Health inspection·January 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #39's quarterly MDS assessment, dated 12/28/23, reflected a BIMS of 14, which indicated he was cognitively intact. Record review of #78's admission record, dated 1/11/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acquired absence of right leg above knee, recurrent unspecified major depressive disorders, mild cognitive impairment of uncertain or unknown etiology, unspecified low back pain, and other chronic pain. Record review of #78's comprehensive MDS assessment, dated 12/20/23, reflected a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #92's admission record, undated, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified urinary incontinence, obsessive-compulsive personality disorder, and recurrent, major depressive disorder. Record review of Resident #92's quarterly MDS assessment, dated 10/24/23, reflected a BIMS of 11, which indicated he had moderate cognitive impairment. Record review of Resident #96's admission record, dated 1/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including end stage renal disease (final stage of chronic kidney disease), bilateral primary osteoarthritis of knee, unspecified pain, pain in right ankle, right foot joints and left knee, and cramp and spasm. Record review of Resident #96's comprehensive MDS assessment, dated 12/8/23, reflected a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #113's admission record, dated 1/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement) with dyskinesia (uncontrolled, involuntary muscle movement) with fluctuations, unspecified depression, unspecified single episode major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, unspecified anxiety disorder, and unspecified low back pain. Record review of Resident #113's comprehensive MDS assessment, dated 11/23/23, reflected a BIMS score of 14, which indicated he was cognitively intact. During an observation of Resident #113's bedroom on 1/9/24 at 10:30 A.M., there were brown-colored stains on Resident #113's bed sheets and a clear plastic bag filled with dirty towels sitting near the footboard on Resident #113's bed. There was also another clear plastic bag filled with soiled clothes sitting on the floor in front of Resident #113's bed. There was a cracker wrapper and crumbs on the floor in front of Resident #113's bed. During an interview with Resident #113 on 1/9/24 at 10:32 A.M., Resident #113 revealed staff cleaned his room and changed his bed sheets daily. Resident #113's also revealed staff last changed his bed sheets that morning. Resident #113 revealed staff had not come into his room that morning to clean his room. Resident #113 also revealed he often had bags of laundry sitting on his bed and floor. Resident #113 revealed he was not bothered by the bags of laundry sitting on his bed and floor. During an observation of Resident #96's bedroom on 1/09/24 at 10:44 A.M., there was an empty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 2 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication cup labeled with Resident #96's first name sitting on Resident #96's overbed tray in front of Resident #96's bed. There were also cracker wrappers and crumbs on the floor next to Resident #96's bed. In Resident #96's restroom, there were dark, brown-colored stains in the toilet bowl and a pile of towels on the floor next to the trash can. During an observation of Resident #113's bedroom on 1/10/24 at 10:13 A.M., there were still brown-colored stains on Resident #113's bed sheets. There were also dark brown stains on the floor in front of Resident #113's nightstand and red-colored stains on Resident #113's privacy curtain. During an observation of Resident #92's bedroom on 1/10/24 at approximately 11:21 A.M. and 2:12 P.M., Resident #92's bed sheets were stained with a dark, brown-colored substance. There were also soiled clothes on the floor next to Resident #92's bed. The bed sheet stain and soiled clothes were visible to anyone who entered Resident #92's room. During an observation of Resident #23 and 78's bedroom on 1/10/24 at 12:06 P.M., the bedroom had a strong bowel movement odor upon entry. During an observation and interview of Resident #39's restroom on 1/10/24 at 12:22 P.M., there were soiled bedsheets and towels on the floor. During an interview with Resident #39, Resident #39 revealed there was water coming out of the restroom floor approximately a week ago. His family called staff, and the staff put the sheets and towels on the restroom floor and had not removed it since. When asked if he had seen the restroom, Resident #39 stated, I have not gotten out of bed in a while, so I do not know what it looks like. During an observation and interview with Resident #92 on 1/11/24 at approximately 9:32 A.M., Resident #92's bed sheets were still not changed. During an interview with Resident #92, Resident #92 revealed his bed sheets got stained the day before (1/10/24) by him accidentally spilling coffee. Resident #92 also revealed staff would change the bed sheet when they got to him. During an observation on 1/11/24 at 12:39 P.M., Resident #92's stained bed sheets remained the same, but the bed sheets were flipped over so the stain was no longer visible. During an interview with CNA N on 1/11/24 at approximately 2:05 P.M., CNA N revealed she was assigned to Resident #92's room on 1/10/24 and 1/11/24. CNA N also revealed she had not been able to change Resident #92's bed sheets because she did not know Resident #92 needed help with changing his bed sheets. She was not aware that the bed sheets were soiled from the day before (1/10/24). CNA N also revealed there was no need to flip Resident #92's bed sheets over because she already knew what the bed sheets looked like. CNA N revealed it was not acceptable for residents' bed sheets to be that soiled. CNA N was observed walking out of Resident #92's room, leaving the soiled bed sheets, and soiled clothes on the floor. During an interview with the Administrator on 1/11/24 at 2:09 P.M., the Administrator revealed the facility did not have a policy and procedure for changing bed sheets. The surveyor also requested a copy of the housekeeping inspection forms and deep clean check off lists for Residents #23, 39, 78, 96, and 113's rooms from December 2023 through January 2024. During an observation and interview with the social worker on 1/11/24 at approximately 2:19 P.M., the social worker was called to Resident #92's room to observe Resident #92's bed sheets. During an interview with the social worker, the social worker revealed it was unacceptable for staff to leave (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 3 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the residents' soiled bed sheets in the residents' rooms, on the residents' beds, and walk away. The social worker was observed calling for staff to change Resident #92'S bed sheets and she picked up the soiled clothes from the floor. During an observation of Resident #113's restroom on 1/11/24 at 2:51 P.M., there was a pile of soaked towels in the sink and a pile of dirty towels next to the trash can. In Resident #113's bedroom, there were still red-colored stains on Resident #113's privacy curtain. There was still faint, brown-colored stains on Resident #113's bed sheet. During an observation of Resident #96's bedroom on 1/11/24 at 3:00 P.M., there were faint, brown-colored stains on Resident #96's bed sheets. During an observation of Resident #23 and 78's restroom on 1/11/24 at 3:10 P.M., there were brown-colored stains inside the toilet and brown-colored stains on the floor. In Resident #78 and #23's bedroom, there was a strong bowel movement odor upon entry. During an interview with Resident #23, Resident #23 revealed the restroom needed to be cleaned because there was blood in the toilet and on the floor. Resident #23 also revealed the restroom condition had been as the surveyor observed since that morning. Resident #23 was not sure if housekeeping cleaned his room that morning. An attempt to interview Resident #78 was made, but he was asleep. During an interview with LVN B on 1/11/24 at 4:42 P.M., LVN B revealed the CNAs and LVNs changed residents' bed sheets every time residents were showered, spilled on themselves, or requested the bed sheets to be changed. LVN B also revealed CNAs and LVNs must immediately clean spills on the floor. LVN B revealed housekeeping staff cleaned residents' rooms, mopped residents' floors, and discarded residents' trash. LVN B also revealed residents could develop skin infections or other health issues by residing in unkept and unclean rooms. During an interview with LVN C on 1/11/24 at 4:45 P.M., LVN C revealed CNAs and LVNs changed residents' linens on residents' shower days, whenever a resident was observed to be soiled, and whenever a resident requested to have their linens changed. LVN C revealed housekeeping staff cleaned residents' rooms daily. LVN C revealed Resident #113's room was difficult to keep clean because Resident #113 often threw his clothes and spilled food on the floor. LVN C revealed CNAs and housekeeping staff often swept and mopped the floor. LVN C revealed CNAs and LVNs did not document whenever they cleaned residents' rooms. LVN C also revealed CNAs and LVNs documented whenever they changed residents' bed linens on residents' shower sheets. LVN C revealed residents' shower sheets were submitted to managers (floor nurses or ADONs) and the managers checked them. LVN C also revealed shower sheets were checked daily and whenever residents were showered. LVN C revealed she was not sure if housekeeping staff documented whenever they cleaned residents' rooms. LVN C revealed residents could be negatively affected by residing in dirty rooms. During an interview with the Administrator on 1/11/24 at 6:48 P.M., the Administrator revealed her expectation for staff was to maintain a sanitary and clean environment and change residents' bedsheets as needed and on residents' shower days. The Administrator also revealed it was not appropriate for residents' bedsheets to be soiled and the bed sheets should have been immediately addressed and changed. The Administrator revealed she expected CNAs, CMAs, and LVNs to change residents' bedsheets. The Administrator also revealed clinical staff (CNAs, CMAs, and LVNs) did not document when they changed residents' bedsheets. The Administrator revealed she expected leadership (all department heads) to make rounds to residents' rooms to verify bedsheets were clean and changed. The Administrator revealed that leadership did not make rounds to residents' rooms on 1/10/24. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 4 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she expected charge nurses to hold CNAs accountable for not changing residents' bedsheets. The Administrator also revealed laundry staff could also verify if residents' bedsheets were not changed by how often bed sheets were brought into the laundry room to be cleaned. The Administrator revealed residents' moods could be impacted if they sat in soiled bed sheets because the bed sheets were not sanitary, created odors, and a bad environment for them. The Administrator revealed housekeeping staff cleaned residents' rooms daily and deep cleaned on a rotational basis monthly. The Administrator revealed the housekeeping supervisor rounded daily, which should also be documented. The Administrator revealed the residents could be impacted if their rooms were left dirty for a few days. The Administrator revealed the regional supervisor and veteran affairs land board electronically checked and visited the facility monthly and quarterly to verify that residents' rooms were cleaned. The Administrator also revealed the onsite veteran affairs representative also checked the housekeeping supervisor's documentation during the weekdays. During an interview with the HS on 1/12/24 at 2:25 P.M., HS revealed he worked at the facility for three months. HS revealed he was trained and in-serviced on physical environment monthly and by online trainings he completed. HS revealed housekeepers cleaned residents' rooms. HS revealed housekeepers completed checklists and date and time stamped whenever residents' rooms were cleaned. HS revealed he verified housekeepers' completed checklists. HS revealed housekeepers should have cleaned residents' rooms. HS revealed there were housekeepers who called out during the time of the survey. HS revealed his backup staffing plan was calling other housekeepers who were not on the schedule and him stepping in to clean residents' rooms. HS revealed residents could be negatively impacted by residing in rooms that were left unkept and unclean. During an interview with HK A on 1/12/24 at 2:43 P.M., HK A revealed she worked at the facility for 4 months. HK A also revealed she was trained and in-serviced as a group on physical environment by the HS monthly and individually every few days. HK A revealed housekeepers cleaned residents' rooms and bathrooms. HK A revealed housekeepers did not clean bodily fluids. HK A revealed residents' rooms were cleaned 1-3 times daily. HK A revealed housekeepers documented and date and time stamped on logs whenever a resident's room was cleaned. HK A revealed the HS verified and reviewed housekeepers' logs daily. HK A also revealed she primarily worked on 200-300 hall and sometimes other hallways. HK A revealed some residents, such as Resident #113, normally had messy rooms and housekeepers were required to clean those rooms often. HK A revealed residents could be negatively impacted by residing in unkept and unclean rooms. HK A revealed if a resident's room was left unkept and unclean, she was trained to clean the resident's room. HK A also revealed the HS did not reach out to her to ask if she could work during her off days. Record review of the facility's deep clean checkoff lists from December 2023 through January 2024, provided by the Administrator on 1/11/24 at 5:48 P.M., reflected forms for Resident #39, dated 1/10/24, and 113, dated 1/2/24, which reflected when housekeeping staff last deep cleaned those rooms. No other deep clean checkoff lists were provided. Record review of the facility's quality inspection control housekeeping forms from December 2023 through January 2024, provided by the Administrator on 1/11/24 at 5:51 P.M., reflected forms for Resident #23, 39, 78, 96, and 113's rooms, which reflected housekeeping staff cleaned Resident #39's room on 12/28/23 and 1/10/24, 23 and 78's room on 1/3/24, 96's room on 12/26/23 and 12/29/23, and 113's room on 12/29/23 and 1/2/24. No other quality inspection control housekeeping forms were provided. Record review of the facility's housekeeping and laundry policy and procedure, undated, reflected staff were required to clean residents' rooms daily and deep clean residents' rooms once per month or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 5 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as needed throughout any given month. Staff were also required to share cleaning schedules and calendars with the Administrator monthly. Staff were required to make beds and launder and hang residents' curtains. In residents' restrooms, staff were required to pick up and pull trash, dust mop, sanitize sinks, commode, tank, bowl, and base, brush inside of bowl, and damp mop the floor. In residents' bedrooms, staff were required to set up calendars outlining what rooms were to be cleaned on certain days, coordinate with the charge nurse at the start of shift to have the room ready, empty trash, replace trash liner, dust all horizontal (flat) surfaces, spoke clean all vertical surfaces, dust mop floor, damp mop floor, nurse assistants were required to strip beds, and supervisor was to adjust to clean sometime during the day if the room was not ready. A blank copy of the deep clean checkoff list, 5-step daily room cleaning, 7-step daily washroom cleaning, housekeeping quality control inspection form, and a calendar outlining what rooms were to be cleaned in January 2024 were attached. Event ID: Facility ID: 675857 If continuation sheet Page 6 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to have an assessment that accurately reflected the status for 1 of 2 Residents (Resident #149) reviewed for assessment accuracy. Residents Affected - Few Resident #149's discharge MDS dated [DATE] reflected he was discharged to Short Term General Hospital (acute hospital), while he was discharged home with family. This failure affected 1 resident and placed him at risk of not receiving the proper care and services due to inaccurate records. Findings included: Review of resident #149's face sheet dated 01/11/2024 revealed a [AGE] year-old male with an admission date of 09/27/2023. Diagnoses included chronic respiratory failure with hypoxia (below normal level of oxygen in the blood), Crohn's disease (type of inflammatory bowel disease) unspecified with unspecified complications, benign prostatic hyperplasia (enlarged prostate) without lower urinary tract symptoms, chronic pain syndrome, atherosclerotic heart disease of native coronary artery without angina pectoris (hardening of arteries due to gradual plaque buildup), typical atrial flutter(abnormal heart rhythm), chronic systolic congestive heart failure (condition in which the heart can't pump blood well enough to meet your body's needs), abdominal aortic aneurysm (a bulge or weakened area in the aorta) without rupture, unspecified depression (mood disorder causing persistent feelings of sadness), and unspecified insomnia (sleep disorder causing difficulty falling asleep or staying asleep). Review of resident #147's minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 meaning cognition intact. Resident #149 was system selected during the facility's annual survey to investigate hospitalization. Review of Resident # 149's clinical records reflected an original admission date of 09/27/2023 and a discharged date of 10/19/2023. Review of Resident # 149's progress notes dated 10/18/2023 reflected facilities interdisciplinary team met and determined resident no longer met medical necessity requirements and was being discharged home with family. Review of Resident # 149's IDT discharge summary signed 10/20/2023 by the Director of Social Services reflected resident was discharged home. Review of Resident #149's MDS dated [DATE] reflected the resident was discharged to Short Term General Hospital (acute hospital). In an interview on 01/11/2024 at 11:56 AM with the family via phone call it was said by family member that Resident #149 was not hospitalized and was picked up from the facility upon discharge. In an interview on 01/11/2024 at 12:40 PM with the Director of Social Services, she said she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 7 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few familiar with Resident #149's care. She said the resident was discharged home with family. She said Resident #149 was at baseline during discharge, no decline or changes in mood or behavior. She said Resident #149 was overall independent and she had no identified concerns when he was picked up by his family on discharge. In an interview on 01/11/2024 at 01:00 PM with the DON he said the MDS was monitored regularly on monthly systems check. He said the MDS was monitored by nursing leadership to include the DON, the Pharmacy nurse, the wound care nurse, the Medical Director, and the social worker. He said it was important to monitor for MDS discrepancies because it was how care plans were made. When asked what an adverse event of an inaccurate MDS could be, he said many different things could go wrong depending on the section that was inaccurate. He said it was his expectation for all MDS's to be accurate. In an interview on 01/11/2024 at 01:20 PM with the Regional MDS Coordinator, when asked about her expectation on the MDS accuracy she stated, It should be 100%, we strive for perfection. She said that the MDS's were monitored in house through clinical startup and systems review. When asked about the importance of an MDS she said it was important because it drives clinical care. She said she does not believe there would be any adverse events. In an Interview on 01/11/2024 at 07:00 PM with the Administrator she said it was her expectation that the MDS would be accurate. She said that an inaccurate MDS could affect facility reimbursement as well as care provided. She said if they were not documented accurately, staff would not know if there was a change in condition. POLICY: When asked for a copy of the facility policy regarding MDS and its accuracy she said that they don't have a facility policy regarding MDS, that they use the CMS RAI (Resident Assessment Instrument) Manual located on the CMS website. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 8 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Residents #44, 77, and 127) of 36 residents' rooms observed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #44's nasal tubing for his oxygen machine was changed out weekly, the flow rate on the oxygen machine was at levels according to his Med Dir's orders, and the distilled water used to fill the cylinder on the oxygen machine was not expired. 2. The facility failed to ensure Resident #127's nasal tubing for his oxygen machine was labeled, dated, and changed out weekly and the cylinder was filled with distilled water when the oxygen machine was in use. 3. The facility failed to ensure Resident #77's nasal tubing for his oxygen machine was properly stored when not in use, changed out weekly, and the nebulizer was properly stored when not in use. These deficient practices could place residents at risk of infections. Findings included: Record review of Resident #44's admission record, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with (acute) exacerbation, acute and chronic respiratory failure with hypercapnia (when a person has high levels of carbon dioxide in their blood), unspecified anxiety disorder, dependence on supplemental oxygen, respiratory failure unspecified with hypoxia (low levels of oxygen in a person's body tissues), personal history of COVID-19 and unspecified parkinsonism. Record review of Resident #44's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 12, which indicated he had moderate cognitive impairment. Record review of Resident #44's care plan, dated [DATE], reflected he needed oxygen therapy related to COPD with interventions including Resident #44 requesting change to tubing every two weeks. Resident #44 also had heart disease and was at risk for associated cardiac complications with interventions including oxygen as ordered/recommended by his Med Dir. Record review of Resident #44's Med Dir orders, dated [DATE], reflected the following: -Change O2 and/or nebulizer tubing every week every night shift every Sunday, ordered, and started on [DATE] and no end date -O2 filter check, clean and/or replace filter every week every day shift every Sunday, ordered on [DATE], started on [DATE], and no end date -O2 sats every shift for O2, ordered on [DATE], started on [DATE], and no end date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 9 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 -Oxygen at 2-4 liters per N/C SOB/comfort maintain >90% every shift for severe COPD related to COPD with (acute) exacerbation, ordered and started on [DATE] and no end date -Albuterol Sulfate Nebulization Solution (2.5 mg/3ml) 0.083% 3 ml inhale orally via nebulizer every 6 hours as needed for SOB, ordered, and started on [DATE] and no end date Residents Affected - Some Record review of Resident #77's admission record, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), adjustment disorder with mixed anxiety and depressed mood, dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance, chronic kidney disease stage 3B, acute and chronic respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), unspecified depression, unspecified obesity, and Alzheimer's disease with late onset. Record review of Resident #77's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #77's care plan, dated [DATE], reflected he had altered cardiovascular status with interventions including oxygen therapy as ordered. Resident #77 also had altered respiratory status/difficulty breathing with interventions including as, needed oxygen, as indicated. Record review of Resident #77's Med Dir orders, dated [DATE], reflected no Med Dir orders related to respiratory care. Record review of Resident #127's admission record, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease unspecified, obstructive sleep apnea(when you stop breathing while asleep or have almost no airflow) (adult) , unspecified asthma uncomplicated, chronic respiratory failure with hypercapnia (when you have high levels of carbon dioxide in your blood) and dependence on supplemental oxygen. Record review of Resident #127's comprehensive MDS assessment, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #127's care plan, dated [DATE], reflected he had altered respiratory status/difficulty breathing with interventions including oxygen settings as ordered. Resident #127 also had heart disease with interventions including oxygen as ordered/recommended by his Med Dir. Record review of Resident #127's Med Dir orders, dated [DATE], reflected the following: -O2 sats every shift, ordered and started on [DATE] and no end date -Oxygen tubing to be changed on Sunday nights at bedtime every Sunday for oxygen use, ordered on [DATE], started on [DATE] and no end date During an observation and interview with Resident #77 on [DATE] at 3:50 P.M., Resident #77 had his oxygen machine next to his nightstand. The nasal tubing was on the ground and labeled and dated [DATE]. During an interview with Resident #77, Resident #77 revealed he last used his oxygen machine two nights ago ([DATE] ). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 10 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Some During an observation and interview with Resident #44 on [DATE] at 4:31 P.M., the nasal tubing near the oxygen machine was labeled and dated [DATE]. The second nasal tubing connected was labeled and dated [DATE]. The flow rate on the oxygen machine indicated 4.5 L. There was also a 1/2 filled gallon of distilled water next to the oxygen machine that was labeled and dated [DATE]. During an interview with Resident #44, Resident #44 revealed the nurses poured and changed the distilled water in his oxygen machine daily and changed out his tubing weekly. During an observation of Resident #127's O2 machine on [DATE] at 9:16 A.M., Resident #127 was sleeping with even respirations and wearing the nasal tubing. There was no label or date on the nasal tubing. During an interview with Resident #127 on [DATE] at 12:45 P.M., Resident #127 confirmed the nasal tubing was not labeled and dated. Resident #127 also revealed the nasal tubing was changed that morning. During an observation and interview with Resident #127 on [DATE] at 10:13 A.M., Resident #127 complained of water in the nasal tubing. There was still no label or date on the nasal tubing. During an interview with LVN B, LVN B revealed the facility's policy and procedure required staff to replace the residents' nasal tubing and put a label and date on the nasal tubing. LVN B revealed she used distilled water to fill the oxygen machine cylinder and confirmed Resident #127 was receiving oxygen. LVN B revealed residents could be at risk for infection if the nasal tubing was not labeled and dated because the nasal tubing could be old. LVN B also revealed nasal tubing was to be changed weekly. LVN B confirmed there was no label and date on Resident #127's nasal tubing. Resident #127 stated, [LVN B] will take care of me, and expressed trust in the care he received from LVN B. During an observation of LVN B in Resident #127's room on [DATE] at 10:21 A.M., LVN B checked Resident #127's nasal tubing and oxygen machine. LVN B stated, Has no water in bottle, when referring to the empty cylinder. During an observation and interview of Resident #127 on [DATE] at 10:45 A.M., Resident #127 was up in his wheelchair watching television. During an interview with Resident #127, Resident #127 denied any concerns and revealed his nasal tubing was labeled and dated. Resident #127 also revealed the staff changed his nasal tubing again before labeling and dating it. Resident #127 denied any concerns and stated, They have me taken care of. During an interview with the Administrator on [DATE] at 2:08 P.M., the Administrator revealed the facility did not have a policy and procedure for nebulizers and spirometers. During an observation of Resident #44 on [DATE] at 2:44 P.M., Resident #44 was lying in bed and wearing the nasal tubing. The nasal tubing near the oxygen machine was still labeled and dated [DATE]. The second nasal tubing connected was still labeled and dated [DATE]. There was a 1/4 filled cylinder attached to the machine. There was also a 1/4 filled gallon of distilled water next to the oxygen machine that was labeled and dated [DATE]. During an observation of Resident #77 on [DATE] at 3:04 P.M., Resident #77 was lying in bed and watching television. The nebulizer was sitting on Resident #77's nightstand. The nasal tubing was wrapped in a circle and sitting on top of the oxygen machine. During an interview with Resident #77, Resident #77 stated he did not want the surveyor to look at his oxygen machine and wanted the surveyor to leave his room because he wanted to be alone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 11 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Some During an interview with LVN B on [DATE] at 3:16 P.M., LVN B revealed she worked at the facility since [DATE]. LVN B revealed she started as an agency nurse and was not trained on how to change the oxygen nasal tubing and refill the oxygen machine's cylinder. LVN B revealed she was in-serviced on the topics previously mentioned every day that week and last week by the DCE. LVN B revealed she learned how to change nasal tubing, label, and date the nasal tubing with tape, to ensure the nasal tubing was labeled and dated, and changed every Sunday. LVN B revealed nurses were responsible for changing residents' nasal tubing every Sunday and filling residents' oxygen machine cylinders with distilled water. LVN B revealed CNAs could inform nurses about residents' oxygen machine cylinders requiring a refill if the distilled water was low. LVN B revealed nurses labeled and dated distilled water gallons whenever they opened one for a residents' oxygen machine. LVN B revealed distilled water was discarded after 30 days. LVN B revealed not discarding distilled water after 30 days and not changing residents' nasal tubing could place residents at risk of an infection because the nasal tubing and distilled water could be gross and dirty. LVN B also revealed nurses documented changing residents' nasal tubing and filling residents' oxygen machine cylinder with distilled water in residents' electronic health records. LVN B revealed nurses did not document when distilled water was discarded. LVN B also revealed the distilled water gallon in Resident #44's room was labeled and dated [DATE] because that was when the water gallon was opened. LVN B revealed nurses were filling Resident #44's oxygen machine cylinder with distilled water opened in [DATE] because Resident #44 finished his newer distilled water gallon, and the facility ran out of distilled water. LVN B also revealed the facility received more distilled water gallons on [DATE]. LVN B revealed Resident #44 had the distilled water gallon in his room because he was anxious about his nasal tubing and not having any distilled water for his oxygen machine. During an observation of the central supply room and interview with the CS on [DATE] at 3:50 P.M., Room C128 had gallons of distilled water sitting on one of the shelves. The distilled water gallons had expiration dates of [DATE]. Room A115, which was the linen storage near 200-300 hall, had one gallon of distilled water sitting on one of the shelves. The distilled water also had an expiration date of [DATE]. During an interview with the CS, CS revealed she last purchased and restocked the gallons of distilled water for the facility on [DATE]. CS also revealed she restocked the distilled water supply at each nursing station, supply room, and main central supply room throughout the facility. CS revealed all staff had access to the main and other supply rooms and nursing station if they needed more distilled water. CS also revealed she restocked distilled water weekly and checked inventory daily. CS revealed she had no documentation reflecting when and how much distilled water supply was stocked and restocked in the facility. During an interview with LVN B on [DATE] at 4:42 P.M., LVN B revealed if a resident's nasal tubing were on the ground, she would change out the tubing. LVN B also revealed residents could be at risk for infection if they used tubing that was on the ground. LVN B revealed nurses usually stored nasal tubing and other oxygen machine-related supplies on a residents' nightstand. LVN B also revealed nurses usually stored residents' nebulizers in bags. LVN B also revealed nasal tubing could not be wrapped around residents' oxygen machines. LVN B revealed nasal tubing could not touch a surface, must be on the resident when in use or changed out. LVN B also revealed if oxygen machine supplies were left in an open space, residents could be at risk for infection and their oxygen flow being blocked. During an interview with LVN C on [DATE] at 4:45 P.M., LVN C revealed she worked as a nurse at the facility since 2016. LVN C revealed she was trained and in-serviced on O2 tubing, distilled water discarding, and O2 storage. LVN C revealed she was last in-serviced earlier that week and two weeks prior by the DCE or another nurse on the previously mentioned topics. LVN C also revealed she learned how to change nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 12 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Some tubing once a week, label, and date nasal tubing, make sure to clean O2 filters, and make sure to label and date everything placed on the oxygen machine. LVN C revealed she was taught on how to store the nasal tubing, the nebulizer, and the spirometer. LVN C also revealed she was taught not to leave the nasal tubing, the nebulizers, and the spirometers (an apparatus for measuring the volume of air inspired and expired by the lungs) laying out in the open and to place the supplies in a plastic bag when not in use. LVN C revealed it was not proper practice for the supplies to be on the ground or left on a resident's nightstand. LVN C also revealed staff must change out the supplies if the supplies were left on the ground or on the resident's nightstand before the resident's next oxygen use. LVN C revealed a resident could be at risk of bacteria and respiratory issues if their nebulizer, nasal tubing, and spirometer were left on the ground or on their nightstand. LVN C also revealed nurses checked the cylinders on the oxygen machine daily. LVN C also revealed nurses changed out cylinders and nasal tubing weekly. LVN C revealed CNAs could inform nurses if residents' nasal tubing were on the floor. LVN C also revealed nurses checked O2 levels on the oxygen machine daily and on every shift to make sure residents were getting the correct O2 level. LVN C revealed if resident's O2 order was not being followed, residents could be impacted depending on the resident's diagnoses. LVN C also revealed nurses were to label and date the distilled water used to fill the cylinders on the oxygen machine. LVN C revealed she was not sure when the distilled water should be discarded after it was opened. LVN C also revealed if staff used distilled water that was opened a few months ago, it would not impact residents' health. LVN C revealed Resident #77 was not on continuous oxygen care. LVN C explained Resident #77 might have an order for O2 as needed for SOB. LVN C was not sure if Resident #77 used oxygen during the night shift, but she knew he did not use it during the day shift. LVN C revealed nasal tubing wrapped around the oxygen machine was not safe, but it was something Resident #77 did when he was not using the oxygen machine. LVN C also revealed Resident #77 had not used the oxygen machine in last two or two and a half months since she worked on his hallway, but she did not know if he used it during the night shift. LVN C revealed residents' nasal tube changeouts were documented. LVN C also revealed nurses did not document refilling the cylinder on the oxygen machine. During an interview with the Med Dir on [DATE] at 5:32 P.M., Med Dir was not sure what the expiration on distilled water and how long distilled water was good for use after it was opened. When asked if distilled water opened from October being used for respiratory care was still good, Med Dir revealed she was not sure. Med Dir explained there could be a potential risk to the resident, but if the distilled water had been kept closed, the water could still be good. Med Dir was not aware of any policy and procedure for distilled water in the facility. Med Dir revealed nasal tubing should be stored in a neat and tidy manner. Med Dir explained if the nasal tubing was not in use, then it needed to be stored in a clean container or in bags that hung near the machine. Med Dir expected facility staff to observe if nasal tubing was on the floor. Med Dir revealed facility staff should pick up any nasal tubing that was on the floor and sanitize it or throw it away, which depended on if the nasal tubing was visibly soiled or had any tears. Med Dir revealed if nasal tubing were not sanitized, then the risk is potential for the resident, which could result in infection or irritation. Med Dir also revealed spirometers were issued to each resident on a needed basis and was kept at the residents' bedside table or in their drawer. Med Dir revealed if the spirometer was soiled, she expected facility staff to clean it with a sanitizing wipe. Med Dir also revealed she expected the oxygen flow rate to remain in the prescribed range according to orders. Med Dir explained there were times where the resident may change the oxygen flow rate or a nurse using judgement may increase it and then call and inform the provider. Med Dir revealed if a resident received an oxygen flow rate above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 13 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 the prescribed amount, one of the side effects was that it could cause confusion. Level of Harm - Minimal harm or potential for actual harm During an interview with Administrator on [DATE] at 6:48 P.M., Administrator revealed she expected residents' nasal tubing to be stored in bags when not in use. Administrator also revealed residents did not store their nasal tubing back in bags. The Administrator revealed she expected staff to observe residents' nasal tubing and if it was observed on the floor, then the tubing should be removed and discarded. The Administrator also revealed if the residents' nasal tubing was on the ground, she expected staff to sanitize the tubing appropriately or replace them. Administrator revealed the procedure for the residents' nasal tubing was to use sanitized wipes. Administrator also revealed distilled water was good for 2-3 years if it was properly stored. Administrator was not sure how long the O2 concentrator was good until it needed to be replaced. Administrator revealed distilled water was properly stored if used by room temp with the caps sealed. Administrator could not confirm how staff were verifying distilled water gallon was removed or sealed. Administrator revealed nasal tubing should be changed on Sundays/weekly. Administrator was not sure about the oxygen cylinders. Administrator revealed nasal tubing should be pulled off, cleaned, and put back in as needed during rounds daily. Administrator also revealed the proper storage for spirometers was bagging them when not in use. Administrator revealed she expected staff to sanitize or replace the spirometer if not bagged and not in use. Administrator explained the environmental factors could impact a resident if the nasal tubing was left on the ground and they used the nasal tubing. Administrator revealed residents could be impacted by the spirometer not being bagged after its last use, but it depended on the environmental conditions. Residents Affected - Some Record review of the facility's oxygen respiratory tubing/equipment management policy and procedure, revised [DATE], reflected the following, Compliance Guidelines: To maintain properly functioning equipment and decrease the potential for the spread of infection by maintaining clean equipment and tubing bottles and masks. Procedure: All Respiratory Tubing & Humidifier Bottles: 1. Change tubing weekly and provide storage receptacle for proper storage when not in use. 2. Pre-Filled Humidifier bottles may be used and if used should be changed when empty and may change as needed if indicated. 3. Refill humidifier (refillable) bottles as per manufacturer's recommendation. 4. Change refillable humidifier bottle monthly and as needed and fill with distilled/purified water and avoid using tap water. Note: confirm the expiration date as per manufacturer. 5. Change out masks monthly or sooner as needed. 6. Air filters should be changed and/or cleaned at least monthly and PRN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 14 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted as required for 1 of 3 days (0/1/09/24) reviewed for nursing services and postings. Residents Affected - Many The facility failed to post the required staffing information for 01/09/24. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Finding included: Observation on 01/09/24 at 10:30 AM, revealed the staffing numbers for 01/08/24 posted near the receptionist desk in the front lobby. Observation on 01/09/24 at 5:26 PM, revealed the staffing numbers for 01/08/24 still posted near the receptionist desk in the front lobby. During an interview on 01/11/24 at 9:12 AM, with the receptionist, she stated, CS was responsible for posting the staffing numbers located near her desk. During an interview on 01/11/24 at 9:40 AM, with CS, she stated she was responsible for posting the daily staffing. She stated she printed several days at a time and put them in the page holder on the wall. She stated on her way out of the building at night, she removed the sheet for the current day, and the next day's posting was visible. She stated she got called away on a family emergency on Monday 01/08/24 and did not change the posting on the way out of the building. She stated without the posting people would not know how many of each discipline was in the building. During an interview on 01/11/24 at 3:24 PM, with the Director of Nurses, he stated the staffing coordinator was responsible for posting the daily staff report . He stated because he was new in the position, he expected the report be posted daily but he was not sure what failure could be caused by not posting the report. During an interview on 01/11/24 at 7:05 PM, the Administrator stated CS was responsible for updating the staffing post daily. She stated the RN supervisor was responsible for the posting on CS's days off. She stated on Tuesday, 01/09/24, she had removed the staffing sheet from 01/08/24 early in the day. She realized later that evening the 01/08/24 had been printed twice so when she removed the old sheet, instead of the sheet for 01/09/24 being displayed, it was a duplicate of 01/08/24. She stated missing a day of posting the information did not meet her expectations. She stated the ratio of staff to resident care could be affected or they could misrepresent their actual numbers. Review of the Direct Staffing Hours Posted & Survey Results policy, revised January 2023, reflected in part, Guidelines: The community should post the direct care staffing hours daily in a place readily accessible to residents, family members, and legal representatives of residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 15 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for three (3 ) of four (4) medications carts reviewed. 1. LVN A failed to sign out narcotic after administering medication to Resident # 97 from Medication Cart #1 . 2. LVN I failed to administer medication to Resident # 37 after popping the medication and had expired medications on the 500 hall medication cart. 3. LVN J, LVN L, and CMA K failed to lock the medication carts (MCU cart-#1, 300 hall nurses #2, CMA cart #3). 4. The 300-hall nurse's cart had undated insulin pen for Resident # 108 and LVN J failed to sign the narcotics bookfor Medication cart . This deficient practice placed residents in the facility at risk for receiving medications which were ineffective and/or not safe. Finding included: 1. Review of Resident 97's undated face sheet revealed a [AGE] year-old male with admission date of 12/16/2021. Diagnoses included dementia in other diseases classified elsewhere without behavioral disturbance, cognitive communication deficit, and other idiopathic peripheral autonomic neuropathy (disorders affecting the peripheral nerves that automatically (without conscious effort) regulate body processes) . Review of Resident #97's annual MDS assessment dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Review of Resident #97's Care Plan dated 12/23/2021 revealed resident has dementia or impaired thought processes related to mild cognitive impairment. Record review of Resident #97's physician orders reflected the following order: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 16 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Pregabalin Capsule 150 MG Give 1 capsule by mouth two times a day related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY dated 08/13/2022. In an observation on 01/10/2024 at 09:08 am, while checking the MCU nurse's medication cart with LVN A, revealed Resident #97's narcotic count sheet for Pregabalin 150 mg reflected 5 pills remaining while the blister packet reflected 4 pills remaining. In an interview on 01/10/2024 at about 09:10 am, LVN A stated she gave Resident #97 his medication earlier and did not sign it out because she was busy. LVN A also stated they were supposed to sign the medication out right after giving it to the resident. 2. Review of Resident #37's undated face sheet revealed a [AGE] year-old-male with admission date of 07/05/2023. Diagnoses include bipolar disorder and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of Resident # 37's quarterly MDS assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #37's Care Plan dated 07/05/2023 revealed Resident #37 to have a Self-Care deficit related to diagnoses of Heart disease, Dementia, Spinal stenosis (narrowing) , at risk for experiencing discomfort or pain r/t: Chronic back pain, Chronic poor health noted. In an observation on 01/10/24 at 10:15 am, while checking the 500-hall nurse's medication cart with LVN I, revealed a cup of medication found on the top draw of the cart with no name. The observation revealed a bottle of tums with an expiration date of September 2023 and a bottle of Vitamin D3 with an expiration date indicating the month only, no year. In an interview on 01/10/24 at about 10: 20 am LVN I stated the medications in the cup belong to Resident #37. LVN I stated medications should be prepared just before it was given to the resident, not pre-popped. LVN I stated Resident #37 didn't like to be woken up from sleep that is why his medications were in the cart. LVN I stated the medication was prepared by the medication aide and when he took the medication to Resident #37, Resident #37 did not want to get up. LVN I stated the bottle of TUMS expired on September 2023 and there was no way to determine when the bottle of Vitamin D3 expired because the year was not visible. LVN I stated night shift was responsible to check the medication carts daily for expiration dates while day shift was responsible to check once a week. LVN I stated expired medications were not supposed to be on the medication cart because the effectiveness of the medication had decreased. 3. Observation on 01/09/24 at 12:29 PM revealed an unlocked medication cart #1 on the MCU. LVN L was wandering in the dining room. In an interview on 01/09/24 1at 2:52 PM LVN L stated, I might have just done that when I was looking for gloves. It's a treatment cart so there are creams and ointments in there. We are supposed to lock carts so residents couldn't get into it . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 17 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 01/10/24 at about 09:57 AM revealed the 300-hall medication cart being left open while CMA K was in the room with a resident and the medication cart was not within sight. Observation on 01/11/24 at about 09:56 AM revealed 2 medication carts (cart #2 & #3) on the 300 hall being left open with no staff within sight. It was also observed that CMA K walked from the 200 hall and took over one of the carts(#3) while LVN J walked out of a resident's room on the 300 hall and took over the other cart (cart #2). In an interview on 01/11/24 at 09:57 AM CMA K stated the medication cart (cart#3) was not supposed to be left open because there were medications in the cart. She stated when residents get into the cart, they might take the wrong medication. CMA K stated they were told by administration not to leave the cart open. In an interview on 01/11/24 at 10:01 AM LVN J stated she did not know she left her medication cart (cart #2) open because she was good at closing it. LVN J stated the medication cart was not supposed to be left open. She stated it was dangerous because a resident could take the wrong medication. 4. Review of Resident # 108's undated face sheet revealed a 62 - year-male with admission date of 12/06/2021. Diagnosis included type 2 diabetes mellitus with diabetic neuropathy (disorders affecting the peripheral nerves that automatically (without conscious effort) regulate body processes) . Review of Resident #108's annual MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Review of Resident #108's Care Plan dated 12/15/2021 revealed that hehad a Self-Care deficit related to Heart disease, Diabetes, and Diabetes Mellitus. Review of Resident# 108's physician orders reflected the following: Lantus Solostar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 40 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY. In an observation on 01/11/24 at 10:04 AM, while checking the 300-hall nurse's cart with LVN J, revealed an undated insulin pen for Resident # 108. It was also revealed that LVN J did not sign the narcotics book when she took ownership of the medication cart at about 6:00 AM . In an interview 01/11/24 at 10:04 AM with LVN J she stated the insulin pen for Resident # 108 was not dated and was not sure when it was opened. LVN J stated Lantus insulin is good for 28 days after being opened. LVN J stated insulins were to be dated when opened. LVN J stated she was supposed to sign the narcotic book indicating she took ownership of the medication cart right after she counted with the off going shift at 6:00 AM. LVN J stated she would sign later. After interview, about 10 minutes later, staff still did not sign the narcotics book. In an interview on 01/11/2024 at about 10:41 AM the Pharmacy Nurse stated her role was to order medications, notify the team of new orders, destroy medications, pick up discontinued medications and expired medications from the different units, train and in-service staff regarding medication administration, storage, and labeling. The Pharmacy nurse stated pre popping of medications was not allowed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 18 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because if a resident refused a medication the staff would end up wasting the medication. The Pharmacy Nurse stated, we were not supposed to keep expired medications on the medication cart, the nurses were supposed to check the cart once a week, and remove expired medications. She stated expired medications were not effective. The Pharmacy Nurse stated the nurses and medication aides were supposed to sign the narcotic medications out once it was taken from the cart to make sure the count was correct. The Pharmacy Nurse stated staff were to sign the Narcotic book once they have counted and taken the keys from the off going shift to take over ownership of the medication cart. The pharmacy Nurse stated staff were not supposed to leave the medication carts open because it was a risk for residents to take the wrong medication. Review of facility's policy titled Medication Cart Use and Storage dated 03/15/2019 reflected: The nursing Team Members (Nurses & CMA's) use the medication cart to systematically distribute physician ordered medications to residents. .Security--The medication cart and its Storage: bins are kept locked until the specified time of medication administration. Drawers unlocked and facing inward, and within sight of the nurse. .Document administration in the eMAR record and update the Individual Control Drug Record for Controlled drugs. .Lock the medication cart. .Lock the medication room or medication cart storage area. Review of facility's policy titled Medication Administration dated March 2019 reflected: Resident medications are administered in an accurate, safe, timely, and sanitary manner. . Prepare medications immediately prior to administration. . Never administer medications from an unmarked container. . Initial the electronic administration record after the medication is administered to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 19 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 (Resident #11, Resident #51, Resident #54, Resident #62, Resident #77, Residents #105, Resident #116, Resident #135, and Resident #137) out of 148 residents reviewed for infection control. Residents Affected - Some The facility failed to: 1. Isolate a resident with confirmed scabies (Resident #105) and five other residents (Residents #11, #51, #54, #62, #116, and #137) presented with rashes. On 01/10/24 at7:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/12/24 at 9:27 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. 2. Ensure CMA M administered Resident #135's eye drops in a sanitary condition. 3. Ensure Resident # 77's oxygen tubing was stored in a sanitary manner. These failures placed residents at risk of transmission and/or spread of infection or contagious disease which could lead to infections and hospitalization. Findings included: 1.) Review of Resident #105's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia, chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), hypertension (high blood pressure), and major depressive disorder. Review of Resident #105's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #105's Patient Handout (The summary and physician orders) from the dermatology clinic, dated 01/09/24, reflected in part, Scabies Located on the right proximal dorsal middle finger and right proximal dorsal index finger. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 20 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #105's physician's order dated 01/09/24 at 2:30 PM reflected, Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies Leave on for 8 hours/wash off in AM. Repeat in one week. Review of Resident #105's physician's order dated 01/09/24 at 3:41 PM reflected, Ivermectin oral tablet 3 MG, give 6 tablet [sic] by mouth one time only for Scabies for 1 day Start when in house. The medication was ordered by the Med Dir. Review of Resident #105's Medication and Treatment Administration Records for December 2024, reflected permethrin cream was applied on 01/09/21 at 11:18 PM, Ivermectin tablets were given 01/10/24 at 3:28 AM by the MSU Mgr, and the resident was placed on contact isolation on 01/10/24 during the 6:00 PM to 6:00 AM shift. Review of Resident #105's nursing progress note dated 01/10/24 at 9:07 PM reflected in part, Resident continues follow up Permethrin External Cream 5% due to skin rash for prophylaxis. Medication applied from neck down, scabbed over red rash present to bilateral arms, legs, abdomen, buttocks . Review of Resident #105's nursing progress note dated 01/10/24 at 3:36 PM, written by the Director of Nurses, reflected, Reconfirmed with physician the need for isolation for veteran . Physician states that that veteran was treated with PERMETHRIN 5% CREAM(GM)on 01/09/24 @ 2218, linen was removed, unit was deep cleaned, and veteran is in a private room. No need for isolation at this time. Skin to be assessed daily for 5 days, notify physician of any changes in condition. Review of Resident #11's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, type 2 diabetes, essential hypertension, and chronic kidney disease stage 4. Review of Resident #11's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 5 indicating severely impaired cognition. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #11's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #11's Total Body Skin assessment dated [DATE] reflected turgor - good elasticity, skin color - normal for ethnic group, temperature - warm (normal), moisture - normal, and condition - normal. The assessment reflected no new wounds. Review of Resident #51's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted to the facility 03/15/17 and readmitted [DATE]. His diagnoses included neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), Alzheimer's disease, cerebral infarction (stroke), and osteoarthritis. Review of Resident #51's quarterly MDS assessment dated [DATE], Section B (Hearing, Speech, and Vision) reflected the resident had clear speech, was usually understood, and he usually understands. Section C (Cognitive Patterns) reflected no BIMS score. Section GG (Functional Abilities) reflected he used a wheelchair for mobility with supervision or touching assistance. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 21 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Review of Resident #51's care plan, printed 1/11/24, reflected an Upper chest rash - NEW 1/5/24 with no new interventions documented. Review of Resident #62's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, post-traumatic stress disorder, atherosclerotic heart disease, hypertension, and chronic kidney disease stage 3. Residents Affected - Some Review of Resident #62's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #62's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #62's nursing progress note dated 01/10/24 at 11:26 PM reflected, Resident continues follow up Permithrin External Cream 5 % for prophylaxis day 1/7, red patches noted from neck down to feet, resident has not complained of pain or discomfort so far during this shift. Resident currently resting in bed, with call light within reach. Plan of care continued. Review of Resident #116's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs) , major depressive disorder, essential hypertension, dementia, and benign prostatic hyperplasia (the flow of urine is blocked due to an enlarged prostate gland). Review of Resident #116's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. Section M (Skin Conditions) reflected the resident did not have any ulcers, wounds, or any skin problems . Review of Resident #137's face sheet printed 01/10/24, reflected an [AGE] year-old male admitted to the facility 03/17/23. His diagnoses included unspecified dementia, post-traumatic stress disorder, and adult failure to thrive. Review of Resident #137's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds or other skin problems were present. Review of Resident #137's physician's order, dated 01/10/24, reflected, Permethrin external Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #137's progress note written 01/10/24 at 4:43 PM by MSU Mgr reflected, This writer, DON, DCO assessed skin. Resident has itchy, dry skin. Resident schedule hydrocortisone cream. Will continue plan of care. All parties notified about skin condition. Observation on 01/09/24 at 11:40 PM revealed Resident #105 standing by the nurse's station with two other residents standing nearby. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 22 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Observation on 01/09/24 at 12:28 PM revealed Resident #137, Resident #62, and Resident #11 eating lunch in the dining room/dayroom. Observation on 01/10/24 at 2:15 PM revealed Resident #105 lying in bed in his room. There was no sign on or near the door to indicate if transmission-based precautions were used. There was no PPE outside of the room. Residents Affected - Some During an observation and interview on 01/10/24 at 2:17 PM with LVN A, she stated, Resident #105 had his rash for a while, maybe it had started last week. She stated the resident had gone to the doctor on 01/09/24 and was tested for scabies but she did not have the results. She stated if the results were back, she would have received that information in the morning report. She stated staff wear gloves in the room but no other PPE. She stated they were treating all the residents on the unit prophylactically. She stated she had just received more medication from the pharmacy. Observation revealed seven tubes of Permethrin cream (a medication used to treat scabies) for seven residents on the unit. Observation on 01/10/24 at 2:47 PM revealed Resident #105 lying in bed. There was no sign on the door indicating transmission-based precautions. There was no PPE near the room. Observation on 01/10/24 from 2:45 PM to 3:05 PM revealed nursing staff and housekeeping personnel enter Resident #105's room without gloves or other PPE. Observation on 01/11/24 at 8:32 AM revealed a Contact Isolation sign on the door of Resident #105's room. A cart containing PPE was observed next to the room. Resident #105 was lying in his bed. Observation on 01/11/24 at 9:56 AM revealed Resident #51 as he sat in a wheelchair and wheeled himself up and down the hall. His arms and chest had multiple red dots. He was not able to say how long he had the rash or if it was itching. During an observation and interview on 01/11/24 at 10:10 AM with Resident #105, he stated he had a rash all over his body. LVN A assisted resident to turn and adjusted his clothes to reveal red dots on the resident's neck, torso, both arms, back, and both legs. The resident stated they put some cream on him and he recently showered to wash off the medication. He stated he did not remember taking the six pills that the dermatologist had ordered. LVN A stated she gave him the pills during morning med pass. Observation on 01/11/24 at 3:04 PM revealed Resident #137 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. The check revealed a rash, red dots, on the left side of his trunk from the hip up to the ribs. Observation on 01/11/24 at 3:09 PM revealed Resident #62 had red spots on both legs, both arms, and his trunk. MSU Mgr stated the rash is throughout his whole body except for his face. Observation on 01/11/24 at 3:15 PM revealed Resident #11 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. Resident #11 had a rash covering his right arm. Observation on 01/11/24 at 3:16 PM revealed Resident #116 had a rash of red dots on left side ribs to hip. He declined any further skin check. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 23 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 Observation on 01/11/24 at 4:40 PM revealed an isolation sign on resident #105's room door. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 01/10/24 at 2:25 with the Director of Nurses, he stated, he had been in his current position for a few days and prior to becoming the Director of Nurses he was the Infection Preventionist. He stated only one resident (Resident #105) had been tested for scabies and the results were still pending. He stated isolation or transmission-based precautions were not necessary because scabies was not confirmed. He stated they were treating the whole unit prophylactically and were in the process of notifying all the responsible parties . Residents Affected - Some During an interview on 01/10/24 at 2:40 PM with the DCE, she stated she knew Resident #105 went out for an appointment on 01/09/24. She stated she brought up her concerns that the resident was to be placed on transmission-based precautions but was told by the Director of Nurses that it was not necessary because the residents on the unit were being treated and the diagnosis of scabies was not confirmed. She stated if it was any other suspected contagious disease, the resident would be on isolation or transmission-based precautions while they waited for test results. She stated not placing someone on transmission-based precautions could cause spread of infection. During an interview on 01/10/24 at 2:53 PM with CNA A, she stated, she was the aide assigned to work on the hall with Resident #105. She stated the resident goes out to the dining room or sometimes he just sat with other residents and watched television. She stated she was aware that the resident may have scabies, she heard he was tested, but did not know for sure. She stated she was afraid of taking something home to her family, so she had been putting on two pairs of gloves to protect herself. She stated she had not been instructed to wear any other PPE. During an interview on 01/11/24 at 8:25 AM with the MSU Mgr, she stated, Resident #105 had been placed on contact precautions some time before her shift started. She stated PPE should be worn because you didn't want to get people sick or spread something. She stated by not using TBP, everyone could get sick. During an attempted telephone interview on 01/11/24 at 11:20 AM, a message that requested a return call was left at the dermatology clinic visited by Resident #105. During a telephone interview 01/11/24 at 2:39 PM with a certified dermatology technician at the dermatology clinic, she was told the purpose of the call. She placed the call on hold and talked with the provider. She came back to the call and after some discussion, stated she would have the provider call back. The call was not returned prior to exit of the survey. During an interview on 01/11/24 at 3:18 PM with MSU Mgr, she stated all rashes should have been documented in the electronic medical records. During an interview on 01/11/24 at 3:24 PM with the Director of Nurses, he stated he had verified with the doctor that no isolation was needed. He stated Resident #105 was never on transmission-based precautions just standard precautions and gloves were a part of standard precautions. He stated all residents on the unit were treated prophylactically. He stated he read the dermatologists' report this morning. He stated he talked with the doctor both before and after reading the dermatologist report and isolation was not indicated. When asked the protocol for notifying staff or visitors that PPE is needed, he stated, By putting up a sign, we missed that. He stated the facility policy was followed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 24 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety During a telephone interview on 01/11/24 at 4:15 PM with Resident #105's family member, they stated they took the resident to a dermatologist on 01/09/24. They stated while they were at the office, the dermatologist took the scraping from his hand and looked at it under the microscope and confirmed it was scabies. When they returned to the facility around 1:30 or 2:00 PM, shortly after lunch, they signed him back in at the book at the nurse's station. They stated they gave the Patient Handout including the two prescriptions (permethrin cream and Ivermectin tablets) for treating scabies to the MSU Mgr. Residents Affected - Some During an interview on 01/11/24 at 4:30 PM with MSU Mgr, she stated when Resident #105 and his family member returned from the dermatology appointment on 01/09/24, sometime just after lunch, the family member pulled her aside and told her what the dermatologist said. The family member told her the dermatologist did a scrape and talked about scabies. The family member gave her the paperwork from the dermatologist, she read it and saw that it talked about scabies. She stated she called the Director of Nurses. She stated he read the paperwork form the dermatologist, said he was going to call the doctor, and get right back to her. She stated the paperwork had the order for the two scabies medications. She stated the pharmacy nurse made sure the facility had the medication order. She stated there was an isolation sign on the room door now but it was not there the previous day. During an interview on 01/11/24 at 4:32 PM with the Med Dir, she stated, in general a real infection was confirmed and the resident was treated empirically. She stated it depended on the disease but something like C-diff or scabies, if we suspect it is highly likely, contact precautions would be implemented immediately. She stated she reviewed the facility policies and the policies are all current. Regarding Resident #105, she stated they suspected scabies, but the resident was in a private room and staff used contact precautions right away. She stated, Contact precautions means a gown and gloves are worn for every contact with the resident. If staff did not follow contact precautions, there was the risk of transmission to staff and residents. She stated a resident suspected of scabies should be put on isolation immediately with gloves and gowns. She stated the on-call doctor was notified late in the evening of 01/09/24 and the facility was told to isolate the resident. The Med Dir stated at no point in time did they tell the Director of Nurses not to isolate the resident. She stated scabies is infectious and should be treated like any contagious disease. She stated, The instant they come back with the paperwork is when it all starts. She stated she did not see the paperwork from the dermatologist until this morning. They suspected scabies and initiated precautions right away. She stated the resident started treatment that night. She stated his rash was diffuse but not on his feet or the palms of his hands. During a telephone interview on 01/11/24 at 5:16 PM with Resident #105's family member, they stated the resident was scheduled for a follow up visit with the dermatologist at the end of January. They stated the Med Dir saw Resident #105's rash and thought the resident should be seen before the end of January. The family member made multiple calls and they were able to secure the appointment on 01/09/24. During an interview on 01/11/24 at 7:05 PM with the Administrator, she stated they follow guidance to keep everyone safe. She stated the policies are based on CDC and CMS guidelines and doctors' recommendations. She stated she was aware Resident #105 was going to the dermatologist for a follow up visit. She stated she was aware he had a scraping done and received prescriptions. She stated, I left it to the medical team. She stated she did not know when he got his treatment. She stated she saw the paperwork from the dermatologist on 01/10/24 . She stated if an infection was not contained it could spread to other residents or staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 25 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the Scabies Identification, Treatment and Environmental Cleaning policy revised 08/16 reflected in part, 8. Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing . Review of the CDC's website https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html#S accessed 01/11/24, contact precautions in addition to standard precautions should be used until 24 hours after initiation of effective therapy to prevent the spread of scabies. Review of the CDC's website https://www.cdc.gov/parasites/scabies/gen_info/faqs.html accessed on 01/11/24 reflected The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Review of the World Health Organization website https://www.who.int/news-room/fact-sheets/detail/scabies accessed 01/11/24 reflected Scabies can lead to skin sores and serious complications like septicaemia (a bloodstream infection), heart disease and kidney problems. This was determined to be an Immediate Jeopardy (IJ) on 01/10/24 at 7:20 PM the Administrator, Director of Nurses, and Regional Nurse Coordinator were notified. The Administrator was provided with the IJ template on 01/10/24 at 7:20 PM. The following POR submitted by the facility was accepted on 01/12/24 at 12:33 PM:

F880 - Infection Control The facility failed to follow CMS and CDC guidance addressing infection control in that 7 residents are being treated for a contagious infection without isolation precautions. All residents were at risk of being exposed to scabies, which likely could result in severe itching, rash, sores, thick crusts on skin, and secondary bacterial infections. 1. Action: Immediate The Charge Nurse notified resident #105's MD/NP. The MCU Charge Nurse on duty assessed resident #105. Rash isolated to top of hands, with no other skin irritations present. Date Completed: 1/10/24 Director of Nurses immediately placed resident#105 on contact precautions. Date Completed: 1/10/24 2. Action: The MDS nurse and IDT initiated a review of resident #105's care plan on 1/10/24, and has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 26 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 revised and updated to include the rash area to the bilateral hands. Level of Harm - Immediate jeopardy to resident health or safety Date initiated: 1/10/24 Residents Affected - Some 3. Action: The IDT initiated a review of all residents' care plans who reside on the MCU (secured memory care unit). The MDS nurse updated all care plans for risk for infection. Date completed: 1/11/24 Date Completed: 1/11/24 4. Action: Resident #105's room was cleaned by direct care staff members. Resident #105's clothes, and linens were removed and washed, all no washable items were place on plastic bags as indicated. The Director of Nurses validated that the resident was treated as per physician's orders, and that the room, clothing, and linens were appropriately bagged and laundered. 1. Wash linens in hot water and dry on hot temperature before any use. Follow the isolation practice for contact isolation when handling the contaminated linens or clothing. Bag belongings that cannot be disinfected or laundered in a plastic bag, tied/sealed for up to 3 days. Clean clothing may be returned to the resident's room after the first dose of treatment. 2. Consider washing at least 3-4 changes of clothing in hot water and dry on hot temp prior to providing to resident to be worn while being treated. Completion Date: 1/10/24 5. Action: Risk--All residents who actively reside on the MSU (secured memory care unit) may have been at risk; Therefore, facility implemented prophylactic treatment as recommended by the facility's medical director. The facility's medical director recommended prophylactic treatment for all 30 residents who reside on the MSU. The Director of Nurses will validate that all residents on the MCU received the prophylactic treatment as per physician's orders. Additional measures that were in place to minimize the risk of spreading was keeping resident 105 in a private room on the secured unit, isolated and separated form others, continued consistent staffing to the unit, which minimizes the spread throughout the community, access to supplies, provide PPE ( gloves and gowns) supplies to isolation room, gloves, hand hygiene supplies throughout the secured unit, as well as the deep cleaning and laundering interventions for resident #105 and all others residing in memory care unit. On 1/10/24, following the IJ concern being cited the Director of Nurses implemented contact precautions for resident #105. Date Completed: 1/11/24 6. Action: Nurses conducted a resident skin sweep on residents who reside on the MCU (secured care unit): There were no findings or indication of infectious outbreak. All residents on the MCU have the skin results documented in each of the resident's electronic health record progress. Date Completed: 1/10/24 7. Action: The Regional Nurse conduct re-education to the Director of Nurses, Assistant Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 27 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Nurses, and Infection Preventionist prior to them proceeding with in-service training. In-service provided: Scabies Information, Scabies response guide, Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE(gown and gloves) and Hand Hygiene Practices. Date Completed: 1/11/24 Residents Affected - Some 8. Action: The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist conducted in-service education to all staff prior to assuming their next shift. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all newly hired staff during orientation. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all agency staffers upon entrance to facility prior to assuming their assignment. Inservice training provided: o Scabies Information o Scabies response guide o Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gloves and gown) and Hand Hygiene Practices Date Completed: 1/11/24 and on-going 9. Action: The Director of Nursing and Infection Preventionist conducted staff education consisting of the identification and reporting of s/s scabies, infection control practices and hand hygiene practices. All staff assigned to that designated area have received the education and the in-servicing was also extended to all staff and no staff will work their next shift unless the staff member has received the scabies related in-service. regarding infection prevention and control measures to include but not limited to: o Scabies Information o Scabies response guide o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 28 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gown and gloves) and Hand Hygiene Practices Completion Date: 1/11/24 10. Action: The Administrator, Director or Nurses conducted and Ad Hoc QAPI review of this situation and IJ Plan of Removal with the facility's Medical Director. Completion Date: 1/11/24 The Survey team monitored the Plan of Removal on 01/12/24 as followed: Record review of Resident #105's progress notes revealed a note, documented by MSU Mgr on 1/10/24 at 5:24 PM, stated, This writer, DON, DCO assessed skin. Resident has itchy rash and scaly. Resident recieves schedule clobetasol propionate cream, ketoconazole shampoo, fluocinonide external cream. Resident denies itching at this time. Will continue plan of care. All parties notified about skin condition. Note, documented by Pharmacy Nurse on 1/9/24 at 3:53 PM, stated, Resident seen by dermatology, new order for permethrin 5% topical cream and Ivermectin 3mg x 6 tablets for one time dose. MSU Mgr was attempted to be contacted on 01/12/24 at 5:41 PM. A voicemail was left with call back number. Med Dir and Attending Physician were attempted to be contact on 01/12/24 at 5:42 PM but the office was closed. Record review of Resident #105's skin and wound assessment, documented by RN N on 1/10/24, revealed he had good elasticity turgor, normal skin color, warm temperature, normal moisture, normal condition, and no new wounds. Record review of Resident #105's skin and wound evaluation, documented by RN N on 1/11/24, revealed he had a rash on left upper abdomen, acquired in-house, wound been present since 12/14/23, wound bed epithelial, 100% of wound covered with surface intact, no evidence of infection, pink or red color and scab, exudate none, periwound attached: edge appears flush with wound bed or as a sloping edge, intact with unbroken skin, no induration present, no swelling or edema present, normal periwound temperature, no pain frequency, healable for goals for care, no dressing appearance, cleaning solution or debridement, no dressing applied, topicals for care, stable progress, practitioner and RP notified. Record review of Resident #105's Dermatology consult, dated 1/9/24, revealed orders and instructions for applying permethrin 5% topic cream on neck down to feet, ivermectin 3mg tablet 6 by mouth at once, expectations, contaminated clothing, contacting office if scabies fails to resolve, and skin education. Record review of Resident #105's care plan revealed staff reviewed the care plan and included a revision, documented by Regional Nurse Coordinator on 1/11/24, that noted Resident #105's had rash to hand. Goal was to assess redness, blisters, or discoloration through review date and skin injury will resolve without associated complications through review date. Interventions included apply treatment as ordered and follow community's practice for assessing skin, reporting skin concerns to charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 29 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 nurse, doctor, resident, or RP, and follow skin protocol in place as indicated. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #105's order summary report, dated 1/12/24, revealed the following orders: Contact Isolation Precautions: Strict Isolation required in which all care, therapy and other services are provided in private room r/t an active infection. Every shift for 7 days. Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies leave on for 8 hours/wash off in AM. Repeat in one week. Residents Affected - Some Record review of all residents' care plans who resided on MCU (secure memory unit) revealed staff updated all care plans to include risk for infection. Record review of all MCU residents' progress notes and order summary report revealed they were ordered and received prophylactic treatment as recommended by MD. Record review of all MCU residents' progress notes and skin assessment results revealed they were assessed by nurses for skin issues and had findings documented on assessments in EHR. Record review of in-services revealed the DON, the ADON, and the IP were re-educated on contact precautions by the regional nurse and Abuse and neglect by the ADM on 1/10/24. Visual aids for contact precautions and washing hands were included. The DON, the ADON, and the IP were also re-educated on scabies, scabies response guide, infection control and prevention isolation practices, preventing the spread of infection of communicable disease/conditions, utilizing isolation precautions, which included PPE and hand hygiene practices on 1/10/24 by the regional nurse. Record review of in-services revealed the ADON, the DON, and the ADM re-educated staff prior to assuming their next shift, newly hired staff[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 30 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 the resident's medical record included documentation that indicated the resident received education on the influenza immunization for 3 of 5 residents (Resident #39, Resident #44, and Resident #77) residents reviewed for immunizations. Residents Affected - Some 1. The facility failed to ensure Resident #39's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 2.The facility failed to ensure Resident #44's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. 3. The facility failed to ensure Resident #77's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings included: 1. Review of Resident #39's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included type 2 diabetes (a condition that affects the way the body processes blood sugar), nondisplaced fracture of the left femur (a broken hip), dysphagia (difficulty swallowing), and muscle wasting and atrophy of both legs (thinning of muscle mass). Review of Resident #39's quarterly MDS assessment, dated 12/28/23, reflected a BIMS score of 14 indicating intact cognition. Review of Resident #39's undated immunization report reflected he received a flu immunization on 10/18/23. Review of Resident #39's progress notes dated 10/18/23, did not reflect documentation of immunization education provided. 2. Review of Resident #44's face sheet printed on 01/11/24 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), hearing loss, acute and chronic respiratory failure (not enough oxygen or too much carbon dioxide in the blood), type 2 diabetes (a condition that affects the way the body processes blood sugar), dependence on supplemental oxygen, and Parkinsonism (a progressive disorder that affects the nervous system). Review of Resident #44's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 indicating mild cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 31 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0883 Level of Harm - Minimal harm or potential for actual harm Review of Resident #44's undated immunization record reflected he received a flu immunization on 10/17/23. Review of Resident #44's progress notes dated 10/17/23, did not reflect documentation of immunization education provided. Residents Affected - Some 3. Review of Resident #77's face sheet printed 01/11/24 reflected a [AGE] year-old male admitted to the facility 07/28/22. His diagnoses included Parkinsonism (a progressive disorder that affects the nervous system), permanent atrial fibrillation (irregular heartbeat), atherosclerotic heart disease (arteries become narrowed and hardened due to buildup of plaque), dementia, and hypertension (high blood pressure). Review of Resident #77's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Review of Resident #77's undated immunization reflected the resident received the flu immunization 10/17/23. Review of Resident #44's progress notes dated 10/17/23, did not reflect documentation of immunization education provided. During an observation and interview on 01/11/24 at 1:40 PM, with the DCE, she opened each of the five sampled residents' immunization documentation in the electronic medical record. The documentation included a box to be checked if education was provided. Observation revealed the box was not checked for Resident #39, Resident #44, or Resident #77. For each resident, the DCE stated, No education. She stated it was important to provide education about the immunizations so the resident would know the risks and benefits. She stated she would review the records to see if the education was documented in a different location. A policy regarding immunizations and documentation of education provided to the three residents were requested. During an interview on 01/11/24 at 3:24 PM, with the Director of Nurses, he stated, the resident, if they are their own responsible party, or the designated responsible party was provided education on the phone before each immunization was administered. He stated the person who administered the immunization was responsible for documenting the site of administration, the lot number, and which immunization was given. He stated most of the time the education was documented in a progress note rather than checking the education box on the screen where the site and lot number were documented. He stated the Infection Preventionist was responsible for providing and monitoring immunizations. A policy regarding immunizations and documentation of education provided to the three residents were requested. During an interview on 01/11/24 at 7:05, the Administrator stated immunizations should be offered and made available when appropriate and when in season. She stated the resident or responsible party needed to be educated to the risks and benefits of each immunization to decide if they wanted the immunization. She stated education needed to be documented in the medical record. She stated without immunizations, there could be increased illness and without education the residents would not know if they desired or needed the immunizations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 32 of 33 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 675857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504 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 0883 Level of Harm - Minimal harm or potential for actual harm Review of the Resident Vaccinations policy, revised 01/22, reflected in part, The community will document in the medical record education provided to the resident or resident's representative regarding the benefits and potential side effects of vaccine/immunization type. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 33 of 33