Health inspection·July 10, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dysfunction of bladder, unspecified, dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage, covid-19 ,vascular dementia, unspecified severity, with other behavioral disturbance, prolonged grief disorder, acute cough, anxiety disorder, unspecified, major depressive disorder, recurrent severe without psychotic features, dysphagia following cerebral infarction, pain in right shoulder, gastro-esophageal reflux disease with esophagitis, without bleeding, diaphragmatic hernia(dome-shaped muscular barrier between the chest and abdominal cavities) without obstruction, primary osteoarthritis, left shoulder, other specified diseases of liver, ulcer of esophagus with bleeding, epilepsy, unspecified, not intractable, without status epilepticus, unspecified abnormalities of gait and mobility, cerebral infarction, unspecified, presence of automatic (implantable) cardiac defibrillator, dysarthria and anarthria(motor speech disorders), hyperlipidemia, unspecified, essential (primary) hypertension. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 05 out of 15. Record review of Resident #2's Care plan face sheet revealed that his care plan was completed on 12/21/2022. Record review of resident #2's Care plan dated 12/21/2022 indicated the facility did not review the care plan after the most recent MDS assessment dated [DATE]. Record review of Resident #3's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder recurrent, unspecified, contracture-left knee, dysarthria and anarthria, ataxia(loss of muscle control), unspecified, other speech disturbances, chronic venous hypertension (idiopathic) with inflammation of bilateral(both) lower extremity, contracture-right knee, aphasia, pain in thoracic spine(longest region of the spine), unspecified atrial fibrillation, covid-19, other specified abnormal findings of blood chemistry, need for assistance with personal care, muscle weakness (generalized), other malaise(debility of health), difficulty in walking-not elsewhere classified, essential (primary) hypertension, spinal stenosis(narrowing of the lumbar spinal column that produces pressure on the nerve roots), dysphagia, constipation, unspecified, irritable bowel syndrome without diarrhea. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 out of 15. Record review of Resident #3's Care plan face sheet revealed that his care plan was completed on 12/22/2022. Record review of resident #3's Care plan dated 12/22/2022 indicated the facility did not review the care plan after the most recent MDS assessment dated [DATE]. Record review of Resident #4's face sheet revealed an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease with late onset, chronic kidney disease, stage 2 (mild), syncope and collapse, benign prostatic hyperplasia without lower urinary tract symptoms, history of falling, hypotension unspecified, allergic rhinitis unspecified, presence of cardiac pacemaker, essential (primary) hypertension, disorder of lipoprotein metabolism(body can't convert fats into energy), unspecified, type 2 diabetes mellitus without complications, hereditary neuropathy(genetic nerve damage) and idiopathic neuropathy(undetermined nerve damage) unspecified, other reduced mobility, anxiety disorder unspecified, cognitive communication deficit, muscle weakness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 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 - Some (generalized), difficulty in walking-not elsewhere classified, dental sealant status, need for assistance with personal care, personal history of covid-19, gastro-esophageal reflux disease without esophagitis, change in bowel habit, covid-19, unspecified abnormalities of gait and mobility, overactive bladder, age-related reticular degeneration of retina, unspecified eye, unspecified lack of coordination. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 10 out of 15. Record review of Resident #4's Care plan face sheet revealed that his care plan was completed on 11/30/2022. Record review of resident #4's Care plan dated 11/30/2022 indicated the facility did not review the care plan after the most recent MDS assessment dated [DATE]. Record review of Resident #5's face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease with late onset, major depressive disorder, recurrent severe without psychotic features, atherosclerotic heart disease of native coronary artery without angina pectoris, primary generalized (osteo)arthritis, gastro-esophageal reflux disease without esophagitis, unspecified osteoarthritis, unspecified site pain, unspecified history of falling, obstructive and reflux uropathy, unspecified need for assistance with personal care, difficulty in walking not elsewhere classified, benign prostatic hyperplasia without lower urinary tract symptoms, cognitive communication deficit, aphasiacovid-19, age-related osteoporosis without current pathological fracture(fracture of the bone weakened by disease), chronic kidney disease stage 2 (mild), other pancytopenia, unspecified sequelae of other cerebrovascular disease, muscle weakness (generalized). Record review of Resident #5's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 out of 15. Record review of Resident #5's Care plan face sheet revealed that his care plan was completed on 11/30/2022. Record review of resident #5's Care plan dated 11/30/2022 indicated the facility did not review the care plan after the most recent MDS assessment dated [DATE]. During an interview with LVN C on 7/10/2023 at 2:39 pm, LVN C stated the RN was responsible for creating the care plans and if care plans are not updated then residents could be at risk of being hurt. LVN C wasn't aware of any policies related to care plans but understood care plans are created with the help of the MDS Assessment. During an interview with CNA D on 7/10/2023 at 2:40 pm, CNA D stated that CNAs was given verbal and sometimes written reports that are from care plans or any changes that happened during the previous shift. CNA D stated that a negative outcome of not having an updated care plan could cause injury to the residents. During an interview with CNA E on 7/10/2023 at 2:43 pm, CNA E stated at the beginning of each shift a report was given to each CNA. CNA E stated that not getting a report or updated care plan could cause the residents being cared for in a manner that is not correct. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 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 - Some During an interview with the ADM on 7/10/2023 at 2:45 pm the ADM stated the MDS Coordinator was responsible for creating the care plans. When asked about the negative outcome of not having an updated care plan, the ADM stated that services would be accurate for the residents. During an interview with the MDS Coordinator on 7/10/2023 at 2:58 pm the MDS Coordinator stated that she was responsible for the MDS Assessments but isn't responsible for the care plans. The MDS Coordinator stated that the Corporate Nurse that comes to the facility once a week is responsible in creating the care plans. During a telephone interview with RN A on 7/10/2023 at 3:18 pm, RN A stated that she visited the facility once a week for the corporate office and stated that she is not responsible for creating care plans. Record Review of the facility's Care Plan policy titled Care Planning-Interdisciplinary Team dated March 2022 revealed the comprehensive, person-centered care plan is developed with seven days of the completion of the required MDS Assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The policy also revealed the interdisciplinary team reviews and updates the care plan as follows: a. When there has been a significant change in the resident's condition. b. When desired outcome is not met; c. When the resident has been readmitted [NAME] the facility from the hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS Assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 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 designate a registered nurse (RN) to serve as the Director of Nurses (DON) on a full-time basis. The facility has been without a fulltime DON since March 18, 2023. The facility failed to ensure that a RN was designated as Director of Nurses on a full-time basis This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings include: Record Review on 7/10/2023 of full time RN, LVN and CNA employee schedules indicated there was no DON coverage for the months of May, June, or July 2023. During an interview on 7/10/2023 with LVN B at 5:54 AM, LVN B stated she had been at the facility since March 2023 and they hadn't had a DON since she had started. LVN B stated the MDS Coordinator was the only RN working at the facility during weekdays. During the Entrance Conference on 7/10/2023 at 6:30 AM, the ADM stated the facility did not have a fulltime Director of Nurses. During an interview on 7/10/2023 with LVN C at 7:07 AM, LVN C stated she had worked at the facility for about a year. LVN C stated the facility had not had a full time DON since March or April of 2023. LVN C stated the negative outcome for not having a fulltime DON was overall safety for the residents and staff. During an interview on 7/10/2023 with CNA D at 7:45 AM, CNA D stated she has worked at the facility for about four years. CNA D stated the facility did not have a DON and had not had one for a few months. CNA D stated that the negative outcome for not having a Director of Nurses was the residents were not getting the medical attention they needed due to the lack of knowledge a DON would have. During an interview on 7/10/2023 with the MDS Coordinator at 7:50 AM, the MDS Coordinator stated she was the Assistant DON for about a year and half and was promoted to DON in November of 2022. The MDS Coordinator stated she needed more of a regular schedule, so she resigned as the DON in February of 2023 and became the MDS Coordinator. During an interview on 7/10/2023 with ADM at 10:11 AM, ADM stated that the last day the facility had a full time DON was 03/18/2023. Policy for RN/DON coverage was requested on 7/10/2023 but wasn't provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 5 of 5