Inspection·March 23, 2023

F 0656 -Foley Catheter care two times a day-order dated 1-20-2023, start date 1-20-2023 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #27's care plan with admission date 2-27-2023 revealed no care plans for catheter care. Residents Affected - Few During an interview on 03-22-2023 at 10:42 AM MA B reported that Resident #27 had a catheter and used a leg bag. MA B stated that Resident #27 used to have the large catheter bag but due to Resident #27's dementia he would not leave it alone and that with a leg bag Resident #27 does not see it under his clothing and therefore will not mess with it. During an interview on 03-23-2023 at 08:45 AM the MDS Coordinator reviewed Resident #27's clinical record and reported that Resident #27 did not have a care plan for his urinary catheter, that Resident #27 had a history of having a urinary catheter then having the urinary catheter dc'd due to difficulty with his urinary retention (difficulty urinating or completely emptying the bladder) and that Resident #27 has had this catheter since the first of January 2023 which was addressed on his last MDS. The MDS Coordinator reported that the catheter should have been addressed in his care plan. The MDS Coordinator verified that it is her job to complete the comprehensive care plans. The MDS Coordinator reported that she started the MDS position the first of March 2023 (after the last MDS Coordinator resigned) and is currently reviewing all care plans for accuracy. The MDS Coordinator reported that she will update Resident #27's care plan to include his catheter. The MDS Coordinator reported that if a care plan does not have the resident's current information and needs, that a resident could possibly not receive the care they need but Resident #27 has orders for his catheter and has documentation that addresses the use of his catheter in the nursing notes, so she feels Resident #27 has received his needed care. During an interview on 03-23-2023 at 09:11 AM the DON reported that a catheter needs to be addressed in the care plan because that is how the CNA's and other staff know how to perform their care on a resident. The DON reported that if a resident's needs are not addressed in their care plans, then they may receive incorrect care or not receive the care they need. Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, undated, revealed the following: Policy Interpretation and Implementation8. The comprehensive, person-centered care plan will -b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -g. Incorporate identified problem area 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 2 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for one (Resident #147) of 13 residents assessed for respiratory care. Residents Affected - Few Resident #147 was wearing/receiving oxygen but did not have an order for oxygen. This failure could place residents requiring oxygen at risk for receiving the wrong amount of oxygen, which could lead to shortness of breath, hypoxemia (below normal levels of oxygen in blood), or oxygen toxicity (condition resulting from the harmful effects of breathing molecular oxygen at increased partial pressures). Findings include Record review of Resident #147's face sheet, dated 03/21/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), chronic diastolic congestive heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body), Alzheimer's disease, and a history of falling. Record review of Resident #147's admission MDS, dated [DATE], revealed a BIMS score of 1 out of 15 which indicated his cognition was severely impaired. Section G revealed he required limited one-person assistance with bed mobility, transferring, dressing and toilet use, and personal hygiene and extensive one-person assistance with eating. Section O indicated that Resident #147 required oxygen therapy while not a resident and while a resident. Record review of Resident #147's care plan, dated 03/14/23, revealed, in part, I have oxygen therapy r/t CHF, Ineffective gas exchange Date Initiated: 03/16/2023 . OXYGEN SETTINGS: Maintain my oxygen settings per physician orders. Check on liter flow when entering my room. Date Initiated: 03/16/2023 Record review of Resident #147's physician's orders dated 03/21/23 revealed no orders for oxygen administration. Record review of Resident #147's physician's orders dated 03/22/23 revealed an order for oxygen administration dated 03/22/23 at 04:23 PM. Record review of Resident #147's Weights and Vitals Summary dated 03/22/23 revealed the following oxygen saturation [The percentage of oxygen in the blood; normal oxygen saturation level for healthy adults is between 95% and 100%.] recordings while Resident #147 was receiving oxygen via nasal cannula: 03/09/23 at 10:36 PM 94% 03/10/23 at 02:42 PM 95% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 3 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 0695 03/10/23 at 10:17 PM 98% Level of Harm - Minimal harm or potential for actual harm 03/13/23 at 01:56 PM 99% 03/13/23 at 09:26 PM 96% Residents Affected - Few 03/14/23 at 08:33 AM 96% 03/14/23 at 11:10 PM 94% 03/15/23 at 10:10 AM 92% 03/15/23 at 10:44 PM 92% 03/16/23 at 11:00 AM 94% 03/16/23 at 11:35 PM 92% 03/17/23 at 02:31 PM 92% 03/18/23 at 03:32 PM 95% 03/18/23 at 10:23 PM 90% 03/19/23 at 03:32 PM 95% 03/19/23 at 10:32 PM 92% 03/20/23 at 11:54 PM 91% 03/21/23 at 02:45 PM 95% 03/22/23 at 10:40 PM 98% During an observation and interview on 03/21/23 at 02:17 PM, Resident #147 was sitting in a recliner in his room receiving oxygen by nasal cannula at 3 liters per minute. Two of Resident #147's family members were in his room with him. They stated he had not been in the facility long and seemed to be doing well. During an observation on 03/22/23 at 08:26 AM Resident #147 was lying in bed on his back asleep receiving oxygen by nasal cannula at 2.5 liters per minute. During an observation on 03/22/23 at 09:03 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 2.5 liters per minute. During an observation on 03/22/23 at 09:54 AM Resident #147 was lying in bed on his back asleep, receiving oxygen by nasal cannula at 3 liters per minute. During an observation and interview on 03/22/23 at 11:00 AM Resident #147 was lying in bed on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 4 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back asleep, receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room and stated he had been on oxygen for several years now, 24/7. During an observation and interview on 03/23/23 at 08:58 AM Resident #147 was sitting in his recliner receiving oxygen by nasal cannula at 3 liters per minute. Resident #147's family member was sitting in his room with him and stated he was doing well. During an interview on 03/23/23 at 09:17 AM LVN C stated she had worked for the facility for a year. She stated nurses and CNAs were responsible for checking oxygen saturation levels for residents and ensuring those receiving oxygen were receiving it at the correct liters per minute. She said the physician's orders determined what liters per minute a resident's oxygen was set to. She said if the order information was not available a resident could be negatively affected. She stated, They would be hypoxic [low blood oxygen], their O2 [oxygen] would drop and they would be lethargic, confused, pale, sweaty, anxious. During an interview on 03/23/23 at 09:22 AM the DON stated nurses were responsible for setting oxygen levels for residents receiving oxygen. She stated the nurses knew what levels to set the oxygen to for residents because it is in their orders. When asked what could happen if the information was not in the orders she stated, They [nurses] could set it too high or not high enough. She stated the nurses were responsible for ensuring orders are in the chart when a resident is admitted to the facility. She stated she did not know why Resident #147 was receiving oxygen since his admission on [DATE] without physician's orders for oxygen until an order dated 03/22/23. She stated a possible negative outcome of administering oxygen to a resident without physician's orders was the resident could have Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and not be a candidate to receive O2 on the level they put it on. Record review of an undated facility policy titled Admission revealed the following: . 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. Medication orders . Record review of an undated facility policy titled Medication and Treatment Orders revealed the following: 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 5 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 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 1 (CNA A) of 4 staff observed for resident care. Residents Affected - Few -CNA A failed to perform hand hygiene or glove changes during incontinent care. This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation on 03-22-2023 09:44 AM CNA A performed incontinent care for Resident #4, CNA A was noted to wash his hands upon entering the room, CNA A then placed gloves, adjusted the residents curtains, placed a transfer belt on the resident, transferred the resident to bed, pulled the resident pants down, checked the front of the resident brief with his gloved hand to determine if the resident was wet, rolled the resident to his side, opened the new brief and placed it at the foot of the bed, removed multiple wipes from the wipe package and placed them on the opened new brief. CNA A then started to remove the used brief the resident was wearing and rolled it under the resident. CNA A used several wipes from on top of the new brief to clean the resident's rectal area, CNA A then placed the new brief under the resident, rolled the resident to his other side, finished removing the used brief, then removed a wipe from the wipe package to clean the penis and groin area (area in the body where the upper thighs meet the lowest pare of the lowest part of the abdomen). CNA A finished placing the new brief, pulled up the resident's cover, placed the resident in a position of comfort, and used the bed controls to lower the bed. CNA A then removed his gloves and placed them in the trash. CNA A then placed the residents fall mat, removed the used supplies and walked down the hallway to the last room on the right where he placed the used supplies in a trash container, then washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care. During an observation on 03-22-2023 at 01:08 PM CNA A performed incontinent care for Resident #11, CNA A was noted to wash his hands upon entering the room,, placed gloves, lowered the residents bed with the electronic control, transferred the resident from her wheelchair with his hands under her armpits to the bed, placed his hands under her back and knees and laid her in the bed, rolled her to her side and lowered her pants, rolled her to her other side and lowered her pants to her knees, then rolled her to her back, placed her new brief next to her right shoulder, removed multiple wipes from the wipe container and placed them on top of the wipe container with several falling off on the bed sheets, CNA A then used several wipes to clean the residents vaginal area, rolled the resident to her left side, cleaned her rectal area, removed her used brief, placed her new brief, rolled her to her right side, finished placing the brief, rolled her to her back, pulled her new brief up and secured the brief, CNA A then pulled the residents pants back up, CNA A then removed and disposed of his gloves, CNA A pulled the residents cover back up, placed the residents call light next to the resident, adjusted the bed with the electric controls, removed the used supplies, exited the room, walked to the last room on the hallway on the right, disposed of the used supplies in a trash container, and washed his hands. CNA A did not wash his hands, use ABHR, or change his gloves while providing incontinent care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 6 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 - Few During an interview on 03-22-2023 at 01:16 PM CNA A reported that if he notices that a hand becomes soiled with BM or other substance then he will switch to his other hand and if that hand becomes soiled then he will change his gloves and wash his hands, this was how he was taught 17 years ago when he received his CNA license. CNA A verified that he had been trained by this facility and has watched several training videos but stated, I often go back to my original training. CNA A reported that if handwashing and glove changes are not done correctly then resident could be at risk for the spread of yeast or infection. During an interview on 03-23-2023 at 09:22 AM the DON reported that during incontinent care hand hygiene should be performed before the care is started, after care is completed, and after the dirty portion of the care/before starting the clean portion/placing the new brief. The DON reported that this same process should be used with handwashing during incontinent care. The DON reported that if either of these processes are not followed then the resident receiving care can be placed at risk for infection or cross-contamination. The DON reported that a staff members glove can become contaminated at any time when dealing with a resident during incontinent care especially when cleaning the resident or when removing the residents dirty brief. The DON reported that she is the person responsible for training all staff on incontinent care and handwashing and she completed all staff training last October 2022. Record review of the facility provided policy titled Handwashing/Hand Hygiene undated revealed the following: Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance do hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 7. Use of alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for the following situations b. Before and after direct contact with residents. h. Before moving from a contaminated body site to a clean body site during resident care. 9. The use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of the facility provided training Peri Care Skills Checklist undated revealed the following: -Wash hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 7 of 8 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 675443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Acres 201 E 15th Friona, TX 79035 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 -Gather supplies Level of Harm - Minimal harm or potential for actual harm -Set supplies on a clean field or surface -Wash hands, Put on gloves Residents Affected - Few -Remove soiled brief -Using clean wipes, clean the genital area -Dispose of soiled wipes, linen protectors, and gloves -Wash hands and put on clean gloves -Place a clean brief -Remove gloves and wash hands -Reposition the resident in bed for comfort -Place call light -Sanitize immediately after leaving the resident room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675443 If continuation sheet Page 8 of 8