Health inspection·June 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attitudes by nurses and CNAs happen every weekend. Nurses and CNAs are not keeping the times for smoke breaks for residents but have no issue taking their own smoke breaks. Resident #18 stated that because of this, RN (Resident #18 would not identify) that works on the weekends, a few nurses aides have walked out of facility due to this RN's negative attitude towards them and the residents. Resident #18 stated that she did not mention this to the DON or ADM because Resident #18 will just avoid contact with RN while she was on duty. Resident #18 stated that by making a complaint about the weekend RN's behavior would just make the situation worse. Record review of Resident #31's clinical record revealed Resident #31 is a [AGE] year-old female who was admitted on [DATE]. Resident has a Brief interview of mental status (BIMS) of 12 and a functional status that requires 1-person physical assist from staff. Resident #31 has the diagnosis included but not limited to the following: ATRIAL FIBRILLATION HYPERTENSION PERIPHERAL VASCULAR DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE During an interview 06/15/23 09:15 AM, Resident #31 stated that nurses and CNAs have been being rude, giving dirty looks, short tempered to Resident #31 since the resident council meeting on 06/13/2023. Resident #31 is a smoker. Resident #31 stated that the weekend RN and CNAs will let smoke time pass for the residents and then when residents ask when the smoke break will be the weekend Nurse stated to Resident #18 that smoke break will happen when I am ready for it to happen. Resident #31 was asked who was the weekend nurse that stated this, and Resident #31 would not give nurse's name. Resident #31 stated after the meeting on Tuesday Resident #18 and Resident #31 had spoken to one another and stated that they would be on the shit list for months to come. Resident #31 was asked, if she had asked the DON or ADMIN could address the behavior of the weekend nurse, Resident #31 stated that by making a complaint it would just make the behaviors from the weekend nurse and CNAs worse. Record Review of policy Texas State [NAME] of Rights of the Elderly-Resident/Family copy, not dated, states the following. An elderly individual is encouraged and assisted in the exercise of an individual's rights. An elderly individual may voice grievances or recommend changes in policy or service without restraint, interference, coercion, discrimination, or reprisal. The person providing services shall develop procedures for submitting complaints and recommendations by elderly individuals and for assuring a response by the person providing services. Record Review of policy Private Notice-Uses and disclosures of health information Resident/Family copy, not dated, states the following: Complaints: A complaint will not result in retaliation. Record Review of policy Smoking policy Resident/Family copy, not dated, states the following: The facility is responsible for informing residents, staff, visitors and other affected parties of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 2 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 0550 smoking policies through distribution and/or posting. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 3 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means of other than a postal service. This failure effected 2 (Resident #18 and Resident #23) of 15 residents. Residents Affected - Few Resident #18 and Resident #23 both have received mail that has been opened without their consent. Neither resident could remember the specific dates. This failure violates the resident's right to privacy and confidentiality, this could cause residents to feel uncomfortable, disrespected, and unsafe in their correspondence with others. Findings include: During Resident Council meeting held on 06/13/23 02:53 PM, the question was asked, do you get mail unopened, Resident #18 stated that she gets her boxes opened, and the staff does not open the boxes in front of her. Other residents in the meeting shook their heads yes to receiving mail already opened but would not elaborate on subject. During interview 06/15/23 08:13 AM, Resident #18 stated that she received a box of mail that was opened but could not give a specific date. Stated that the box was delivered by BOM. When Resident #18 asked BOM about the box being open, BOM stated that it was just easier to open in her office. During interview 06/15/23 08:29 AM, Resident #23 states that envelopes are not opened but boxes are opened but not opened in front of the Resident #23. Resident #23 does have contractures of bilateral arms and hands. But states that her packages should be opened in front of her, not in some random place. During interview 06/15/2023 09:43 AM BOM was asked if mail and packages were opened for residents. BOM stated that envelopes are not opened, and residents really don't receive boxes or packages. BOM stated that she will open packages/boxes only if the resident asks her for help, and that BOM is the only staff member to deliver mail to residents. Record review of Statement of Resident Rights-Resident/Family copy undated states the following: You have the right to: receive unopened mail and to receive assistance in reading and writing correspondence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 4 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility administered expired insulin medication to resident #24 on 9 different occasions. The facility had two expired medications in their e-kit. This deficient practice had the potential to affect all resident in the facility resulting in them receiving medication that could not be affective resulting in exacerbation of their condition and deterioration in their health. Finding include: Record review of Resident #24's face sheet dated 6-14-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), muscle weakness (a lack of muscle strength), malnutrition (lack of proper nutrition), borderline intellectual functioning (characterized by intelligence wherein a person has below average cognitive ability), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and legal blindness (visual acuity less than 20/200). Record review of Resident #24's 4-17-2023 quarterly MDS revealed she had a BIMS of 15 indicating she was cognitively intact, and she had a functionality of being independent with some of her activities of daily living to requiring one-person assistance with dressing and eating. Record review of Resident #24's Order Summary Report with Active Orders as of 6-14-2023 revealed the following order: Humalog Solution (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) - start date of 10-4-2022 Record review of Resident #24's MAR (Medication Administration Record) for June 2023 revealed the following: Humalog Solution (Insulin Lispro) Inject as per sliding scale: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 5 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 0755 if 150 - 200 = 2; Level of Harm - Minimal harm or potential for actual harm 201 - 250 = 4; 251 - 300 = 6; Residents Affected - Some 301 - 350 = 8; 351 - 400 = 10, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) 6-10-2023 at 06:30 AM Blood Sugar was 312 with 8 units of Humalog administered 6-10-2023 at 04:30 PM Blood Sugar was 337 with 8 units of Humalog administered 6-11-2023 at 06:30 AM Blood Sugar was 311 with 8 units of Humalog administered 6-11-2023 at 11:30 AM Blood Sugar was 257 with 6 units of Humalog administered 6-11-2023 at 04:30 PM Blood Sugar was 281 with 6 units of Humalog administered 6-12-2023 at 07:30 AM Blood Sugar was 168 with 2 units of Humalog administered 6-12-2023 at 11:30 AM Blood Sugar was 218 with 4 units of Humalog administered 6-12-2023 at 04:30 PM Blood Sugar was 311 with 8 units of Humalog administered 6-13-2023 at 07:30 AM Blood Sugar was 252 with 6 units of Humalog administered During an observation and interview on 06-13-2023 at 02:24 PM of the A&B medication cart with LVN B Resident #24's Humalog was noted to be marked on the insulin bottle with a date of opened 5-12-2023 and an expiration date of 6-9-2023. LVN B reported after reviewing Resident #24's Humalog insulin bottle that the medication was expired and would need to be replaced. LVN B verified Resident #24's Humalog insulin bottle was 1/3 full and was currently being used. That Resident #24's Humalog insulin was given per sliding scale. LVN B verified that she had administered Resident #24's Humalog insulin the previous afternoon on her shift. LVN B reported that giving an expired medication such as insulin can result in a resident receiving a medication that is not effective, that could have side effects. LVN B reported that insulins should be discarded 28 days after being opened and this insulin was just missed. During an observation and interview on 06-13-2023 at 09:53 AM of the medication room with the DON present noted were two expired medications. Risperidone 1mg tablets (antipsychotic medication used to treat schizophrenia, bipolar disorder, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 6 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 0755 and irritability cause by autism) expired 06/09/2023 Level of Harm - Minimal harm or potential for actual harm Humulin N 100U/ml vile (used to treat diabetes) expired 05/31/2023 Residents Affected - Some When questioned the DON reported that any expired medications should be placed in a lock box located in the medication room, a new medication should be reordered or refilled, and the expired medication is then picked up once a month by the pharmacy and destroyed. During an interview on 06-15-2023 at 08:57 AM the DON reported that all insulins should be marked when they are opened with an expiration date of 28 or 30 days. The DON reported that if an insulin is given after it expired then the residents blood sugars will not be treated as it should, that the blood sugar will not go down. The DON reported that the resident's condition and treatment could be affected. During an interview on 06-15-2023 at 09:24 AM the MDS Coordinator reported that the facility did not have a policy specially on medication safety, but they did have a policy on Medications that Must be Dated When Opened or Storage Condition Changes and Subcutaneous Injection Administration. During an interview on 06-15-2023 at 09:59 AM the DON presented the last training completed on medication safety to include 5 rights, eye, ear, inhaler, etc. administration presented by the MDS coordinator on 2-16-2023. The DON also presented Relias Trainings that she reported all staff are required to take annually titled Minimizing Medical Errors. During an interview on 06-15-2023 at 10:17 AM the MDS Coordinator reported that all insulins should be marked on the bottle when they are opened and when they should expire. The MDS Coordinator reported the all the nurses have an instruction card in their narcotic book on each medication cart that lists the types of insulin and when they expire after opening. All other OTC medications should be marked when they are opened and have an expiration date. The medications in the e-kit should be reviewed each month by the pharmacy and all medications close to expiration should be replaced. If a resident is given an expired medication, then the resident will not receive the full effects of the medication and it could make them sick. The MDS Coordinator reported that giving an expired medication could affect a resident's care. Record review of the facility provided instruction card the MDS Coordinator provided as part of the nursing narcotic book on each medication cart revealed the following: Humalog Inulin Lispro - Vial expires 28 days after opening or removing from refrigerator. Record review of the facility provided training titled Subcutaneous Injection Administration provided by the facility on 2-16-2023 revealed the following 1-Check expiration date of medication . Record review of the facility provided policy titled Medications that Must be Dated When Opened or Storage Condition Changes revealed no information related to this deficiency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 7 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 expired foods were discarded. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: Observation of the refrigerator on 6/13/23 at 9:54AM revealed the following: 1. 3 loose fresh tomatoes in a box, no date. 2. 1 5-pound chub of hamburger meat with an expiration date of 6/7/23. 3. 1 food service bag of boiled eggs, no date Observation of the freezer on 6/13/23 at 10:12AM revealed the following: 1. 3 food services bags of frozen, chopped spinach, no date. 2. 2 2-pound bags of frozen cauliflower, no date. 3. 1 food service bag of frozen meat pies, no date. 4. 20 pounds of frozen peas, open to air, no date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 8 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 5. Level of Harm - Minimal harm or potential for actual harm 1 food services container of frozen King Ranch Chicken, no date. 6. Residents Affected - Many 4 ½ extra-large frozen pepperoni pizzas, no date. 7. 1 food service bag of frozen French toast, no date. 8. 1 4-pound bag of frozen fajita vegetable mix, no date. 9. 2 food service bags of frozen hamburger patties, no date. 10. 2 food service bags of frozen cinnamon rolls, no date. 11. 1 food service bag of frozen chicken wings, no date. 12. 30 pounds of frozen mixed vegetables, open to air, no date. 13. 3 food service bags of frozen waffles, no date. 14. 1 food service bag of frozen turkey chunks, no date. 15. 1 food service bag of frozen hushpuppies, no date. 16. 1 food service bag of frozen carrot rings, no date. 17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 9 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 1 frozen beef brisket, no date Level of Harm - Minimal harm or potential for actual harm Observation of the dry pantry on 6/13/23 at 10:44AM revealed the following: 1. Residents Affected - Many One 4 ½ pound container of pureed rice, open to air, no date. 2. 3 food service containers of protein powder, no date. 3. 1 food service bag of tortilla chips, no date 4. 5 food service bags of Mexican rice seasoning, no date. 5. 1 food service bag of strawberry Jell-O, no date. In an interview on 6/13/23 at 11:07AM, the Dietary Supervisor, [NAME] stated she had been cooking in facilities for 27 years. She stated she was in charge of making sure that food was labeled and dated and was unsure why some of the items in the kitchen had been missed. She stated that staff were also responsible for letting her know when they found something expired and were to throw it out immediately. She stated she in-serviced all the staff on the procedures for food labeling and storage but was still working to ensure it was being done on a regular basis. She stated the negative outcome of open containers and expired food in all parts of the kitchen would be pests could get into the dry foods and residents could become sick if they were served expired foods. Dietary Supervisor stated that there should be labels and dates on all food items in the refrigerator, freezer, and pantry. Record review of the facility's Dietary Services Policy and Procedure Manual for Sanitation and Infection Control: Food Storage, dated 2/2016 revealed the following: Food must be stored in a properly covered container with a date and label identifying with is in the container. Food may remain in the [NAME] box as long as contents and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. All of the following terms will be considered expiration dates for cold food products: Expires by date Best by date Use by date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 10 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 Sell by date Level of Harm - Minimal harm or potential for actual harm Hard cooked eggs may be kept in the refrigerator for 1 week. Raw Hamburger, Ground and Stew Meat may be kept in the refrigerator for 1 to 2 days Residents Affected - Many Record review of the facility's Dietary Services Policy and Procedure Manual for Sanitation and Infection Control: Food Safety, dated 4/2016, revealed the following: Open packaged food, or leftover food is to be tightly wrapped or covered in clean air-tight containers, labeled, and dated, and stored in the refrigerator. Do not keep leftovers in the refrigerator over 3 days (72 hours). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 11 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 to help prevent the development and transmission of communication diseases and infections for 2 (#10, #26) of 30 Residents Residents Affected - Some 1. ADON broke sterile field during a sterile procedure. 2. LVN C failed to use proper hand hygiene techniques when preparing and administering medication to Resident. 3. Admin and Maintenance Supervisor was unable to provide any information regarding the process followed testing for Legionella which is bacteria that promotes pneumonia by inhaling water droplets. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation 06/13/23 10:55 AM Observed ADON perform a straight catheter on Resident #26. The ADON provided privacy for Resident #26, ADON washed hands before putting on new clean gloves. ADON proceeded to take an empty syringe and drain the catheter balloon of the catheter that was currently in place. 15 milliliters of saline was drawn out of the catheter balloon. Resident #26 stated that he didn't believe that he had dislodged the catheter but could not be certain. Catheter was not secured to Resident #26's leg. Once catheter was removed, ADON washed hands with hot water and soap. ADON went to open the sterile gloves that are in the straight catheter packaging. ADON proceeded to break the sterile field by touching the sterile side of the packaging. ADON donned sterile gloves and then proceeded to take the sterile drape and place it on Resident #26. ADON went to remove the residents brief with the sterile gloves and proceeded with opening the sterile swabs to clean Resident #26 penis, after cleaning the resident's penis. the ADON then reached under her arm to reach back behind her to retrieve the catheter for insertion into the resident's penis. The ADON did not lubricate the catheter before inserting the straight catheter into Resident #26's penis. The resident did not vocalize any pain and discomfort when the ADON asked if this was giving him any bladder relief. No urine was seen in the straight catheter. Resident #26 asked ADON for a drink of water, ADON handed resident his cup from his nightstand and then the ADON advanced the catheter further into resident's bladder. Then took the cup back from the resident and returned it to the nightstand. The ADON then placed her right hand on the Resident #26's bed sheets and then reached back to the catheter to readjust the catheter line. This was done a total of 2 times. ADON proceeded to sit resident up in his bed to see if this adjustment would assist with the emptying of his bladder. ADON then takes the bed control and adjust the head of the bed, so resident is sitting up. This procedure takes place with the same pair of sterile gloves the ADON started the procedure with. ADON the proceeds to attach the foley catheter bag to the straight catheter with no security device attached to resident. ADON never changed or washed hands during this process and went from sterile field to dirty area often. When ADON was finished with sterile procedure she removed sterile gloves and washed hands and disposed into trash can in Resident #26's room. During and interview 06/14/23 08:30 AM Interview with ADON to ask what why sterile technique was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 12 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some broken during a straight catheter procedure. ADON stated that she was unaware that she had broken the sterile process. During an observation 06/14/23 07:56AM Medication was being prepared by LVN C for Resident #10. Hand Hygiene was performed with hand sanitizer. Resident #10 was scheduled to receive 1.5 tablets of Sertraline 100mg to equal 150mg. LVN C proceeded to remove 2-100mg tablets from Resident #10's pill packet, LVN C took one of the tablets and proceeded to break pill in half with LVN C's fingernail and proceeded to administer pill to Resident #10. During an interview 06/14/23 08:27 AM Interview with LVN C was asked what the reasoning was for breaking the pill with her bare hand and not cutting pill with a pill cutter. LVN C did not answer the question but did state that her hands were clean. LVN C was asked what a negative outcome from this type of practice would be, LVN C stated that it could be a cause for infection. During an interview 06/14/23 08:54 AM Interview with DON on who performs the training for infection control and sterile techniques. DON stated that she was the infection preventionist and the ADON assisted with this type of training. DON was asked what a negative outcome could be from a break in a sterile field, DON stated that it could lead to infection. During an interview 06/14/23 09:08 AM Interview with ADMIN regarding Legionella and facility testing. ADMIN did not know what Legionnaires was or if there was a policy. Maintenance was not available for questioning. During an interview 06/15/23 09:50 AM Interview with Maintenance Super stated that he did not know what Legionnaires was and stated that he did not know of a process to test for this within the facilities water system and did not know of a policy to address this. Record review of facility policy Infection Control Policy & Procedure Manual-Surveillance dated 2019 states that following: Ensures that appropriate sterile techniques are followed; for example, that staff: Use sterile gloves, fluids, and materials, when indicated, depending on the site and the procedure Avoid contaminating sterile procedures; and Ensure that contaminated/non-sterile items are not placed in a sterile field Record review of facility policy Pharmacy Policy & Procedure Manual-Oral Solid Medication Administration dated 2003 states the following: 6. If it is necessary to divide or split the medication prior to administration, use an approved device or gloved hands. Devices must be cleaned with an alcohol wipe between uses. Any unused portion may not be retained for later use and, must be discarded in a manner so that no one has access to the unused portion. Record Review of facility policy Nursing Policy & Procedure Manual-Catheter insertion, Male/Female dated 2003/revised February 13, 2007, states the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 13 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 Perform male urethral catheterization: Level of Harm - Minimal harm or potential for actual harm a) Put on gloves. Residents Affected - Some b) Place the sterile drape over the legs below the penis. c) Hold the penis and retract the foreskin (if present) with the nondominant hand and cleanse from the meatus outward in a circular motion with antiseptic swabs or cotton balls with an antiseptic held with a forceps. d) Pick up the catheter four inches from the tip. Place the end in the basin to collect the urine and while holding the penis forward and upward with the nondominant hand, insert the lubricated catheter about seven inches. Avoid using any force during the insertion if resistance is met. e) Pinch catheter and collect a specimen if needed and then allow the urine to continue to flow into the basin until the bladder is empty if a single catheterization is being informed. f) If an indwelling catheter is being inserted, test it with the injection of the proper amount of distilled water into the balloon inflation port before insertion into the meatus. Withdraw the fluid and proceed to insert he catheter as above but with an additional ¾ inch inserted to prevent pressure at the neck of the bladder. g) Reinflate the balloon when the catheter is in place through the port with a syringe filled with the proper amount of distilled water for balloon capacity. h) Gently tug on the catheter to insure secure placement. Attach the end to a closed drainage system. i) Remove the gloves and dispose with other used articles according to Universal Precautions. j) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 14 of 15 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 675534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheeler Nursing & Rehabilitation 1000 S Kiowa St Wheeler, TX 79096 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 Place the catheter over the leg and position to not put pressure on the urethra. Level of Harm - Minimal harm or potential for actual harm k) Place in a position of comfort Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675534 If continuation sheet Page 15 of 15