Health inspection·April 11, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Telephone interview on 4/11/2024 at 10:28 am with the MDS Coordinator, she reported the facility followed the RAI manual in completing the MDS. She reported, in general, Aspirin was not coded as an anticoagulant. She stated incorrect codes on a resident's MDS would have reflected inaccurate information on a residents care plan. A record review of the facility's [Resident Assessment Policy] dated October 2023 reflected A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the MDS is submitted to the iQIES as required. #6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. #7. The interdisciplinary team uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment. Event ID: Facility ID: 675826 If continuation sheet Page 2 of 7 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 675826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one resident (Resident #3) of six reviewed. A) The facility failed to ensure Resident #3's Comprehensive Care Plan reflected her risk for skin breakdown and a stage 2 pressure ulcer to the right upper buttocks. This failure could place a resident at risk for errors in provider care, poor wound healing/worsening wound/skin conditions. Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: essential hypertension (elevated blood pressure), unspecified fracture of the left hip, hematuria (blood in the urine), and diarrhea. Review of Resident #3's weekly nursing assessment dated [DATE] reflected Resident #3 had completely limited mobility to her upper and lower extremities. Resident #3 required a wheelchair for mobility. Resident #3 did have pressure relieving devices in use for her chair and bed. Resident #3 wore a brief for incontinence of bowel and bladder. Resident #3 had moist skin. Review of the assessment also reflected Resident #3 had a Braden Scale (a scale used for prediction of pressure ulcers) of 15 indicating she was at risk for developing a pressure ulcer. The weekly assessment reflected Resident #3 did not have a pressure area. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was assessed to have BIMS score of 15 indicating Resident #3 was cognitively intact. Resident #3 was assessed to be dependent on staff for all ADLs. Resident #3 was assessed to be at risk for development of pressure ulcers/injuries. Resident #3 was assessed not to have any pressure ulcers. Review of Resident #3's comprehensive care plan last updated 02/12/24 reflected Resident #3 had no care plan related to risk for skin integrity impairment or risk for pressure ulcers. Review of Resident #3's consolidated physician orders dated 03/28/2024 reflected an order for treatment of pressure ulcer stage two (2) to right upper buttocks with wound dressing daily. The order also reflected an order for Pro-Sources (protein supplement) to be taken daily for promotion of wound healing. Review of Resident #3's weekly nursing assessment dated [DATE] and completed on 4/10/24 reflected Resident #3 had decreased mobility to her upper and lower extremities. Resident #3 did not have any pressure relieving devices in use. Resident #3 had moist skin. Review of the assessment also reflected Resident #3 had a Braden Scale of 15 indicating she was at risk for developing a pressure ulcer. Resident #3 had a pressure area to the right buttocks. Review of care plan 4/9/24 for Resident #3 reflected there was no care plan related to pressure ulcer to right buttocks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675826 If continuation sheet Page 3 of 7 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 675826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Resident #3 on 04/09/24 at 09:43 AM she said she would like to get up daily but has a wound on her buttocks. She said she used Hoyer lift for transfers from her bed to sit in her electric wheelchair. She stated she has had an air mattress to help with pressure to her backside, but she did not like the mattress, so it was removed. She said she was not sure what they were putting on her wound at this time, but it was treated daily. Resident #3 stated she was not drinking her protein because she does not like the taste. In an interview on 04/11/24 at 12:01 PM with the Care Plan Nurse she said generally if a resident's care area assessment within the MDS triggers for skin they would have activated a risk for wounds or skin breakdown care plan. She said if there were new wounds found on a resident, those types of problems were reviewed in the morning meeting. She stated she reviewed physician orders daily and updated the care plan accordingly as changes in residents status occur. The Care Plan Nurse said if there were a new wound, she would have needed to update the care plan according to the physicians' orders. She said that Resident #3's behaviors and refusals of her protein and air mattress should have been care planned. The Care Plan Nurse stated she guessed she just missed care planning the wound and skin. She said the purpose of the care plan was to show the plan, goal, and reflect on changes in treatments as needed for wound healing or prevention of skin breakdown. She said negative outcomes for the resident for not having a care plan could have been a lack of appropriate care. In an interview on 04/11/24 at 12:08 PM with the DON, she stated it was her expectation that all skin risk and wounds should have been care planned. She said that should have also included treatment changes, behaviors related to treatment, refusal of care, nutritional interventions, anything that was completed to promote healing/ prevention should be included on the care plan. The DON said the Care Plan Nurse reviews the Care Area Assessment triggering from the MDS to develop the care plan. The DON said the Care Plan Nurse was also given a copy of physician orders daily to update the care plan as needed with changes in residents condition and treatment. She said the Care Plan Nurse was responsible for updating the care plan and she was responsible for monitoring the Care Plan Nurse. The DON said failure to have accurate care plans related to resident's care could negatively affect the residents by the nursing staff not knowing what services to provide resulting in lack of care for the residents. Review of the facility's policy titled care plans; comprehensive person centered reflected. #7 - the comprehensive, person-centered care plan: a) includes measurable objective goals and timeframes. b) b-describes the services that are to be furnished to attain or maintain the residents highest practicable physical mental and psychosocial wellbeing including: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675826 If continuation sheet Page 4 of 7 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 675826 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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 0656 c) Level of Harm - Minimal harm or potential for actual harm 1-services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her right to refuse treatment Residents Affected - Few d) 2-any specialized services to be provided as result of PASARR recommendations and e) 3-which professional services and responsible for each element of care f) c-included the residents stated goals upon admission and desired outcomes. g) d-builds on the residents' strengths and h) e-reflects currently recognized standards of practice for problem areas and condition. #10-When possible, interventions address the underlying source of the problem not just symptoms or trigger. #11-Assessments of residents are ongoing and care plans are revised as information about the resident and residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675826 If continuation sheet Page 5 of 7 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 675826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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. 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 dietary services. The facility failed to properly seal, label, and date food products in dry storage and the walk-in freezer. These failures placed residents at risk of exposure food contamination and food-borne illness. Findings included: Observation on 4/9/2024 at 9:00 AM in the kitchen's dry storage room reflected 6 individual 6-pound cans of pineapple with dented sides and dented seams. The cans were observed in the canned food rack with the entirety of the remaining canned good items; 1 item of vanilla wafers removed from its original container and stored in an unsealed plastic bag, without a date to signify when the item was removed from its original package or when the item was supposed to expire; 1 item of granola cereal removed from its original container and stored in a plastic bag, without a date to signify when the item was removed from its original package or when the item was supposed to expire; and 3 items of uncooked pasta, removed from their original containers and stored in 3 plastic bags without a date to signify when the item was removed from its original package or when the item was supposed to expire. Observations on 4/9/2024 at 9:10 AM in the kitchen's walk-in freezer reflected 1 item of frozen cinnamon rolls removed from its original container and stored in an unsealed plastic bag, exposed to freezing air, without a date to signify when the item was removed from its original package or when the item was supposed to expire; and 1 item of frozen fish patties removed from its original container and stored in an unsealed plastic bag, exposed to freezing air, without a date to signify when the item was supposed to expire. Interview on 04/11/24 at 12:55 PM with the DS revealed food received in the facility was placed in its respective location and a date was written on the package to signify the date the product was received. When the item was opened, it was either utilized in its entirety or a portion of the product remained. If an item had an unused portion, the item was placed in an airtight container. The remaining portion received a label to signify the product name, a date it was opened, and a date it was expected to expire. If a product reached its expiration date, it was thrown out. Items were sealed, labeled, and dated to keep foods fresh, reduce cross contamination, and prevent the growth of food borne pathogens. The DS stated the label and dating process applied to all foods in the dry storage, the walk-in cooler, and the walk-in freezer. When the food supplier made a delivery, canned goods were supposed to be inspected for dents and compromised seals. If dented cans, or cans with compromised seals were discovered, they were supposed to be refused at the time of delivery. If dented cans, or cans with compromised seals, were discovered later, the cans were supposed to be kept separate from the supply of other canned goods and returned to the supplier on the next delivery. Compromised cans posed a risk of contamination and growth of food-borne pathogens. If a resident ingested a food born pathogen, the resident risked health issues, such as nausea, diarrhea, fever, and unintended weight loss. The DS and the KM were supposed to check dry storage, the walk-in cooler, and the walk-in freezer daily to ensure food products were stored and labeled correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675826 If continuation sheet Page 6 of 7 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 675826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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 Interview on 04/11/24 at 1:08 PM with a KA revealed the facility was supposed to label and date foods received at the facility to ensure that items were used in a first in/first out manner. This meant foods were dated upon receipt and these foods were used before items received later. Once a food product was taken out of its original container, the item was stored in an airtight container with the name, the date it was opened, and the date by of which it was supposed to be used. The first in/first out process reduced the risk of residents consuming spoiled food and subjecting the residents to exposure of food-borne pathogens. If a resident consumed a food-borne pathogen, the resident risked stomach pain, fever, diarrhea, and unintended weight loss. Interview on 04/11/24 at 1:24 PM with the KM revealed the facility utilized the concept of first in/first out to ensure the residents received fresh foods that were free from cross contamination and food-borne pathogens. She stated foods were dated with the date the items were received. If an item was opened, the goal was to use the item in its entirety; however, sometimes there were portions left over. When this occurred, the remaining portions were placed in an airtight container. They were labeled with the product name, the date the product was opened, and the date the product was supposed to expire. Any foods left over past the date of expiration were thrown away. This procedure was utilized for foods in the dry storage, the walk-in cooler, and the walk-in freezer. She stated she, and the DS, checked the food storage areas daily to endure food products were stored, labeled, and dated correctly. Any failure associated with proper storage, labeling, or proper dating fell upon her, the KM, by not having checked up on her staff. If a resident consumed food-borne pathogens, they risked upset stomach, diarrhea, and united weight loss. Interview on 04/11/24 at 1:51 PM with the ADON revealed negative outcomes of a resident having consumed bacteria or food-borne pathogens could have resulted in severe abdominal pain, watery stool, nausea, vomiting, and weight loss. The ADON stated there have been no outbreaks associated with dietary services having resulted in gastrointestinal concerns. Interview on 04/11/24 at 02:00 PM with the ADM revealed his KM submitted weekly reports having signified foods were safely stored, labeled, and dated at each phase of use. Any deviation of the facility policy fell on the KM's failure to supervise her staff. Record review of the facility's [Food Receiving and Storage] policy, dated November 2022, reflected food delivered to the facility was inspected for safe transport and quality before being accepted. Dry storage may be a room designated for the storage of dry goods, such as canned goods. Dry foods were handled and stored in a manner that maintained the integrity of the packaging until they were ready to use. All food stored in the refrigerator, or freezer, were covered, labeled, and dated with the use by date. Any item past the date of expiration was refrozen or discarded. Record review of the FDA 2022 Food Code, section 3-201.11, reflected the FDA considered food in hermetically sealed containers that were swelled or leaking to be adulterated. Depending on the circumstances, rusted, and pitted or dented cans may have presented a serious potential hazard. Section 3-202.15 reflected food packages were supposed to be in good condition and protected the integrity of the contents, so the food was not exposed to adulteration or potential contaminants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675826 If continuation sheet Page 7 of 7