Health inspection·May 30, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many during the weekends if RN assistance was needed. He said there has been no negative outcomes for the residents. He said he does not think there would be any potential negative outcomes for not having an RN on the weekend due to the interventions that have been put in place. In an interview on 5/30/24 at 1:42 pm, the DON said the facility does not have a RN to work on the weekends. She said there has been no negative outcomes of not having an RN on the weekends. She did not think there would be any potential negative outcomes for not having an RN on the weekend due to the resources available to the facility, including an Employment Service Agency. A record review of the facility policy Staffing, dated as revised 09/28/2023, revealed the following [in part]: Policy Statement: Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 observations, interviews, and record reviews, 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 for 1(Resident #1) of 3 residents reviewed for infection control practice. Residents Affected - Few CNA (Certified Nurse Aide) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures could place residents at risk for the spread of infection. Finding include: Review of Resident #1's face sheet, dated 05/30/24, revealed the resident was a 91- year- old female admitted to the facility on [DATE] with diagnoses of diarrhea, rash, and other nonspecific skin eruptions, and need for personal care. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/01/24, revealed Resident #1 required moderate assistance with most activities of daily living (ADL)) and one-person assist. Resident #1 was occasionally incontinent of bladder. Review of Resident #1 care plan dated 03/26/24 revealed Resident #1 experiences bladder incontinence and at risk for skin breakdown. Observation of incontinence care for Resident #1 on 05/29/24 at 10:00 a.m. revealed CNA A assembled supplies including some wipes. She did not wash her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. She wiped resident front to back. CNA A gloves were visibly soiled with urine and fecal matter. She did not change gloves , wash hands, , or perform hand hygiene. CNA A retrieved the clean brief and fastened to Resident #1 with the soiled gloves. CNA A doffed her gloves and walked out of the room without washing hands or performing hand hygiene. In an interview on 05/29/24 at 10:09 a.m. with CNA A, she said she should have washed her hands before starting care and changed the gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A explained she had been employed in the facility since April 2024 and received infection control training about 2 few weeks ago. She stated the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. CNA A was asked why he did not change gloves while providing care, he said he was nervous. During an interview with the interim DON on 05/30/24 at 11:30a.m., she revealed she was aware of some of the concerns raised about infection control. She said the staff were expected to follow the facility policy on incontinent care which included assembling needed supplies, washing hands, donning gloves, and sanitizing hands in between dirty and clean barriers. The DON stated the staff receive annual training and periodically if needed. Review of the facility's Handwashing/Hand hygiene revised 01/20/23 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 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 675058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeplace Manor Healthcare Center 425 SW Ave F Hamlin, TX 79520 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 Policy Statement Level of Harm - Minimal harm or potential for actual harm This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation Residents Affected - Few 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. .3. Wash hands with soap and water, when hands are visibly soiled and after contact with resident with an infectious diagnosis. 4. Use an alcohol-based hand rub containing at least 60% to 95% ethanol alcohol or isopropyl alcohol. 5. Hand hygiene must be performed prior to donning and after doffing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675058 If continuation sheet Page 4 of 4