with a rash should go on isolation. He stated that all residents with rash that went on isolation would prevent the spread of the scabies in the facility if they had not already had spread through the facility. He stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 2 of 4 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 05/22/2023 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 Residents Affected - Some went to the facility on Saturday 5/20/23 to do a skin assessment of all residents and 6 residents were put on isolation for unknown rash. He stated of the 6 residents only one resident was suspected of scabies but not confirmed. During an observation on 5/22/2023 at 10:45 AM 6 residents now on contact isolation for unknown rash in the facility. During an interview on 5/19/2023 at 3:40 PM NA-B stated she got scabies on 5/7/23 in the facility after giving residents showers all day. She stated she believes that they are all over the facility. She stated that she started not feeling well that night and went to urgent care. She stated the doctor did not scrape test her or anything. She stated that the doctor said it looks like scabies but there is no (tracking). She stated at that point she pulled her shirt down to show the top of her chest to the doctor and there was tracking. She stated the doctor diagnosed her with scabies and did prescribe her scabies medication and it worked within about two days she was feeling better, and the rash was gone, this was all done on 5/7/23. She stated she let the facility know she was diagnosed with scabies. She stated she was allowed to come back to work on 5/8/23 but she did not feel well and wanted to stay out of the facility until the entire rash was gone. She stated she returned to work on 5/17/23. She stated the rash has returned as of today 5/19/23. She stated she believes she is just re-infecting herself each time she goes back to work. During an interview on 5/19/2023 at 3:57 PM RN-C stated that because he was the charge nurse, he has worked every hallway and had worked directly with Resident #1. stated that he went to his doctor on 5/10/23 because he started to have red bumps show up all over his body, primarily armpits, forearms, belly, and inner legs. He stated that due to the suspicion of scabies in the facility he told his doctor. He stated his doctor diagnosed him with scabies and he was prescribed scabies medication. He stated he let the facility know that he was diagnosed with scabies. He stated that no scraping test was done to confirm scabies. He stated he started his medication on 5/10/23 and came back to work on 5/12/23. He stated he is about to do his final treatment as of today 5/19/23. During an phone interview on 5/22/23 at 12:35 PM CNA-E stated she has no idea what is in that building but it is bad. She stated if you do not really work in the shower room or with the residents you will not get the rash. She stated but if you work with residents or in the shower room all day, you are going to get some sort of rash. She stated if you are off for a few days the rash seems to go away but when she comes back to work it comes back. She stated it sucks because the facility has no idea how to prevent it. She stated she was sent home today because she had the rash on her left hand. She stated she did not believe the facility knows how to get rid of the issue and once it is gone how to prevent it. During an interview on 5/22/23 at 2:45 PM AD-F stated she did get the rash. She stated that she can be off a few days, and everything will go away but when she comes back to the facility, she will get the rash again. She stated she did not think the facility really knows what it is. She stated she did believe it is scabies and the facility either did not know how to get rid of them or did not know how to prevent them from coming back once they are gone. Record review of facilities Scabies Guidelines dated 6/11/19 states: The goals of scabies treatment are to: kill the mite. Treat any persons who have been in close contact with the infected person. Prevent scabies from returning. Record review of Facilities Transmission-Based (Isolation) Precautions dated 10/24/22 stated: It is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 3 of 4 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 05/22/2023 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 Residents Affected - Some our policy to take appropriate precautions to prevent the transmission of pathogens, based on the pathogens modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy. 8. Contact Precautions. A. intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or resident's environment. Type and during of transmission-Based Precautions chart: Scabies-Contact isolation-duration: 24 hours after initiation of treatment. Prevention and Control: Scabies, per CDC guidelines. Scabies mites generally do not survive more than 2 to 3 days away from human skin. Children and adults usually can return to childcare, school, or work the day after treatment. Accessed: 5/22/2023 https://www.cdc.gov/parasites/scabies/prevent.html#:~:text=Scabies%20mites%20generally%20do%20not,work%20the%2 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675038 If continuation sheet Page 4 of 4