Health inspection·May 9, 2023

F 0578 JAW PAIN Level of Harm - Minimal harm or potential for actual harm MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES Residents Affected - Few MUSCLE WEAKNESS (GENERALIZED) NEED FOR ASSISTANCE WITH PERSONAL CARE OVERACTIVE BLADDER PAIN, UNSPECIFIED PERSONAL HISTORY OF TRAUMATIC BRAIN INJURY PNEUMONITIS DUE TO INHALATION OF FOOD AND VOMIT In a record review on 5/7/23 of Resident #1's clinical record revealed that Resident #1 was a Do Not Resuscitate (DNR). Resident #1's care plan and MDS record both reveal that Resident #1 was a DNR. The DNR in the clinical record was not valid due to insufficient signatures from witnesses on DNR form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 2 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for one(Resident #17) of 13 resident's reviewed for comprehensive care plans. - The facility failed to revise residents care plans timely to reflect residents' current status. This failure could affect residents by placing them at risk of having care plans that are not updated/accurate to their current identified needs. Findings include: Record review of Resident #17's clinical record revealed that Resident #17 is a [AGE] year-old female, was admitted on [DATE] with a brief interview for mental status of 14, and the following diagnosis are included, but not limited to: ACUTE ON CHRONIC COMBINEDSYSTOLIC (CONGESTIVE) ANDDIASTOLIC (CONGESTIVE) HEARTFAILURE ACUTE RESPIRATORY FAILURE WITHHYPOXIA TYPE 2 DIABETES MELLITUS WITHOUTCOMPLICATIONS UNSPECIFIED HYDRONEPHROSIS CHRONIC RESPIRATORY FAILUREWITH HYPOXIA CHRONIC KIDNEY DISEASE, UNSPECIFIED COGNITIVE COMMUNICATION DEFICIT COVID-19 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUTPSYCHOTIC FEATURES MILD COGNITIVE IMPAIRMENT OFUNCERTAIN OR UNKNOWN ETIOLOGY ALCOHOL DEPENDENCE, INREMISSION PAIN, UNSPECIFIED POST COVID-19 CONDITION, UNSPECIFIED NEED FOR ASSISTANCE WITHPERSONAL CARE OTHER REDUCED MOBILITY (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 3 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0657 MUSCLE WEAKNESS (GENERALIZED) Level of Harm - Minimal harm or potential for actual harm POSTHERPETIC POLYNEUROPATHY ATHEROSCLEROSIS OF AORTA Residents Affected - Many ENCOUNTER FOR ADJUSTMENT ANDMANAGEMENT OF VASCULAR ACCESSDEVICE TYPE 2 DIABETES MELLITUS WITHHYPERGLYCEMIA FATTY (CHANGE OF) LIVER, NOTELSEWHERE CLASSIFIED ATELECTASIS CARDIOMEGALY INSOMNIA, UNSPECIFIED RESTLESS LEGS SYNDROME OTHER SECONDARY CATARACT, LEFTEYE ALLERGIC RHINITIS, UNSPECIFIED UNSPECIFIED HEARING LOSS, UNSPECIFIED EAR HYPERLIPIDEMIA, UNSPECIFIED GASTRO-ESOPHAGEAL REFLUXDISEASE WITHOUT ESOPHAGITIS CONSTIPATION, UNSPECIFIED ESSENTIAL (PRIMARY) HYPERTENSION DYSURIA LEFT LOWER QUADRANT PAIN CALCULUS OF KIDNEY HEART FAILURE, UNSPECIFIED VITAMIN D DEFICIENCY, UNSPECIFIED URINARY TRACT INFECTION, SITE NOTSPECIFIED Record review of Resident #17's records revealed the residents care plan stated that she was a full code, however there was a signed DNR in Resident #17's chart dated 04/18/2023, signed by Resident #17's family member. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 4 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview 05/09/2023 10:40 AM Interview with the RN, was asked if there was a reason why a care plan would state that a Resident is a full code, but there is a DNR on file in Residents chart. The RN stated that it just didn't get changed. The RN was asked what a negative outcome of that would be, The RN stated that a code could be ran on the Resident who has a DNR. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 5 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and to designate a registered nurse as the director of nursing on a full-time basis. The facility was without full-time RN coverage for 10 days during the month of April, 2023 and without full-time RN coverage for 8 days in May, 2023. The facility failed to ensure RN weekend coverage and did not have a DON designated for the facility. These failures have the potential to affect the residents in the facility and place them at risk of not having staff with advanced care skills available to assist in their care needs. Findings include: In an interview on 5/7/23 at 9:15AM the RN was asked about the current nurse staffing schedule, and she stated that she is not supposed to be in the facility today, but the weekend LVN tested positive for Covid on Friday, 5/5/23. She stated that her regular schedule is Monday through Friday from 8AM to 5PM. When asked what licensed staff work on the weekends, she stated that there are usually 2 LVNs in the building with 2 CNAs and she is on call, should any problems arise. When asked if their corporate office is aware that they do not have RN coverage on the weekends, she stated that they are aware but have not made much effort to hire any additional RN staff. Record review of staffing schedules for February 2023, March 2023, April 2023, and May 2023 indicated that there was full-time RN coverage for the months of February and March, but the months of April and May were lacking full-time RN coverage, 8 hours per day, 7 days per week. In April 2023, the facility was without RN coverage on 4/1, 4/2, 4/8,4/9, 4/14, 4/15, 4/22, 4/23 and 4/29, 4/30. In May 2023, the facility was without RN coverage on 5/6, 5/7, 5/13, 5/14, 5/20/5/21 and 5/27, 5/28. The schedule indicates that the weekend RN was working on these dates, but previous interviews with staff revealed that she quit working at the facility on March 31, 2023, and they continued to put her on the schedule to look as if they had RN coverage. In a phone interview on 5/7/23 at 11:02AM, family member of resident #13, was asked how she felt the care of her mother was going at the facility and if she felt that there was enough staff on a regular basis, to tend to the needs of her mother. She stated that the care is good, but she feels that the facility seems to be short-handed most of the time. In a phone interview on 5/7/23 at 4:01PM , family member of Resident #15 was asked how she felt the care of the her mother was going at the facility and if she felt that there is enough staff on a regular basis, to tend to the needs of the resident. She stated that the facility was short-staffed all the time. In an interview on 5/8/23 at 1:00PM the Corporate RN was asked about the current nurse staffing at the facility, and she stated that at this moment, the staffing situation is very bad. They have one RN currently on staff and this RN works Monday through Friday from 8AM to 5PM. They usually have 2 LVNs and 2 CNAs in the building on the weekends, with the current RN designated as the on-call nurse. She stated that at night, they only have one LVN and two CNAs in the entire building. She was asked how this nurse staffing issue came to be in the facility and she stated that they had been bought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 6 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many by their current corporate office on February 1, 2023, and at that time, they designated the current RN as the DON and hired an RN to serve as ADON and they had an additional weekend RN as part of their core staff. The RN designated as the DON then decided that she would like to become the MDS Coordinator, so the ADON moved into the DON role and RN #1 became the MDS Coordinator. Both the DON and the weekend RN quit their positions at the end of March, leaving only the current RN on staff. She was asked if the corporate office is aware of this situation and if they are in the process of hiring any additional RN staff and she stated that they are aware and have been trying since the end of March to hire additional RN staffing. She was asked why the corporate office is not utilizing Agency RN staffing and she stated that they don't have the funding to pay agency pay rates, due to their current census of 31 residents. She was asked if she thinks that she has any staff who are being asked to practice outside of their scope and she stated that she doesn't think that there have been any issues. In an interview on 5/8/23 at 1:28PM CNA F, was asked if she felt there is enough staff to care for the residents who live on the North Hall. She stated that 6 (Resident #'s 10, 13, 15, 17, 20 and 27) of the 15 residents who live on the North Hall are two-person assists. If LVN A is providing resident care and one of these 6 residents requires help with a transfer, she must wait until LVN A can assist her. One resident on the North Hall (Resident #186) requires nebulizer treatments four times a day, which requires LVN A to be in the room with her one-on-one for the entire treatment. These treatments take up to 20 minutes each. CNA F stated that she does not want to jeopardize her certificate but feels that it is not safe for the residents to be placed in this situation. CNA F stated that if the Administrator and RN don't update the schedule for this coming weekend, CNA F will be the only person on duty from 6AM-6PM on Saturday, May 13th and Sunday, May 14th. CNA F was asked if the RN is available to her to call when she needs help and she stated that she has quit asking her to come and help, because she says that she is too busy. The RN was asked if she was aware that CNA F will be alone on the North Hall this coming weekend and she stated that she and the administrator have found 2 agency CNAs to come and help with staffing this weekend, but they often have issues with agency staff coming in for their scheduled assignments, especially with this being Mother's Day weekend. The RN was asked what the plan would be if the agency staff do not show up for their assignments and she stated that they do not have a back-up plan at this time. In an interview on 5/8/23 at 2:50PM, CNA C was asked about being the only CNA on the South Hall with only LVN A in the building and she stated that she feels that her residents do not receive the care that they need and deserve. She stated that if she needs help with a resident, she must wait for up to 20 minutes for someone to come, because they are providing care on the North Hall. She stated that this Friday, May 12th will be her 12th day in a row to work by herself on the South Hall, without a day off. She is afraid to jeopardize her certificate, but she is very tired and feels overwhelmed. I asked if the RN would help during the weekdays and she stated that she is usually not available, so she must wait until LVN A can come to the South Hall. She doesn't know what the RN does all day, because she doesn't see her out on the floor. CNA C was asked if she knows why the facility is short-staffed currently and she stated that they just cut back on scheduling, because the facility census is low. In a phone interview on 5/9/23 at 9:50AM the Corporate Owner was asked if he is aware of the staffing issues at the facility and he stated that he is aware but has not had much success in rectifying the situation. I asked if he knew that the facility was without full-time RN coverage, 8 hours per day, 7 days per week and has no RN serving as DON and he stated that he is aware, and that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 7 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Administrator and the RN are doing everything within their power to recruit new staff. I asked what means they are using to recruit new staff and he stated that they are networking with other professionals in the area, advertising in the newspaper and online and utilizing agency staff, whenever possible. He stated that this facility is in a rural area, which makes recruitment much harder that in a larger city. I asked if he has utilized agency staffing for this facility and he stated that he has allowed this facility to use agency staffing, but very often, the agency staff don't show up for their assigned shifts. I asked if he was aware that there are 6 (Residents #'s 10, 13, 15, 17, 20 and 27) out of 15 residents on the North Hall who are 2-person assists and that CNA F sometimes must wait up to 20 minutes to get help with resident transfers. He asked why it would take that long and I explained that resident #186 requires nebulizer treatments, four times per day and those treatments require LVN A must stay with the resident for the duration of those treatments, which take up to 20 minutes. He was not aware of this situation but feels that the Administrator and RN are doing everything that they can to ensure patient safety. In an interview on 5/9/23 at 10:04AM the Administrator stated that they have had to cut back on core staff due to low census and have had a difficult time utilizing agency staffing. I asked if she felt confident that the two agency CNAs would fulfill their shifts this coming weekend and she stated that agency staff do what they want to do. There is no recourse on the part of the facility if agency staff does not show up for their shifts and she has no back-up plan in place. Evidence of the need for additional staffing occurred on 5/9/23 at 10:11AM when the call light from the shower room on the North Hall began to sound. This surveyor observed to see how long it would take for someone to answer the call light and it continued to ring until 10:37AM when this surveyor knocked on the door to the shower room to inquire about what was needed. The Shower Aide stated from behind the close door that she needed assistance transferring Resident #17 from the shower chair to her wheelchair. An additional 3 minutes passed before LVN A emerged from a resident room to assist the Shower Aide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 8 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review; it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 2 medication carts. 3 loose pills were found in the North medication cart and 1 bottle expired medication, was found in the South medication cart. The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings include: During an observation 05/07/23 09:50 AM medication cart, on the south wing of facility. Medication cart was opened by the RN which revealed an expired medication bottle Rytary which had expired 02/2023. Medication was not labeled with a specific resident, when the RN was asked who the expired medication belonged to, the RN stated that was for Resident #28. The RN took bottle of Rytary medication and placed it in the medication room. Unwitnessed if expired medication was disposed of or not. The facility failed to renew expired bottle of Rytary (used for Parkinsons) found in medication cart. Record review of physician's orders reveals that Resident #28 does have an order for medication. Rytary Capsule Extended Release 36.25-145 MG (milligrams) (Carbidopa-Levodopa ER) Give 2 capsule by mouth four times a day related to PARKINSON'S DISEASE. Record review of clinical records for Resident #28, who is an [AGE] year-old male, was admitted to facility on 01/04/2023, with a brief interview of mental status of 14 and the following diagnosis: CEREBROVASCULAR DISEASE, UNSPECIFIED ACUTE KIDNEY FAILURE, UNSPECIFIED PARKINSON'S DISEASE ESSENTIAL (PRIMARY) HYPERTENSION FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT FOLLOWING CEREBRAL INFARCTION CEREBRAL INFARCTION, UNSPECIFIED REPEATED FALLS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 9 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 RHABDOMYOLYSIS Level of Harm - Minimal harm or potential for actual harm BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS Residents Affected - Some IRON DEFICIENCY ANEMIA, UNSPECIFIED ABNORMAL WEIGHT LOSS UNSPECIFIED PROTEIN-CALORIE MALNUTRITION HYPOKALEMIA UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH MOOD DISTURBANCE COGNITIVE COMMUNICATION DEFICIT DYSPHAGIA, OROPHARYNGEAL PHASE OTHER VOICE AND RESONANCE DISORDERS MUSCLE WEAKNESS (GENERALIZED) DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED OTHER REDUCED MOBILITY NEED FOR ASSISTANCE WITH PERSONAL CARE COVID-19 During an observation of medication room on south wing of facility on 05/07/23 09:58 AM, revealed expired medications. Sore Throat Lozenges that expire 01/2023. This medication is an over-the-counter medication with no specific resident prescribed to. During an interview 05/07/23 09:58 AM the RN was asked what the policy on expired medication was, the RN's response was to place it in the box for the expired medication to be destroyed. When the RN was asked about the medication and who it belonged to, the RN stated that it was Resident #28's because he was the only resident on that medication. During an observation 05/07/23 10:13 AM of medication cart on the North wing of facility, medication cart revealed 3 loose pills in the bottom of medication cart. During interview 05/07/2023 10:13 AM LVN B did identify one of the medications as Citalopram hydrobromide (HBR) but was unable to say which resident the pill belonged to. As for the other 2 loose pills they were not identifiable by LVN B and who the medication belonged to was unable to be determined by LVN B. One pill was brown in color and oval shape with IOII on one side of the pill and 40 on the other side of the pill (Citalopram hydrobrimide). The second pill was white round with no markings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 10 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 (unidentifiable). third pill was oval with a S on one side and no other markings (unidientifiable). Level of Harm - Minimal harm or potential for actual harm 05/07/2023 10:13AM LVN B was asked what was the protocol for medications found in the cart. LVN B stated that they are placed in the sharps container. Residents Affected - Some 05/09/23 02:28 PM interview with ADM on how a medication would be destroyed if medication was found and unidentifiable, ADM stated pill would be placed in the sharps container. Policy in evidence. Record review of facility policy titled Hazardous Waste Pharmaceuticals. Dated April 2019 4. Unused and expired pharmaceuticals may be disposed of through a contracted reverse distributor, which is defined as: any person that receives and accumulates prescription pharmaceuticals that are potentially creditable hazardous waste pharmaceuticals for the purpose of facilitating or verifying manufacturer credit. Any person, including forward distributors, third-party logistics providers, and pharmaceutical manufacturers, that processes prescription pharmaceuticals for the facilitation or verification of manufacturer credit is considered a reverse distributor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 11 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods was properly labeled and dated. 2. The facility failed to ensure proper temperature of hot and cold food items. 3. The facility failed to ensure proper thawing procedures. This failure could place the residents at risk of foodborne illnesses. Findings Include: Observation of freezer one on 5/7/23 beginning at 9:01 AM revealed the following: 1. 1 box of 12 Vanilla Ice Cream Sandwiches with no expiration date. 2. 12 dozen tortillas not labeled or dated. 3. 1 dozen frozen breadsticks not labeled or dated 4. Box of flat dough sheets not labeled/dated 5. Box of sirloin tips not dated 6. Open box of Legend Chicken not dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 12 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 Observation of refrigerator one on 5/7/23 beginning at 9:09 AM revealed the following: Level of Harm - Minimal harm or potential for actual harm 7. House Recipe Chocolate Syrup opened/ not sealed/ no date Residents Affected - Some 8. Sweet relish jar- not properly sealed with lid halfway on jar. 9. Box Mighty Milkshakes on lower shelf- not dated 10. 2% box of milk not dated 11. Onion powder- lid open- no date Observation of shelving unit on 5/7/23 beginning at 9:13 AM revealed the following: 1. Bottles of spices of ground mustard, cinnamon, poultry seasoning, rotisserie chicken, light chili powder, onion powder, salt, black pepper, ground nutmeg, and ground cloves were all observed to being open next to stove. 2. Plastic container labeled Onion Powder was turned showing label on back side. Moved to look for date and black marker covering label spelling SALT. No date 3. Cooking oil (vegetable oil) not dated Observation of refrigerator two on 5/7/23 beginning at 9:20 AM revealed the following: 1. Zip lock bag of 3 corn dogs located in refrigerator. No dates. 2. Frozen burritos located in zip lock bag in refrigerator with no date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 13 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 3. Level of Harm - Minimal harm or potential for actual harm Tupperware labeled with oranges was not properly sealed with one side of the lid not secured. Observation of shelf by office door on 5/7/23 beginning at 9:24 AM revealed the following: Residents Affected - Some 1. Box on cart in dry storage area labeled PASTA on masking tape on front of box with spice packets of different varieties inside. 2. Three clear tubs with black lids labeled [NAME] Cereal, Corn Flakes, and Raisin Brand are not dated. Observation of freezer 2 on 5/7/23 at 9:26 AM revealed the following: 1. Bag of frozen cauliflower not dated 2. Bag of frozen spinach not dated 3. Cinnamon sweet roll box not dated 4. 2 bags of frozen yellow squash not dated Observation of walk-in pantry on 5/7/23 beginning at 9:34 AM revealed the following: 1. Dry [NAME] cracker pie crust not dated 2. Box labeled mello-cup three unopened, one opened, no dates 3. Open Sysco vinegar- no date 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 14 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 Bread pudding bag Chef's companion no date Level of Harm - Minimal harm or potential for actual harm 5. Large bag of elbow macaroni not dated Residents Affected - Some 6. Six bags of vanilla instant pudding mix not dated 7. Clear tote labeled Mustard filled with ketchup 8. Clear tote labeled mustard and mayo on front with mayo in permanent marker on lid. 9. 16 out of 19 cans of evaporated milk not dated. Three cans located at front of box have dates on top. 10. 13 out of 13 cans of condensed milk not dated 11. 17 out of 17 cans of diced sweet peppers located in Sysco box not dated. Box is located on shelf with date on the box. 12. Three 28oz Oregano leaves on bottom shelf- 1 out of 3 is not properly sealed and missing a lid. 13. Box of rice- perfect parboiled rice with no date 14. Five out of five bags of brown gravy mix not dated 15. 12 out of 24 Quaker Grit cans not dated. Bottom box has dates on each can while top only has date on outside of box. Cans have not been dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 15 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 Residents Affected - Some An observation of food service with [NAME] A on 5/8/23 at 11:37 AM revealed the following: Surveyor observed kitchen staff during lunch service. Thermometer utilized to obtain temperature of green beans while on steam table. Temperature observed at 204.5 F. [NAME] opened alcohol swab from pack and cleaned thermometer. [NAME] entered thermometer into cooked meat on steam table registering temperature of 175.8 degrees Fahrenheit. [NAME] utilized same alcohol wipe and cleaned thermometer. [NAME] entered into second pan of cooked meat on steam table registering at 136.7 degrees Fahrenheit. Removed thermometer and utilized same alcohol wipe for green beans and cooked meat. Inserted thermometer into gravy on steam table with temperature registering at 190 degrees Fahrenheit. Dietary supervisor obtained new wipe and handed to cook staff. Staff opened wipe, removed thermometer from gravy and cleaned thermometer with new wipe. [NAME] inserted thermometer potato salad with a temperature registering 89.5 degrees Fahrenheit. Removed thermometer and wiped with same wipe opened prior to inserting in potato salad and inserted into smaller batch of potato salad without celery. Registered at 79.6 degrees Fahrenheit. An observation of [NAME] staff A, Dietary supervisor, and [NAME] staff B washing hands in handwashing sink. Staff lathered hands only. [NAME] staff A, Dietary supervisor, and [NAME] Staff B were observed washing hands between 10-15 seconds. A record review of policy on 5/8/23 titled Nutrition policies and procedures state to moisten hands, soap thoroughly and lather to elbow. Policy states to rub hands together for 20 seconds. A record review of food temperature logs revealed that record indicates on 5/8/23, date that temperatures were observed, shows that starch for lunch service registered at a temperature of 40 degrees Fahrenheit. Inaccurate documentation as starch of potato salad was shown to have two separate temperatures of 89.5 degrees Fahrenheit and 79.6 Fahrenheit. Record review of FDA states that cold foods should be maintained at 41 degrees Fahrenheit or less. A record review of Nutrition Policy and Procedures on 5/8/23 indicates, per Dry Storage Guidelines (focus shall be to keep non-refrigerated foods, disposable dishware, and napkins in a clean dry area, which is free of contaminants), (2) tightly sealed opened packages to prevent contacmination or place food in covered containers, (3) containter holding food or food ingredients that are removed from their original packages such as cooking oils, flour, sugar, herbs, and spices are identified with the common name of the food. Section Refrigerated Storage Guidelines stated (14) Refrigerated condiments and salad dressings are properly covered, labeled, and clarly marked to indicated a use by date two months from the date opened. A record review Cold Storage Chart on 5/8/23 indicates that any opened product should be in the refrigerator with expiration of 7-10 business days. Policy on food labeling were requested from dietary manager and had not been provided at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 16 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 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 5 (RN, LVN A, LVN B, LVN E, and CNA C) of 6 staff observed for infection control practices. Residents Affected - Some -RN failed to change from surgical mask to sterile mask when providing dressing change of peripherally inserted central catheter line on Resident #9. -LVN A failed to use proper hand hygiene techniques when providing eye drops to Resident #20 -LVN B and LVN E failed to use proper hand hygiene techniques when providing wound care to Resident #9. CNA C failed to use gloves when providing care for residents. These failures may place residents at an increased risk for transmissible diseases or slow wound healing due to cross contamination. Findings include: Record review of Resident #9 face sheet dated 5/9/23 revealed a [AGE] year old male admitted on [DATE] with readmission on [DATE] with diagnoses that included, but were not limited to, pressure ulcer of right hip stage 4 (deep wound reaching the muscles, ligaments or bones), urinary tract infection (an infection in any part of the urinary system), hyperlipidemia (high cholesterol in the blood), essential hypertension (high blood pressure), and overactive bladder (frequent and sudden urge to urinate that may be difficult to control). Record review of Resident #9's 5-day MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated he is cognitively intact. Resident #9 requires extensive assist with one person assistance with bed mobility, dressing, and toileting. Resident #9 requires limited assistance with 2 person assist with transfers. Resident #9 utilizes a wheelchair for ambulation. Record review of Resident #9's orders revealed Right/Left Hip and Right/Left Ischium Cleanse ulcers with wound cleanser or normal saline, pat dry with gauze, wipe away any debris or drainage. Apply activate collagen particles with hydrogel and pack into all wounds, cover with dry gauze, ABD (abdominal pad dressing) and secure with tape. Monitor for signs and symptoms of infection. Notify MD if infection noted. Everyday shift for wound care. Record review of Resident #9's care plan dated 4/17/23, revealed, in part: Problem: I have actual skin issues related to: impaired circulation - osteomyelitis (bone infection caused by bacteria or fungi) Goal: My skin will remain intact and improve without signs of breakdown . Interventions: Provide wound care / preventative skin care per order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 17 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 Problem: I have pressure ulcers to left hip, right hip or potential for pressure ulcer development related to paraplegia (paralysis of all or part of your trunk, legs and pelvic organs) and osteomyelitis. Level of Harm - Minimal harm or potential for actual harm Goal: My pressure ulcer will show signs of healing and remain free from infection . Residents Affected - Some Intervention: Administer treatments as ordered and observe for effectiveness . Assist me to reposition and or turn at frequent intervals to provide pressure relief. During an observation on 5/7/23 at 1:02 PM of changing a peripherally inserted central catheter line dressing for Resident #9, the RN removed the dirty dressing covering the peripherally inserted central catheter line dressing. The RN had placed sterile field set up on bedside table that had not been cleaned with disinfectant wipes and Resident #9's snuff spit cup was on the table beside the sterile field. Upon removing dressing from peripherally inserted central catheter line, the RN removed gloves and performed hand hygiene. LVN E went into the bathroom to retrieve a trash liner to place in trash can. LVN E did not perform hand hygiene after touching trash can liner before placing gloves on to assist the RN. The RN opened sterile kit, at which time, she did not change her surgical mask to sterile mask provided in sterile kit. Sterile technique was followed in the cleaning of the area around and insertion site, sterile dressing was applied to sterile clean peripherally inserted central catheter line with date and initials placed on dressing. During an interview on 5/7/23 at 4:14 PM with LVN E when asked why she did not perform hand hygiene before placing gloves on after moving trash can. LVN E stated that she was not going to touch anything or assist with the dressing changes. When asked what a negative outcome would have been if she was to assist the RN and have touched the RN's sterile field, LVN E replied, That would have been bad. During an interview on 5/7/23 at 4:23 PM with the RN when asked why she did not change her surgical mask to the sterile mask located in the sterile kit, the RN stated she already had a mask on and did not think that it needed to be the sterile one. When asked was there a reason LVN E did not perform hand hygiene after transferring trash can liner, the RN stated that she should have done it. When asked what a negative outcome could have been had LVN E assisted with the dressing change, the RN stated it would have increased the risk of infection. During an observation on 05/08/23 at 09:27 AM of wound care for Resident #9, LVN B washed her hands with soap and water prior to placing gloves on. LVN B with assistance from CNA C rolled resident on to right side and removed his dressing from his left hip wound. No wound measurements were taken at this time. LVN B stated it was not wound measurement day and they measure the wounds once a week. LVN B discarded dirty dressing and removed gloves. LVN B went to Resident #1's bathroom and washed her hands with soap and water. LVN B put new gloves on. LVN B used index finger, inserted finger into cup of collagen particles with hydrogel, appearance of sand consistency, and packed wound with activate collagen particles with hydrogel into wound. LVN B removed gloves and replaced gloves without washing hands. LVN B placed a 2x2 gauze and abdominal pad dressing over gauze and then secured with tape. LVN B removed gloves and then washed her hands with soap and water. During an interview on 5/8/23 at 10:02 AM with LVN B, when asked what a negative outcome about packing the wound then removing her gloves but not washing her hands to put new gloves on and then replacing clean dressings could potentially be, LVN B replied, cross contamination and infection into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 18 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 other wounds. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20 face sheet, dated 5/9/23, revealed a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with a diagnosis that included, but were not limited to, Type 2 diabetes mellitus with hyperglycemia (high blood sugar), left foot drop (weakness or paralysis of the muscles involved in lifting the front part of the foot), cardiac murmur (heart sounds such as whooshing or swishing caused by vibrations resulting from the flow of blood through the heart), spinal stenosis (condition where spinal column narrows and compresses the spinal cord), seasonal allergic rhinitis (the body's immune system overreacts to outdoor stimulants such as mold spores and pollen). Residents Affected - Some Record review of Resident #20's, quarterly 4/8/23 MDS, revealed a BIMSs score of 13 out of 15 indicates resident is cognitively intact. Resident 20 requires extensive assistance with two-person assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #20 is independent with no setup help with locomotion on unit, however activity has only occurred only once or twice. Resident review of Resident #20's orders revealed Pataday Ophthalmic Solution 0.2% instill 1 drop in both eyes two times a day for allergies. During an observation on 05/08/23 at 08:48 AM of administration of medication for Resident #20, LVN A was observed administering eye drops to Resident #20. LVN A did not perform hand hygiene prior to or after administering eye drops to Resident #20. During an interview on 5/8/23 at 09:07 AM with LVN A when asked why hand hygiene was not performed prior to or after administering eye drops to Resident #20., LVN A stated that she should have but just 'didn't'. When LVN A was asked what a negative outcome could be by not performing hand hygiene, LVN A stated that infection could take place. During an observation on 5/8/23 at 12:55PM, CNA C was observed picking up a sheet with blood on it with no gloves on, holding the sheet against her clothing from Resident #9. CNA C was observed then placing sheet into a bag and tying the bag closed. No hand hygiene performed. During an interview on 05/08/23 at 12:58 PM CNA C was asked why she picked the bloody sheet up without gloves on and CNA C stated that she 'just forgot to do it'. When asked what a negative outcome from bloody sheets having come in to contact with her clothing and then going into another room, CNA C stated cross-contamination and the possibility of infection. Record review of the facility provided policy titled Handwashing/Hand Hygiene revised August 2019, revealed the following: Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 19 of 20 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 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pampa Nursing Center 1321 W Kentucky Pampa, TX 79065 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 f. Before donning sterile gloves; Level of Harm - Minimal harm or potential for actual harm m. After removing gloves 10. Single-use disposable gloves should be used: Residents Affected - Some a. before aseptic procedures; b. when anticipating contact with blood or body fluids; and c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Record review of the facility provided policy titled Wound Care revised October 2010, revealed the following: Steps in the procedure: 2. Wash and dry your hands thoroughly. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Record review of the facility provided policy titled Administering Medications, revised April 2019, revealed the following: 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 20 of 20