Inspection·March 7, 2025

F 0656 gain in 1 day. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's physician order, dated 02/19/25, reflected Daily weights with a start dated of 10/19/24. Residents Affected - Few Review of Resident #3's Weight Summary in her EMR, dated 02/19/25, reflected Resident #3's daily weight was not taken on the following dates: 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, & 02/17/25. Record review of a facility face sheet for Resident #14 dated 02/19/2025, reflected an [AGE] year-old female who was admitted to the facility 03/06/2024 Resident #14's diagnoses included: chronic fatigue (serious condition that causes extreme tiredness that doesn't improve with rest), history of falling (has a history of falling, which can indicate a higher risk of future falls), delusional disorder (someone firmly believes things that aren't true, even when presented with evidence that contradicts their beliefs) and essential primary hypertension (high blood pressure with no clear, identifiable cause). Record review of Resident #14's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #14's Quarterly MDS reflected she required substantial/maximal assistance in the areas of shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #14's Quarterly MDS reflected she was dependent in the areas of toileting hygiene and personal hygiene. Resident #14's MDS Section J1800 reflected that Resident #14 has had falls since admission/entry or reentry or the prior assessment with no injuries. Record review of Resident #14's Care Plan dated 02/19/2025 reflected Resident #14 was care planned for I am at risk for falls r/t: Hx, of falls, use of psychotropic meds, and heart disease, actual falls: 11/27/2024, 12/16/2024, & 12/21/2024. Resident #14's care plan did not reflect she had falls on 02/15/2025. Review of the facility's Fall incidents, dated 02/18/25, reflected Resident #14 had a fall on 02/15/25. During an interview with Resident #3 on 02/20/2025 at 9:15 am, Resident #3 stated that sometimes she did not feel like being weighed. Resident #3 stated being weighed daily was a hassle. Attempted to interview Resident #14 on 02/19/2025 at 10:45 am but was not successful due to her severe cognitive impairment. During an interview with LVN C on 02/20/2025 at 11:25 am, LVN C stated that Resident #3 had an order for daily weights. LVN C stated that Resident #3 refused to be weighed. LVN C stated that Resident #3 refused her daily weights usually once or twice a week. LVN C stated Resident #3 had an order for daily weighs due to her diagnosis of CHF. LVN C stated that the resident was often weighed during her physical therapy appointment due to her liking to be weighed in her wheelchair. During an interview with the MDS Coordinator on 02/20/2025 at 12:10pm, the MDS Coordinator stated she was responsible for updating resident's care plans. The MDS coordinator stated she was not aware of Resident #3's refusals. MDS coordinator stated if a resident has refused care frequently that should be care planned. The MDS coordinator stated that Resident #3's refusals of care should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 2 of 11 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 03/07/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm discussed in the morning meeting and care planned. The MDS Coordinator stated she was responsible for updating Resident #14's care plan to reflect her most recent fall on 02/15/25. The MDS coordinator stated she was not present during the morning meeting when the fall was discussed and forgot to update the resident's care plan. The MDS coordinator stated that a resident may not receive the appropriate care if the resident's care plan was not accurate or up to date. Residents Affected - Few During an interview with the DON on 02/20/2025 at 12:15pm, the DON stated that Resident #3 was not weighed on the following dates: 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, & 02/17/25 due to Resident #3 refusing. The DON stated that Resident #3's nurse was responsible for her being weighed daily per physician orders. The DON stated that Resident #3 was not care planned for refusal. The DON stated there would not be any negative outcome from Resident #3 not being care planned for refusals due to staff documenting her refusal. The DON stated that Resident #14's fall on 02/15/2025 should have been reflected on her care plan. The DON stated that MDS coordinator is responsible for updating care plans. The DON stated a negative outcome would be the resident's most recent fall would not be reflected on the care plan. During an interview with the ADM on 02/20/2025 at 1:10pm, the ADM stated the DON was responsible for ensuring residents who required daily weights are weighed. The ADM stated that a negative outcome of Resident #3 not being weighed daily was the resident could have an increase or decrease in weight. The ADM stated that his expectations were for all residents' physician orders to be followed as ordered. The ADM stated that his expectation was for all refusals of care to be documented and care planned. The ADM stated that if a resident was not care planned for refusals, they may not receive the proper care and the appropriate intervention would not be put in place to assist the resident. The ADM stated it was the MDS coordinator's responsibility for updating care plans with prior or new concerns. The ADM stated it was his expectation for care plan to be updated within 24 hours to reflect Resident #14's most recent fall. The ADM stated if a resident's care plan was not updated to reflect their most recent fall, the appropriate intervention may not be put in place for the resident to receive the highest quality of care. The ADM stated the facility used the RAI manual for care planning. Review of the Resident Assessment Instrument Manual dated October 2024, reflected the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 3 of 11 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 03/07/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #3 and #100) of nine residents reviewed for quality of care. Residents Affected - Few The facility failed weigh Residents #3 and #100 daily according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization. Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses including congenital stenosis of aortic valve (a person born with a narrowed aortic valve in their heart), chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), and essential primary hypertension (high blood pressure with no clear, identifiable cause). Review of Resident #3's annual MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Resident #3's annual MDS section I reflected Resident #3 had diagnoses of heart failure and hypertension. Resident #3's annual MDS reflected that Resident #3 required partial/ moderate assistance in the areas of toileting hygiene, upper body dressing, and lower body dressing. Resident #3's annual MDS reflected that Resident #3 was dependent in shower/bathe self and putting on/taking off footwear. Review of Resident #3's care plan, dated 02/19/25, reflected Resident #3 was care planed for I have heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema (swelling cause by fluid building up in body tissues), CHF/Heart Failure, Hyperlipidemia/ High Cholesterol, Hypertension. Resident #3 had an intervention of daily weight in the morning for CHF, give PRN torsemide if greater than 3 lb weight gain in 1 day. Review of Resident #3's physician order, dated 02/19/25, reflected Daily weights with a start date of 10/19/24. Review of Resident #3's Weight Summary in her EMR, dated 02/19/25, reflected Resident #3's daily weight was not taken on the following dates: 02/02/25, 02/05/25, 02/26/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, 02/17/25. Review of Resident #100's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a condition where a person has type 2 diabetes and narrowed arteries due to diabetes), type 2 diabetes mellitus with hyperglycemia (condition where a person with type 2 diabetes has high blood sugar levels), hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic disease (a condition where chronic kidney disease (CKD) is caused by high blood pressure (hypertension) and is classified as being in stages 1 to 4 of CKD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 4 of 11 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 03/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few progression, or where the specific stage of CKD is not clearly stated, indicating a general chronic kidney disease due to hypertension), chronic kidney disease, stage 4 (severe) (indicates a significant decline in kidney function where the kidneys are moderately to severely damaged, resulting in a reduced ability to filter waste from the blood, with an estimated glomerular filtration rate (eGFR) (a measurement of how well your kidneys are filtering waste products form your blood) between 15-29 ml/min, often accompanied by noticeable symptoms like swelling, fatigue, and potential complications like anemia and high blood pressure), anemia in chronic kidney disease (a condition where the blood has fewer red blood cells than normal), moderate protein-calorie malnutrition (state where a person has a significant but not severe deficiency in both protein and calories, typically characterized by a weight that is between 75-85% of their ideal body weight, noticeable muscle wasting, and potential signs of nutritional deficiencies, but not as extreme as in severe malnutrition). Review of Resident #100's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating he was cognitively intact. Resident #100's admission MDS also reflected he was dependent in the following areas: shower/bathe and putting on/taking off footwear. Resident #100 required substantial/maximal assistance in the following areas: oral hygiene, toileting hygiene, upper /lower body dressing, and personal hygiene. Resident #100 needed setup or cleanup assistance with eating. Review of Resident #100's care plan, dated 02/19/25, did not reflected Resident #100 is to be weighed three times a week. Record review of the Care plan on 03/07/2025 at 12:40PM reveal no interventions for weight gain. Review of Resident #100's physician order, dated 12/8/2024 and revised on 2/16/2025, reflected Resident #100 should be weighed every day on Mondays, Thursdays, and Sundays. Resident #100 had a previous physician order start dated 9/1/24 with a revision date 8/2/2024 of vitals should be taken one time a day ending on the first of every month. Record review of the Medical Record conducted 03/07/2025 at 11:57AM reveals diet orders changed from Renal diet, Minced and Moist texture, Thin/Regular consistency written on 08/07/2024 was changed to Regular diet, Regular Texture, thin/regular consistency on 12/06/2024 to meet resident preference. Face sheet reads Waiver signed by RP for Regular Diet, No fluid Restrictions. Review of Resident #100's Weights Summary in his EMR, dated 02/20/25, reflected Resident #100's weights had not been documented as ordered beginning from 9/1/2024 to current. Here are the dates and times, weights, and how the resident was weighed: Dates & Times Weights (pounds) Scale 8/2/2024 at 7:48 AM 120.6 Wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 5 of 11 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 03/07/2025 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 0684 10/7/2024 at 13:23 PM Level of Harm - Minimal harm or potential for actual harm 112.8 Standing Residents Affected - Few 11/8/2024 at 9:56 AM 114.0 Sitting 12/5/2024 at 17:38 PM 113.0 Sitting 1/9/2025 at 13:22 PM 113.0 Wheelchair 1/19/2025 at 11:27 AM 114.0 Sitting 2/6/2025 at 10:37 AM 134.0 Sitting 2/16/2025 at 13:44 PM 140.0 Sitting 2/17/2025 at 8:38 AM 141.0 Sitting During an interview with Resident #3 on 02/18/25 at 2:05 PM, Resident #3 stated she was not weighed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 6 of 11 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 03/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily. Resident #3 stated that sometimes she refused to be weighed and other times the nurse forgot to weigh her. Resident #3 stated that staff were not consisted with taking her weight so now she does not want to be weighed. During an interview with LVN A on 02/20/25 at 11:15 AM, LVN A stated she did not know Resident #100 was supposed to have his weight taken 3 times a week until it popped up in the computer system. LVN A stated she has fixed it that it that a symbol pops up in the MAR which indicates the resident needs to be weighed. LVN A stated Resident #100 must be weighed for edema in reference to CKD stage 4. She stated the nurse is responsible for taking the residents vitals, but the CNAs can take vitals also. During an interview with LVN B on 02/20/25 at 11:35 AM, LVN B stated sometimes Resident #100 refused to have his weight taken. LVN B had no answer for why he did not get weighed 3 times a week as ordered by the physician, and she stated she would get back to the surveyor with the results. LVN B never returned. During an interview with LVN C on 02/20/2025 at 11:25 am, LVN C stated that Resident #3 had an order for daily weights. LVN C stated that Resident #3 does refuse to be weighed. LVN C stated that Resident #3 refused her daily weights usually once or twice a week. LVN C stated that Resident #3 has an order for daily weights due to her diagnosis of CHF. LVN C stated that the resident was often weighed during her physical therapy appointment due to her liking to be weighed in her wheelchair. During an interview with the DON on 02/20/2025 at 12:15pm, the DON stated that Resident #3 was not weighed on the following dates 02/02/25, 02/05/25, 02/26/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, 02/17/25 due to her refusing. The DON stated that Resident #3's nurse was responsible for her being weighed daily per physician orders. During an interview with DON on 02/20/25 at 11:43 AM, DON stated Resident #100 had cardiac issues and if he is gaining too weight, it can cause shortness of breath. The DON stated the floor nurses are responsible to make sure the weights are done. DON stated he expects the nurses to follow doctor orders. During an interview with the ADM on 02/20/2025 at1:10pm, the ADM stated the DON was responsible for ensuring residents who required daily weights are weighed. The ADM stated that a negative outcome of Resident #3 not being weighed daily was the resident could have an increase or decrease in weight. The ADM stated that his expectations were for all residents' physician orders to be followed as ordered. During an interview with the NP on 03/07/2025 12:02PM she stated she was aware of the weight gain Ressident #100 had and had discussed with the MD. She also stated the weights were ordered so that she could monitor the resident's heart failure and be able to treat the swelling of his left leg. Furthermore, she stated residents have the right to refuse weights and consume foods of their choice. She stated the weight gain of the resident was not a concern. During a second interview with the NP conducted on 03/07/2025 at 4:14PM, she stated she had tried to educate the Resident #100 and his representative regarding his excessive intake of sugar and sodas. She also acknowledged the resident's excessive consumption of sugary snacks. During an interview with NP on 03/07/2025 at 12:02PM she stated the weight gain was not a risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 7 of 11 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 03/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete imminent harm to Resident #100. This was confirmed in an interview with the MD during an interview on 03/07/2025 at 3:11PM. Review of the facility policy Quality of Care dated January 2023 reflected The comprehensive assessment of a resident, the community will ensure resident receive the treatment and care in accordance with professionals standards of practice, the comprehensive person-centered care plan, and the resident's choices. Event ID: Facility ID: 675857 If continuation sheet Page 8 of 11 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 03/07/2025 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 - 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #120) observed for infection prevention. Residents Affected - Few The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN-D provided wound care for Resident #120 without wearing a gown. This deficient practice could place residents at-risk for spread of infection. Findings included: Record review of Resident #120's face sheet dated 06/08/2023 reflected he was an [AGE] year-old man, with an initial admission date of 06/08/2023 with diagnoses which included: Chronic Diastolic (Congestive) Heart Failure (a condition where the heart muscle is weakened and cannot pump blood effectively), Chronic Kidney Disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), Chronic Pain Syndrome (a condition characterized by persistent pain that lasts for at least 3 months and significantly impacts a person's life), Hyperkalemia (a condition where the potassium level in the blood is too high), Long Tern (Current) use of Anticoagulants, Gastro-esophageal Reflux Disease (a condition that occurs when stomach contents flow into the esophagus), without Esophagitis (an inflammation of the esophagus, the tube that carries food from the mouth to the stomach), Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland that can cause urinary symptoms) with lower Urinary Tract Symptoms, Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), and Atherosclerosis of Coronary Artery Bypass Graft(s) (a buildup of fatty plaque in the graft that can limit blood flow), and Unspecified with Unstable Angina Pectoris (a type of chest pain where the exact cause is unknown). Record review of Resident #120's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment. Further review reflected Resident #120 was assessed as having an unstageable pressure ulcer present upon reentry to the facility. Record review of Resident #120's Active Orders dated 02/14/2025 reflected orders which included: Enhanced Barrier Precautions start date 02/19/2025. WC: Clean area to right heel with normal saline. Apply Leptospermum honey and calcium alginate daily to the area and cover with a bordered gauze. Apply pressure relieving boot to right foot as indicated. start date 02/18/2025. Record review of Resident #120's Care Plan dated last reviewed 01/19/2025 reflected a Problem which included My skin is fragile, and I am at risk for skin injury-new or worsening skin condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 9 of 11 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 03/07/2025 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 Thin, fragile, loose skin. Actual skin impairment Deep Tissue Injury-Unstageable to right heel, initiated 08/23/2023 and revised 01/24/2025. This problem area included the following interventions: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few Apply treatment as ordered; initiated 08/23/2023 and Keep clean & dry and apply skin barrier cream as indicated.; Initiated 08/23/2023 Follow community's practice for assessing skin, reporting skin concerns to charge nurse doctor, resident or representative and follow skin protocol in place as indicated; Initiated 10/04/2023 Give dietary supplements to promote healing/resolving as indicated/ordered; Initiated 08/23/2023 I use therapeutic off-loading boots/Right heel protectors as indicated; Initiated 02/05/2025 Observation on 02/19/2025 at 09:16 a.m., reflected there was a sign indicating Enhanced Barrier Precautions above the head of the bed in Resident #120's room, and there was no supply of PPE available outside the door/room. Further observation revealed LVN D put on gloves but did not put on or wear a gown while performing wound care for Resident #120. During an interview with LVN D on 02/19/2025 at 01:30 p.m., LVN D stated that the wound care doctor considered open wounds to require gown and gloves during wound care. During an interview with the DON on 02/19/2025 at 01:56 p.m., the DON stated the resident should have been on EBPs. The DON stated a negative outcome of failure to abide by EBPs would be the spread of infection. Record review of facility policy titled Infection Prevention and Control revised 4/1/2024 reflected In addition to isolation practices, Enhanced Barrier Precautions (EBP) may be implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 10 of 11 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 03/07/2025 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 Residents/Patient with the following clinical indication should be under EBP: Level of Harm - Minimal harm or potential for actual harm Significant wounds such as chronic wounds, ulcers, open Pressure Ulcers or complicated/non-healing surgical incisions or wounds, and/or open wounds require a dressing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675857 If continuation sheet Page 11 of 11