Health inspection·December 8, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The care plan indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fellow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 2 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 out at 11:50 p.m. Level of Harm - Immediate jeopardy to resident health or safety Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. Residents Affected - Few During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/22/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 3 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 Level of Harm - Immediate jeopardy to resident health or safety The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: Identification of Residents Affected or Likely to be Affected: Residents Affected - Few The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Upon an allegation of abuse, Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. Resident will be interviewed. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with CNA A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 4 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 Level of Harm - Immediate jeopardy to resident health or safety having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors. Department Supervisors are subsequently training their staff. Residents Affected - Few DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 5 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 4. Level of Harm - Immediate jeopardy to resident health or safety Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. Residents Affected - Few 5. Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52 PM: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 6 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 BOM Level of Harm - Immediate jeopardy to resident health or safety Cook N Residents Affected - Few Dietary Aide Q Dietary Aide P MDS Coordinator Housekeeper R Housekeeper S Housekeeper T Housekeeper V LVN W Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE admission Coordinator RN FF Director of Rehabilitation Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 7 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0600 Treatment Nurse Level of Harm - Immediate jeopardy to resident health or safety Activities Assistant Residents Affected - Few AD CNA HH CNA KK CNA LL Transportation Supervisor LVN MM CNA NN LVN PP Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. They were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if they were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 8 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #1) residents reviewed for abuse. Residents Affected - Few The facility failed to follow facility policy of each resident having the right to be free from abuse, corporal punishment, and involuntary seclusion by not protecting Resident #1 from physical abuse by a staff member. The facility failed to implement their policy by providing training to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for abuse, neglect, and injuries of unknown origin. Findings include: 1. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. Record review of the Provider Investigation Report dated 12/6/22 indicated Housekeeper CCC witnessed CNA A slap Resident #2 on the back. The Provider Investigation Report indicated Housekeeper CCC also witnessed Resident #2 hit CNA A in the throat. The Provider Investigation Report indicated CNA denied slapping Resident #1 in the back. The Provider Investigation Report indicated CNA admitted to pushing Resident #1 due to Resident #2's aggression. The Provider Investigation Report indicated CNA A was suspended pending investigation. The Provider Investigation report indicated the facility determined the event to be unfounded. Record review of a written statement dated 12/6/22 by CNA A indicated Resident #2 was pulling on the computer wires at the nurse's station. The written statement indicated CNA A tried to take the computer wires from Resident #2. The written statement indicated Resident #2 grabbed CNA A by the throat and then Resident #2 hit CNA A in the throat with his fist. The written statement indicated CNA A pushed Resident #2 to get him off her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 9 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of an Investigation Statement/Interview dated 12/6/22 with Housekeeper CCC indicated on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The MDS indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fellow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record revie of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 10 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked out at 11:50 p.m. Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident because even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/5/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off of her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 11 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Level of Harm - Immediate jeopardy to resident health or safety Upon an allegation of abuse, Residents Affected - Few Resident will be interviewed. Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with C. N. A. A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors on 11/17/2023. Department Supervisors are subsequently training their staff. DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 12 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 been completed. Level of Harm - Immediate jeopardy to resident health or safety DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents Affected - Few Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. 4. Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 13 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Residents Affected - Few Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M BOM Cook N Dietary Aide P Dietary Aide Q MDS Coordinator Housekeeper R (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 14 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Housekeeper S Level of Harm - Immediate jeopardy to resident health or safety Housekeeper T Residents Affected - Few LVN W Housekeeper V Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE admission Coordinator RN FF Director of Rehab Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance Treatment Nurse Activities Assistant CNA HH AD CNA KK CNA LL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 15 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0607 Transportation Supervisor Level of Harm - Immediate jeopardy to resident health or safety LVN MM Residents Affected - Few LVN PP CNA NN Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. There were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if there were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 16 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review the facility failed to ensure residents were free of any significant medication errors for 2 of 7(Resident #3 and Resident #4) residents reviewed for medication errors. Residents Affected - Some The facility failed to ensure Resident #3 received only medication he was prescribed. The facility failed to ensure Resident #4 received long-acting insulin instead of short-acting insulin. The noncompliance was identified as PNC. The noncompliance began on 1/14/23 and ended on 5/30/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for not receiving the intended therapeutic benefit of the medications or experiencing adverse reactions relating to receiving a medication that was not ordered for them. Finding Include: 1. Record review of the face sheet dated 11/22/23 indicated Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), COPD, hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol), and hypothyroidism (decreased thyroid function). Record review of the Discharge MDS dated [DATE] indicated Resident #3 required supervision with bed mobility, transfers, and eating. The MDS indicated Resident #3 required extensive assistance with eating, toileting, and personal hygiene. The MDS did not indicated Resident #3 had a diagnosis of diabetes. Record review of the care plan last revised 1/13/23 indicted Resident #3 wandered aimlessly related to his confusion and resided on the secured memory unit. Record review of the physician orders dated 11/22/23 indicated Resident #3 did not have an order for insulin. Record review of the Medication Error Report dated 1/14/23 indicated Resident #3 was administered 4 units of Humulin R (a short-acting insulin used to treat elevated blood sugar) instead of the resident who was prescribed the medication. The Medication Error Report indicated immediate action taken by the facility included checking Resident #3's blood sugars, notification to the physician and family, and providing the resident with a snack. The Medication Error Report indicated Resident #3 was oriented to person only. Record review of the nursing progress note dated 1/14/23 at 10:30 p.m. written by LVN QQ indicated, [Resident #3] was given 4 units of Humulin R accidently. Checked blood sugar 95 (normal blood sugar range 70-100) at this time. Gave snack and doctor notified. Awaiting further instructions. RN Supervisor was called and [family] aware of incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 17 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the nursing progress note dated 1/14/23 at 11:21 p.m. written by LVN QQ indicated, [Resident #3] Blood sugar rechecked is 122 at this time and is not having any symptoms of hypoglycemia (decreased blood sugar) at this time . Record review of the nursing progress note dated 1/15/23 at 12:22 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar checked is 141 at this time has no signs and symptoms of hypoglycemia . Record review of the nursing progress note dated 1/15/23 at 12:59 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar checked 143 at this time alert and talking to staff . Record review of the nursing progress note dated 1/15/23 at 1:37 a.m. written by LVN QQ indicated, [Resident #3] awake and alert watching TV and drinking Dr. Pepper. Blood sugar 145 at this time and shows no signs and symptoms of hypoglycemia . Record review of the nursing progress noted dated 1/15/23 at 2:02 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar checked 145 shows no signs and symptoms of hypoglycemia is alert talking to staff and drinking his soda. Record review of the nursing progress note dated 1/15/23 at 2:35 a.m. written by LVN QQ indicated, [Resident #3] asleep at this time blood sugar checked and is 147 at this time and has no signs and symptoms of hypoglycemia . Record review of the nursing progress note dated 1/15/23 at 3:04 a.m. written by LVN QQ indicated, [Resident #3] asleep at this time blood sugar checked is 120 at this time awakened and alert x 1 (alert to only person, place, or time) and shows no signs and symptoms of hypoglycemia . Record review of the nursing progress note dated 1/15/23 at 3:35 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar checked is 121 at this time has no signs and symptoms of hypoglycemia at this time is alert and talking to staff. Record review of the nursing progress note dated 1/15/23 at 4:32 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar checked 122 at this time had no signs and symptoms of hypoglycemia alert and talking to staff. Record review of the nursing progress note dated 1/15/23 at 5:35 a.m. written by LVN QQ indicated, [Resident #3] Blood sugar rechecked 117 at this time resident sitting up in dining area waiting for breakfast and talking with other residents at the table . Record review of the nursing progress note dated 1/15/23 at 6:13 a.m. written by LVN SS indicated, [Resident #3] Blood sugar rechecked 109 at this time resident sitting up in dining area waiting for breakfast and talking with other residents at the table with him. Record review of the nursing progress note dated 1/15/23 at 7:04 a.m. written by LVN SS indicated, [Resident #3] Blood sugar rechecked 110 at this time sitting up in dining area eating breakfast and talking with the other residents at the table with him. Record review of the nursing progress note dated 1/15/23 at 8:16 a.m. written by LVN SS indicated, [Resident #3] sitting in dining room watching TV, no signs and symptoms of hypoglycemia, blood sugar 211. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 18 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0760 Level of Harm - Minimal harm or potential for actual harm Record review of the nursing progress note dated 1/15/23 at 8:25 a.m. written by LVN SS indicated, RN supervisor stated to stop hourly blood sugar During an interview attempt on 11/15/23 at 12:44 p.m. LVN QQ did not answer the phone and a voicemail was left. Residents Affected - Some 2. Record review of the face sheet dated 1/22/23 indicated Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including diabetes, COPD, muscle weakness, hypertension, morbid obesity, and chronic kidney failure. Record review of the Quarterly MDS dated [DATE] indicated Resident #4 understood others and was understood by others. The MDS indicated Resident #4 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #4 required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene and was independent with eating. The MDS indicated Resident #4 had a diagnosis of diabetes. Record review of the care plan last revised 8/28/23 indicated Resident #4 was at risk for hyper/hypoglycemia related to diagnosis of diabetes with intervention including insulin as ordered: Insulin Glargine Subcutaneous Solution and Insulin per sliding scale: Insulin Aspart Injection Solution. Record review of the physician orders dated 11/22/23 indicated Resident #4 had orders for insulin aspart (a short-acting insulin) injection solution 100 units/milliliter inject per sliding scale before meals starting 2/09/23 and insulin glargine (a long-acting insulin) subcutaneous solution 100 units/milliliter inject 22 units one time a day starting 11/03/23. Record review of the Medication Error Report dated 5/22/23 at 6:39 a.m. indicated Resident #4 was given 22 units of Novolog (Insulin Aspart) instead of Levemir (Insulin Detemir-a long-acting insulin). The Medication Error Report indicated immediate action taken included notification of the RN supervisor, DON, physician, and family, new order to check Resident #4's blood sugar every 15 minutes x 4 then every 30 minutes x 2. The Medication Error Report indicated Resident #4 was oriented to person, place, time, and situation. Record review of the nursing progress note dated 5/22/23 at 6:55 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 203 at this time, no signs and symptoms of hypoglycemia . Record review of the nursing progress note dated 5/22/23 at 7:10 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 227 at this time, no signs and symptoms of hypoglycemia. Record review of the nursing progress note dated 5/22/23 at 7:25 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 183 at this time, no signs and symptoms of hypoglycemia. Record review of the nursing progress note dated 5/22/23 at 7:40 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 278 at this time, no signs and symptoms of hypoglycemia. Record review of the nursing progress note dated 5/22/23 at 8:10 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 215 at this time, no signs and symptoms of hypoglycemia. Record review of the nursing progress note dated 5/22/23 at 8;40 a.m. written by LVN RR indicated, [Resident #4's] finger stick blood sugar 207 at this time, no signs and symptoms of hypoglycemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 19 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview attempt on 11/22/23 at 10:00 a.m. the Medical Director was out of the office for the holidays and not available for interview. During an interview on 11/22/23 at 10:38 a.m. the DON said she expected staff to abide by the 5-rights of medication administration when administering medications to residents. The DON said a resident should never receive a medication they do not have an order for. The DON said a resident should not receive short-acting insulin if the order is for long-acting insulin. The DON said if a resident received insulin and did not have an order for insulin or received short-acting insulin instead of long-acting insulin it could cause them to have an adverse reaction such as hypoglycemia. Record review of the facility's Medication Administration policy dated October 2012 indicated, .Always follow the five rights: Right Medication, Right Resident, Right Time, Right Amount, and Right Route. Check the physician's order for direction of Medication Administration Record (MAR). Check label on medication and compare to the order on the medication administration record . Record review of the facility's Administration of Injections policy dated April 2020 indicated, .Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice .verify physician's order and labeling prior to administration and compare to the medication administration record . The facility had corrected the noncompliance by the following: Reassessing LVN QQ for Medication Administration Competency In-servicing nurses and MAs on Medication Administration and 5 Rights of Medication Administration (right patient, right drug, right time, right dose, and right route) on 1/16/23 In-servicing nurses and MAs on Medication Administration on 5/23/23 Reassessing nurses and MAs on Medication Administration Competencies between 5/22/23 and 5/30/23 The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of an in-service dated 1/16/23 indicated nurses were in-serviced regarding Medication Rights and 5 Rights of Medication Administration (right patient, right drug, right time, right dose, and right route). Record review of LVN QQ's Medication Administration Competency dated 1/21/23 indicated she successfully met all competencies including identification of resident, explanation to resident of medication and what to do in the event of signs and symptoms of an adverse reaction, administering injections using proper technique, and no significant medication error observed during medication observations. Record review of an in-service dated 5/23/23 indicated nurses were in-serviced regarding Medication Administration. Record review of a random sample of nurse and MA Medication Competencies dated 5/22/23 through 5/30/23 indicated sampled nurses and MAs successfully met all applicable competencies including identification of resident, explanation to resident of medication and what to do in the event of signs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 20 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete symptoms of an adverse reaction, administering injections using proper technique, and no significant medication error observed during medication observations. Staff interviewed (LVN QQ, LVN SS, RN TT, RN VV, LVN WW, LVN XX, MA YY, MA ZZ, LVN AAA, RN BBB, LVN D, LVN K, and LVN Y) on 12/8/23 between 2:30 p.m. and 4:50 p.m. were able to name the 5 Rights of Medication Administration and proper medication administration including checking physician orders, injections only to be administered by licensed nurses, and checking the medication label against the MAR. Event ID: Facility ID: 675873 If continuation sheet Page 21 of 22 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 675873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418 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 0837 Level of Harm - Potential for minimal harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interview and records review the governing body failed to appoint an administrator who is Licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body. The facility failed to appoint a Licensed Administrator after the immediate resignation by the previous Administrator. This failure could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. Findings Include: 1. Record review of the Notice of Termination dated 11/09/23 for the previous Administrator indicated the effective date of termination was 11/08/23. The Notice of Termination indicated the previous Administrator's termination reason was resignation. The Notice of Termination indicated the previous Administrator was not eligible for rehire. During an interview on 11/15/23 at 8:43 a.m. the DON said the facility did not currently have an Administrator. During an interview on 11/16/23 at 2:30 pm the DON said the previous Administrator had resigned last week (week of 11/6/23 through 11/10/23), effective immediately. The DON said the facility did not have an interim Administrator at this time. The DON said the Regional [NAME] President was in the process of getting his provisional Administrator license for Texas because as of right now he was only licensed in Alabama for nursing facility administrator. During an interview on 11/22/23 at 11:45 a.m. the DON said the facility did not have a policy regarding having an Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 22 of 22