Health inspection·January 25, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 , updated October 2023, indicated, .Completion of an OBRA admission assessment must occur in any of the following admission situations . when the resident has been in this facility previously and was discharged return not anticipated .For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600) . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 2 of 42 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 01/25/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, and interview the facility failed to coordinate assessments with pre-admission screening and resident review (PASARR ) program under Medicaid to the maximum extent practicable to avoid duplicative testing effort which included referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment ensure a PASRR screening was completed for residents with mental disorders or an intellectual disability for 4 of 7 residents (Residents #129, #26, #57, and #121) reviewed for PASRR Level I screenings. The facility failed to ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #129, #26, #57, and #121 who had a diagnosis of mental illness upon admission. These failures could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of Resident #129's face sheet, dated 01/25/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #129 had diagnoses which included PTSD (a mental health condition that developed following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), and depression (sadness). Record review of Resident #129's quarterly MDS assessment, dated 11/30/2023, indicated Resident #129 understood and understood others. Resident #129's BIMs score was 04, which indicated he was severely cognitively impaired. Resident #129 required limited assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and supervision with eating. Resident #129 was not currently considered by the state-level II PASRR process to have a serious mental illness. The MDS reflected Resident #129 had an active diagnosis of PTSD. Record review of Resident #129's comprehensive care plan, dated 05/31/2023, reflected Resident #129 had a risk of complications related to the diagnosis of PTSD. Record review of Resident #129's comprehensive care plan, dated 05/31/2023, indicated Resident #129 had a diagnosis of depression. Record review of Resident #129's PASRR Level 1 Screening form, dated 05/23/2023, reflected Resident #129 had no evidence or indicator of a mental illness. Record review of Resident #129's Order Summary Report, dated 01/23/2024, indicated Resident #129 had an order for Zoloft (medication used to treat depression) 50 milligrams give 1 capsule by mouth one time a day related to depression with a start date of 07/01/2023. During an interview on 01/25/2024 at 10:44 AM, the PASRR Coordinator said when a resident admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 3 of 42 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 01/25/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to a facility from another facility and the receiving facility noticed an error (such as they have them marked as a no for mental illness but they have a diagnosis of PTSD) they were responsible to call the previous facility and have them correct the PASRR level 1 screening. She said if the other facility refused to correct the PASRR level 1 screen, then the admitting facility should fill out a form 1012 and correct the error. She said once the receiving facility completed form 1012, they should be able to change the PASRR Level 1 screening to indicate mental illness. She said once it was changed and submitted through the facility computer system, then she would get an alert through the electronic system to come out and do a PASRR evaluation. She said the receiving facility should not have to contact her as that was the procedure. 2. Record review of the face sheet, dated 01/24/2024, revealed Resident #26 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the significant change MDS assessment, dated 09/07/2023, revealed Resident #26 was not currently considered by the state level II PASRR process to have serious mental illness. The MDS revealed Resident #26 had clear speech and was understood by staff. The MDS revealed Resident #26 was able to understand others. The MDS revealed Resident #26 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #26 had an active diagnosis of PTSD. Record review of the comprehensive care plan, initiated on 03/07/2023, revealed Resident #26 had a history of trauma that affects him negatively. Record review of the PASRR Level 1 Screening form, dated 02/21/2023, revealed Resident #26 had no evidence or indicator of a mental illness. 3. Record review of Resident #57's face sheet, dated 01/25/2024, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included Post-Traumatic Stress Disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and unspecified dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #57's admission MDS, dated [DATE], indicated Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. Resident #57 understood others and made himself understood. Resident #57 had a BIMS score of 12, which indicated his cognition was moderately impaired. Resident #57 had an active diagnosis of PTSD. Record review of Resident #57's, undated, comprehensive care plan, indicated Resident #57 was at risk for complications related to PTSD. The care plan interventions included, allow resident time to express feelings, do not argue with resident and notify physician as needed. Record review of the PASRR Level 1 Screening form, dated 08/08/2023, indicated Resident #57 had no evidence or indicator of dementia or a mental illness. During an interview on 01/23/2024 at 3:36 p.m., the Regional Clinical Consultant stated a Form 1012 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 4 of 42 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 01/25/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or PE had not been completed for Resident #26 or Resident #57. The Regional Clinical Consultant stated the MDS Coordinator was responsible for ensuring these forms were completed. During an interview on 01/24/2024 at 9:45 a.m., the MDS Coordinator stated she was responsible for ensuring the PASRR Level 1 was completed accurately. The MDS Coordinator stated when Resident #26 and Resident #57's PASRR Level 1 was reviewed and saw it was incorrect the local authority should have been contacted. The MDS Coordinator stated the previous MDS Coordinator was responsible for contacting the local authority for Resident #26 and Resident #57. The MDS Coordinator stated a Form 1012 should have been completed to correct the inaccurate PASRR Level. The MDS Coordinator stated she was not the one reviewing the PASRR Level 1 at the time Resident #57 was admitted . The MDS Coordinator stated it was important for the residents to be screened for PASRR to ensure they got the right services. During an interview on 01/24/2024 at 10:36 a.m., the PASRR Coordinator stated the MDS Coordinator should have contacted the referring entity and had them correct the PASRR Level 1. The PASRR Coordinator stated it was important to ensure the PASRR Level 1 was completed correctly to determine if the residents could receive services or not. 4. Record review of the face sheet dated 01/25/2024 indicated Resident #121 was a 77-old-male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Post-Traumatic Stress Disorder (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), other recurrent depressive disorders (repeated episodes of depression), and anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #121 was understood and understood others. The MDS assessment indicated Resident #121 had a BIMS score of 13, which indicated his cognition was intact. The MDS section, Preadmission Screening and Resident Review indicated Resident #121 did not have a serious mental illness. The MDS section, Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of depression and Post-Traumatic Stress Disorder. Record review of the care plan last reviewed 11/23/2023, indicated Resident #121 had a diagnosis of depression and was at risk for complications related to Post-Traumatic Stress Disorder and anxiety disorder. Record review of the Order Summary Report dated 01/23/2024 indicated Resident #121 had an order for Fluoxetine HCL (medication used to treat depression) 20 milligrams give 3 capsules by mouth one time a day related to other recurrent depressive disorders with a start date of 01/23/2024. Record review of Resident 121's PASRR Level 1 Screening completed on 02/07/2023 indicated in section C0100 no evidence of this individual having mental illness. During an interview on 01/25/2024 at 2:22 PM, MDS Coordinator L said she was responsible for coordinating the PASRR process in the facility. MDS Coordinator L said if she noticed a PASRR Level 1 screening was not correct she should call the local authority for further instructions. MDS Coordinator L said for Resident #121 the local authority should have been contacted when the facility noticed he had the diagnosis of Post-Traumatic Stress Disorder and his PASRR Level 1 screening did not indicate he had a mental illness. MDS Coordinator L said Resident #121's PASRR Level 1 screening should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 5 of 42 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 01/25/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm have indicated yes, he had a mental illness. MDS Coordinator L said at the time of Resident #121's admission she was not responsible for PASRR, therefore she did not know why the local authority had not been contacted. MDS Coordinator L said the previous MDS Coordinator responsible for PASRR was no longer at the facility. MDS Coordinator L said it was important for the PASRR Level 1 screening to accurately reflect the resident so they could have the services they needed provided to them. Residents Affected - Some During an interview on 01/25/2024 at 4:55 PM, the Administrator said he had only been at the facility for 14 days. The Administrator said the MDS Coordinator was responsible for the PASRR process. The Administrator said he expected them to follow the PASRR process. The Administrator said it was important for the PASRR Level 1 screenings to be accurate for the residents to receive the extra services they needed. Record review of the facility's undated policy titled, Preadmission Screening and Resident Review (PASRR), indicated, .To ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that the individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs Procedure: 1. The PASRR will be completed prior to admission of a resident to the facility with mental disorders or intellectual disabilities . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 6 of 42 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 01/25/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 7 residents reviewed for care plans related to PTSD. (Resident #68) The facility failed to ensure Resident #68's care plan reflected his diagnosis of PTSD, that included triggers for potential re-traumatization. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and potential re-traumatization. The findings included: Record review of the face sheet, dated 01/25/24, revealed Resident #68 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the quarterly MDS assessment, dated 11/22/23, revealed Resident #68 had clear speech and was understood by staff. The MDS revealed Resident #68 was able to understand others. The MDS revealed Resident #68 had a BIMS score of 8, which indicated moderately impaired cognition. The MDS revealed Resident #68 had no behaviors or refusal of cares. The MDS revealed Resident #68 had an active diagnosis of PTSD. Record review of the comprehensive care plan initiated on 01/25/24, after surveyor intervention, revealed Resident #65 was at risk for complications related to a diagnosis of PTSD. The problem, goal, and interventions did not address potential triggers to prevent re-traumatization. During an interview on 01/25/24 beginning at 11:37 AM, MDS Coordinator L stated she was responsible for ensuring PTSD was included on the care plan. MDS Coordinator L was unsure why Resident #68 did not have a care plan for his diagnosis of PTSD. MDS Coordinator L stated she thought the diagnosis was included on his care plan. MDS Coordinator L stated it was important to ensure a diagnosis of PTSD was included on the care plan so staff would have known his history to provide proper care. MDS Coordinator L stated it was important to ensure PTSD triggers were identified and addressed to prevent re-traumatization of the residents and for the safety of the residents and staff members. During an interview on 01/25/24 beginning at 05:31 PM, the Administrator stated he expected PTSD diagnoses to be included on the care plan. The Administrator stated the MDS Coordinator's and nursing staff were responsible for ensuring PTSD was included on the care plan. The Administrator stated it was important to ensure a diagnosis of PTSD was included on the care plan because it impacted care. Record review of the Care Plan policy, revised June 2019, revealed .The comprehensive care plan has been designed to: a. Identify care needs that include resident's strengths, history, and preferences; b. Incorporate risk factors; c. Establish goals in measurable outcomes; d. Include individualized approaches to meet resident's goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 7 of 42 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 01/25/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 30 (Residents #57 and #299) residents reviewed for ADL care. Residents Affected - Few 1. The facility did not ensure Resident #57 was provided his scheduled bath/showers. 2. The facility failed to ensure Resident #299 received his shower as scheduled on 01/22/2024. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of Resident #57's face sheet, dated 01/25/2024, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnoses which included Stage 4 chronic kidney disease (moderately or severely loss of kidney function). Record review of Resident #57's admission MDS, dated [DATE], indicated Resident #57 understood others and made himself understood. Resident #57 had a BIMS score of 12, which indicated his cognition was moderately impaired. Resident #57 was dependent for personal hygiene, toileting, shower/bath and required supervision with oral hygiene. Record review of Resident #57's, undated, comprehensive care plan, indicated Resident #57 required assistance with daily personal care, which included oral care related to weakness. The care plan interventions included, assist resident with bathing, dressing, grooming as needed, and encourage resident to participate in care. Record review of the undated, 400 & 500 Hall Shower Schedule indicated Resident #57 was scheduled to receive showers Monday, Wednesday, and Friday. Record review of Resident #57's PRN Bathing/Shower report, dated 12/28/203-01/23/2024, indicated no documentation for Resident #57 for 4 out of 5 scheduled bath/showers. During an interview on 01/23/2024 at 8:16 a.m., Resident #57 was lying in bed looking into the hallway. When the State surveyor introduced herself, Resident #57 stated no wonder they came in and gave me a bath. When asked if he had been receiving his showers as scheduled, he stated it's been a minute which indicated he could not remember. Resident #57 was unable to give the last time he was showered or given a bed bath. Resident #57 stated not getting his bed bath/shower made him feel dirty. During an interview on 01/24/2024 at 5:28 p.m., CNA Z stated CNAs were responsible for giving residents bath or showers. CNA Z stated Resident #57 never refused a bed bath or shower when she worked. CNA Z stated Resident #57 should receive a bed bath or shower on Monday, Wednesday, and Friday. CNA Z stated ADL care was charted on the facility's charting system. CNA Z stated it was important for Resident #57 to receive his bed bath or shower so he could feel and look clean. CNA Z stated this failure could potentially put Resident #57 at risk for an infection or could cause his wound to his buttocks to worsen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 8 of 42 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 01/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/25/2024 at 9:20 a.m., CNA BB stated CNAs were responsible for giving residents bath or showers. CNA BB stated Resident #57 liked to receive his bed bath or shower. CNA BB stated Resident #57 should receive a bed bath or shower on Monday, Wednesday, and Friday. CNA BB stated she was not able to give Resident #57 a bed bath on 01/19/2024 due to him being a two person assist and not having staff available. CNA BB stated she reported to LVN AA about not being able to give Resident #57 a bed bath. CNA BB stated it was important Resident #57 received his bed bath/shower as schedule to prevent further skin break down to his buttocks. During an interview on 01/25/2024 at 9:33 a.m., Unit Manager G stated CNAs were responsible for giving showers. Unit Manager G stated Resident #57 should receive showers or bed baths on Monday, Wednesday, Friday. Unit Manager G stated she was not aware of staff not being able to provide him a bed bath/shower. Unit Manager G stated if the CNAs were not able to provide a shower or bed bath, they were supposed to report that to their charge nurse and the charge nurse should have reported it to her. Unit Manager G stated to her knowledge she could not remember if the charge nurse on 01/19/2024 reported to her that CNA BB was not able to give Resident #57 a shower. Unit Manger G stated it was important for the residents to receive their baths/showers to make sure they were getting the care they needed. Unit Manager G stated this failure could potentially put Resident #57 at risk for an infection. An attempted telephone interview on 01/25/2024 at 9:51 a.m. with LVN AA, was unsuccessful. During an interview on 01/25/2024 at 4:21 p.m., the DON stated the charge nurse was responsible for ensuring the CNAs performed ADLs. The DON stated CNAs were supposed to complete bed bath/showers according to their schedule and the nurses were supposed to follow up and ensure the baths/showers were completed. The DON stated the unit managers were ultimately responsible for ensuring the residents had their showers as scheduled. The DON stated she did daily rounds and any concerns with care were addressed through a grievance and then investigated. The DON stated she was not aware Resident #57 was not receiving his bed baths/showers as scheduled. The DON stated he had not reported this issue to her. The DON stated it was important to ensure showers/bed baths were given to helps with skin integrity, reduce infections, and overall help the resident to feel clean. During an interview on 01/25/2024 at 5:15 p.m., the Administrator stated he expected residents to receive their bed baths/showers as scheduled and PRN. The Administrator stated it was important for the residents to receive their showers for general cleanliness, hygiene, and dignity. 2. Record review of a face sheet dated 01/25/2024, indicated Resident #299 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Post-Traumatic Stress Disorder (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it) and altered mental status. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #299 was usually able to make himself understood and understood others. Record review of the MDS assessment indicated Resident #299's BIMS score was 14, which indicated his cognition was intact. The MDS assessment indicated Resident #299 did not exhibit rejection of care. The MDS assessment indicated Resident #299 was independent with all his ADLs, which included showers and personal hygiene. Record review of the care plan with date initiated 01/11/2024 indicated Resident #299 required assistance with his daily personal care which included oral care because he was a new admission to the facility with interventions which included assist resident with bathing, dressing, and grooming as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 9 of 42 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 01/25/2024 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 0677 needed. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #299's Order Summary Report dated 01/23/2024 indicated droplet precautions-influenza (a type of infection control measure used to prevent the spread of respiratory infections that are spread through droplets produced by coughing or sneezing) with a start date of 01/21/2024. Residents Affected - Few Record review of the undated 400 & 500 Hall Shower Schedule indicated Resident #299 received showers Monday, Wednesday, and Friday. The shower schedule did not indicate a time or shift all that was indicated was PM. Record review of Resident #299's electronic health record indicated only PRN (as needed) Bathing/Shower. The PRN Bathing Shower record indicated Resident #299 had not received a shower 01/22/2024 and 01/23/2024. During an observation and interview on 01/23/2024 at 10:00 AM, Resident #299 said he had not received a shower since he had been on isolation. Resident #299 said he was told he would not be able to get a shower because he was on isolation. Resident #299 said he had not refused showers, and it would make him very happy if he could get one. Resident #299's hair appeared greasy and disheveled. During an interview on 01/24/2024 at 4:51 PM, Unit Manager G said Resident #299 received showers on Monday, Wednesday, and Friday on the 2 PM- 10 PM shift. Unit Manager G said she was made aware Resident #299 had not received his shower Monday, and the CNAs had told Resident #299 he could not get a shower because he was on droplet precautions. Unit Manager G said she had educated the staff regarding this, and Resident #299 would get a shower that afternoon. Unit Manager G said if a resident required special precautions, they could still receive their shower, but it would be done after everybody else's shower had been given and they had to wear a mask. Unit Manager G said it was important for the residents to receive their showers for their health and well-being. During an attempted phone interview with CNA X on 01/25/2024 at 8:42 AM, CNA X did not answer the phone. During an interview on 01/25/2024 at 8:54 AM, LVN F said the CNAs should give the residents their showers. LVN F said she was not aware Resident #299 was told he could not get a shower due to being on droplet precautions. LVN F said she monitored that the CNAs gave showers by reviewing the shower sheets. LVN F said it was important for the residents to receive their showers to maintain their health and cleanliness. During an interview on 01/25/2024 at 9:05 AM, Unit Manager G said the CNAs did not use shower sheets, and all showers were documented in the resident's electronic health record. During an interview on 01/25/2024 at 4:57 PM, the Administrator said any of the residents could have a shower when they wanted one. The Administrator said he expected the staff to give the residents a shower whenever they requested one. The Administrator said it was important for the residents to receive their showers for their hygiene. During an interview on 01/25/2024 at 5:53 PM, the DON said the charge nurses were responsible for ensuring the CNAs completed their tasks, which included showers. The DON said even if a resident required special precautions, they should receive their showers. The DON said it was important for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 10 of 42 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 01/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm residents to receive their showers for their skin integrity, to reduce the risk of infection, and to make them feel clean. Record review of the facility's policy revised October 2012, titled, Shower/Tub Bath, indicated, . To promote cleanliness and comfort . 5. Encourage the resident to bathe him/herself. Assist as needed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 11 of 42 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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #33 and Resident #92) and 2 of 7 halls (Halls 700 and 800) reviewed for accidents and supervision. 1. The facility failed to ensure the bathroom for Resident #33 and Resident #92 was free of leaking water. 2. The facility failed to ensure the Residents on Hall 700 and Hall 800 were adequately supervised. These failures could put residents at risk of serious bodily harm, physical impairment, or death. Findings Include: 1.Record review of Resident #33's face sheet, dated 01/25/24, indicated Resident #33 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. Resident #33 had diagnoses which included arthritis (causes joint pain, stiffness, and inflammation), leg cramps (painful, involuntary muscle contractions that can last seconds or minutes), Benign prostatic hyperplasia, also called BPH (a condition in men in which the prostate gland is enlarged and not cancerous). Record review of Resident #33's quarterly MDS assessment, dated 12/26/23, indicated Resident #33 understood and understood others. Resident #33's BIMs score was 13, which indicated he was cognitively intact. Resident #33 was independent with toileting, personal hygiene, transfer, dressing, eating, and bed mobility. The MDS indicated he was always continent of bowel and bladder. Record review of Resident # 33's comprehensive care plan, dated 06/01/22, indicated he was at risk for falls related to gait/balance problems and the use of a walker for ambulation. During an observation and interview on 01/22/24 at 2:48 p.m., Resident #33 said everything was going well except for the bathroom commode leaked and the square patched area in the middle of the bathroom floor where they attempted to patch still leaked water. He said he felt it could be a fall risk because he and his roommate walked. He said he told unknown staff and it had not been fixed. Observation of the bathroom revealed water on the right side of the commode and an area near the center of the bathroom floor that appeared to have been patched remained with water leaking from around the edges. 2. Record review of Resident #92's face sheet, dated 01/25/24, indicated Resident #92 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #92 had diagnoses which included stroke (lack of adequate blood supply to brain cells deprived them of oxygen and vital nutrients which can cause parts of the brain to die off), seizures (when too many of your brain cells become excited at the same time) and anxiety (feeling of fear). Record review of Resident #92's quarterly MDS assessment, dated 12/26/23, indicated Resident #92 understood and understood others. Resident #92's BIMs score was 14, which indicated he was cognitively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 12 of 42 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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm intact. Resident #92 required a set up for eating and was independent with toileting, personal hygiene, transfer, dressing, and bed mobility. Resident #92 was always continent of bowel and bladder. Record review of Resident #92's comprehensive care plan, dated 09/04/23, indicated Resident #92 was at risk for injury (falls) related to impaired mobility. Residents Affected - Some During an interview and observation on 01/24/24 at 4:50 p.m., LVN M went into Resident #33 and Resident #92's bathroom and saw the water next to the commode and the area on the floor where water came up from the floor. She said she was not aware of the water leak but could see a potential hazard because both residents walked. She asked Resident #92 about the water, and he said it had been that way for an unknown amount of time. LVN M said she would put in a work order in TELS. During an interview on 01/25/24 at 1:42 p.m., the Maintenance Supervisor said he was not aware of any issues in the bathroom of Resident #33 or Resident #92. He said he would not know unless someone filled out a TELS (a system used for services to help with day-to-day maintenance work), for him to fix the issue. He said if water was leaking, he could see a potential for a fall. During an interview on 01/25/24 at 2:52 p.m., Unit Manager O said she was not aware of any water leaks in Resident #33 or Resident #92 bathroom. She said anyone who entered Resident #33 and Resident #92's bathroom was responsible for ensuring water was not on the floor. She said if water were on the floor, it could be a fall risk. She said a maintenance person fixed the water leak around the commode this morning (01/25/24) after the surveyor's intervention. She said she was not aware of the patch on the floor in the bathroom that was leaking. Unit Manager O and the State Surveyor walked into Resident #33's bathroom and noted the patched area had not been fixed and water was seeping from under the floor. She said she would notify maintenance. During an interview on 01/25/24 at 3:43 p.m., the DON said she was not aware of any water issues in Resident #33 or Resident #92's bathroom. She said all staff were responsible for ensuring floors were dry. She said if a staff member noted any water in Resident #33 or Resident #92's bathroom, they should have alerted maintenance and filled out a TELS form in the computer system. She said water on the floor could cause a fall and risk of injury. During an interview on 01/25/24 at 4:20 p.m., the Administrator said any staff member who had been in Resident #33 or Resident #92's bathroom should have noticed water on the floor. He said the staff should have placed an order in TELS. He said water on the floor in the bathroom could be a slip-fall risk. Record review of maintenance TELS did not reveal any work order for Resident #33 or Resident #92's leaking commode or leaking patched area in their bathroom before surveyor intervention. 3. During an observation on 1/22/24 at 2:15 p.m., CNA S was observed sleeping in the dining room with the residents walking around in the dining room on (Hall 700 and Hall 800-Memory Care Unit). Residents in the dining room were very active and were socializing with other residents. During an interview on 1/23/24 at 8:37 a.m., CNA S stated she was sorry about sleeping and when the State Surveyor woke her up to ask her a question on locating a resident in the dining room. CNA S stated she also helped with transportation sometimes. CNA S stated she was supposed to be supervising the residents. CNA S stated the charge nurse oversaw her. CNA S stated it was important to watch and supervise the residents to prevent injuries, altercation and or falls with the resident's safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 13 of 42 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 01/25/2024 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 0689 CNA S stated LVN T oversaw her. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/23/24 at 4:00 p.m., the DON stated the abuse coordinator was the Administrator and in the administrator's absence it would be her. The DON stated she had been employed at the facility about 7 years. The DON stated she did not expect staff to be sleeping while working at the facility. The DON stated she was not aware of CNA S sleeping while working in the dementia care unit. The DON stated that if she had found employee's sleeping that she would immediately terminate that employee. The DON stated she had not ever witnessed staff sleeping at the facility. The DON stated it would be important for staff to not be sleeping while watching residents in the locked unit for safety of the resident's and staff and to keep the residents engaged. The DON stated the Administrator oversaw her. Residents Affected - Some During an attempted phone interview on 1/24/24 at 2:59 p.m., LVN T was unavailable to be reached by phone. During an interview on 1/24/24 at 3:24 p.m., the Administrator stated the residents should be supervised in the locked units. The Administrator stated he did expect staff to be awake and alert while supervising the residents when working on the dementia unit. The Administrator stated he was not aware of CNA S sleeping in the dementia care unit. The Administrator stated he had not witnessed staff sleeping at the facility The Administrator stated he did conduct random checks in the locked units every day. The Administrator stated staff had not had any in-services on supervisions for Alzheimer's. The Administrator stated he believed all staff needed more education on supervision because, Education makes the world go round. The Administrator stated staff had not been counseled on supervision to his knowledge. The Administrator stated there was adequate staff in the dementia care unit. The Administrator stated it was important for staff to ensure they were supervising the residents to ensure staff were doing the right thing when no one was looking and for residents to ensure the resident's safety and well-being. During an interview on 1/255/24 at 5:40 p.m., the DON stated the facility did not have an incident and accident policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 14 of 42 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 01/25/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 9 residents with a nebulizer machine (Resident #57) and 4 of 11 residents who received oxygen (Resident's #130, #47, #57, and #81) that were reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #47 oxygen was placed on 2 LPM as ordered by the physician. 2. The facility failed to administer oxygen at 2L via nasal cannula as prescribed by the physician for Resident #57. 2a. The facility failed to properly store Resident #57's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. 3. The facility failed to ensure Resident #130's nasal cannula tubing was changed weekly. 3a. The facility failed to ensure Resident #130's nasal cannula tubing was changed weekly. 4. The facility failed to ensure Resident #81's oxygen concentrator filter was free from a brown-like substance. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 01/25/2024, revealed Resident #47 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of heart failure (progressive heart disease that affects pumping action of the heart muscles that causes fatigue and shortness of breath), non-ST (part of an electrocardiogram between the QRS complex and the T wave) elevation myocardial infarction (heart attack), and chronic bronchitis (an inflammation of the airways in your lungs that causes a frequent cough with mucus for two years or longer). Record review of the significant change MDS assessment, dated 12/04/2023, revealed Resident #47 had clear speech and was understood by staff. The MDS revealed Resident #47 was able to understand others. The MDS revealed Resident #47 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS revealed Resident #47 had shortness of breath or trouble breathing while lying flat. The MDS revealed Resident #47 received oxygen therapy while a resident at the facility. Record review of the comprehensive care plan, revised on 12/05/2023, revealed Resident #47 was receiving oxygen related to signs and symptoms of shortness of breath. The interventions included: administer oxygen as prescribed by the physician at 2 LPM per nasal cannula. Record review of the order summary report, dated 01/25/2024, revealed Resident #47 had an order, which started on 06/07/2023, for continuous oxygen at 2 liters per nasal cannula for signs or symptoms of shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 15 of 42 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 01/25/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the MAR, dated January 2024, revealed Resident #47 was receiving oxygen at 2 LPM via nasal cannula for shortness of breath. During an observation and interview on 01/22/2024 beginning at 1:36 PM, Resident #47 was laying in the bed with his head elevated. The oxygen concentrator was set at 1 LPM and the nasal cannula was in Resident #47's nose. Resident #47 stated he did not know what his oxygen setting should have been set at. Resident #47 had no shortness of breath or signs of respiratory distress during the interview. During an observation on 01/23/2024 beginning at 10:56 AM, Resident #47 was laying in the bed with his head elevated. The oxygen concentrator was set at 1 LPM and the nasal cannula was in Resident #47's nose. Resident #47 had no shortness of breath or signs of respiratory distress. During an observation on 01/24/2024 beginning at 4:33 PM, Resident #47 was laying in the bed with his head elevated. The oxygen concentrator was set at 1 LPM and the nasal cannula was in Resident #47's nose. Resident #47 had no shortness of breath or signs of respiratory distress. During an interview on 01/25/2024 beginning at 3:28 PM, LVN P stated the nurses were responsible for ensuring oxygen was set at the ordered settings. LVN P stated the order was on the computer and it was required to sign it off on the MAR. LVN P stated the sign off was only to ensure the oxygen was on, not that it was on the correct settings. LVN P stated Resident #47 was supposed to wear oxygen at 2 LPM. LVN P was unsure why the oxygen settings were at 1 LPM. LVN P stated it was important to ensure oxygen was set to the correct settings because it was dangerous and could harm him. LVN P stated oxygen set at lower than ordered settings could have caused his oxygen level to decrease. During an interview on 01/25/2024 beginning at 3:39 PM, Unit Manager R stated the nurses were responsible for signing off on oxygen orders. Unit Manager R stated she expected the nurses to ensure oxygen concentrators were set at the ordered settings and that the residents were wearing the oxygen. Unit Manager R stated oxygen concentrators were monitored weekly during room rounds by management staff. Unit Manger R stated it was important to ensure oxygen was set at the correct settings to ensure oxygen levels did not drop or the residents did not develop signs or symptoms of respiratory distress. During an interview on 01/25/2024 beginning at 5:14 PM, the DON stated the charge nurse was responsible for ensuring oxygen was set at the ordered settings. The DON stated the Unit Manager was responsible for monitoring to ensure oxygen concentrators were set at the appropriate settings. The DON stated it was important to ensure oxygen was set at the ordered settings, so staff followed the physician's orders and did not compromise the respiratory system. During an interview on 01/25/2024 beginning at 5:31 PM, the Administrator stated he expected staff to ensure oxygen concentrators were set at the correct settings. The Administrator stated the charge nurse was responsible for ensuring oxygen concentrators were set at the ordered settings. The Administrator stated the Unit Manager was responsible for monitoring the charge nurse. The Administrator stated it was important to ensure oxygen concentrators were set at the correct settings to prevent hypoxia (low oxygen level). 2. Record review of Resident #57's face sheet, dated 01/25/2024, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 16 of 42 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 01/25/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the physician order report, dated 01/25/2024, indicated Resident #57 had an order for oxygen at 2 liter per minute continuous with a start date 08/10/2023. The physician order report indicated Resident #57 received Budesonide Inhalation Suspension (medication used to prevent difficulty breathing) 0.5 mg/2ml, inhale orally via nebulizer two times a day related to COPD with a start date 09/27/2023. Record review of Resident #57's admission MDS, dated [DATE], indicated Resident #57 understood others and made himself understood. Resident #57 had a BIMS score of 12, which indicated his cognition was moderately impaired. Resident #57 received oxygen therapy. Record review of Resident #57's, undated, comprehensive care plan indicated Resident #57 was at risk for respiratory distress related to diagnosis of COPD. The care plan interventions included, continuous oxygen at 2 LPM, change oxygen and/or nebulizer tubing weekly and observe for s/sx of respiratory distress (restlessness, wheezing, SOB, diaphoresis [sweating], tachycardia [fast heart rate], etc.). During an observation and interview on 01/23/2024 at 8:29 a.m., Resident #57 was lying in bed wearing oxygen via nasal cannula. Resident #57's five-liter oxygen concentrator was set on 3 LPM. Resident #57 stated he wore oxygen all the time due to SOB. Resident #57's nebulizer mask was lying inside the nebulizer machine and was not covered. During an observation on 01/24/2024 at 8:45 a.m., Resident #57 was lying in bed wearing oxygen via nasal cannula. Resident #57's five-liter oxygen concentrator was set on 1.5 LPM. Resident #57's nebulizer mask was lying on the bedside table and was not covered. During an observation, interview, and record review on 01/24/2024 at 8:49 a.m., LVN CC stated she was Resident #57's charge nurse. LVN CC observed with the surveyor Resident #57's oxygen concentrator set at 1.5 LPM and nebulizer mask lying on the bedside table. LVN CC stated she did not know what his settings should be. After LVN CC reviewed Resident #57 electronic medical records, LVN CC stated the rate should be at 2 liters per minute and the mask should be covered when not in use. LVN CC stated this failure could potentially put Resident #57 at risk for a hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and respiratory infection. During an observation on 01/25/2024 at 9:15 a.m., Resident #57 was lying in bed wearing oxygen via nasal cannula. Resident #57's five-liter oxygen concentrator was set on 1.5 LPM. Resident #57's nebulizer mask was lying on bedside table and was not covered. During an interview on 01/25/204 at 1:43 p.m., the RN Supervisor stated she was the charge nurse for a few hours for Resident #57. The RN Supervisor stated the charge nurse was responsible for ensuring the oxygen settings were correct and the nebulizer mask was covered when not in use. The RN Supervisor stated she had not been in the room because she had just got assigned to Resident #57 a few minutes before prior to surveyor intervention to ensure the oxygen settings were correct and the nebulizer mask was covered. The RN Supervisor stated it was important to make sure the resident was getting the correct amount of oxygen that was ordered by the physician to prevent hypoxia. The RN Supervisor stated it was important to ensure the mask was covered when not in use to keep germs from entering and possibly causing a respiratory infection. During an interview on 01/25/2024 at 3:18 p.m., Unit Manager G stated she expected Resident #57's nebulizer mask be stored in a bag when not in use. Unit Manager G stated she expected Resident #57 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 17 of 42 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 01/25/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm oxygen to be set at 2 liters per minute per the physician orders. Unit Manager G stated at this time there was not a monitoring process for the failures mentioned above. Unit Manager G stated it was important to ensure the correct amount of oxygen was being administered to prevent hypoxia or over oxygenate due to the disease process (COPD). Unit Manager G stated the risk associated with not keeping the nebulizer mask covered was respiratory infection. Residents Affected - Some 3. Record review of Resident #130's face sheet, dated 01/25/2024, indicated Resident #130 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the physician order report, dated 01/25/2024, indicated Resident #130 had an order for oxygen at 2 liter per minute PRN for oxygen saturation <90 with an order date 12/26/2023. Record review of Resident #130's quarterly MDS, dated [DATE], indicated Resident #130 understood others and made himself understood. Resident #130 had a BIMS score of 14, which indicated his cognition was intact. Resident #130 received oxygen therapy. Record review of Resident #130's undated comprehensive care plan, indicated Resident #130 was at risk for respiratory distress related to diagnosis of COPD, chronic rhinitis [common cold], and cough/congestion. The care plan interventions included, continuous oxygen at 2 LPM, change oxygen and/or nebulizer tubing weekly and observe for s/sx of respiratory distress (restlessness, wheezing, SOB, diaphoresis [sweating], tachycardia [fast heart rate], etc.). Record review of the TAR dated 01/01/2024-01/31/2024, indicated: LVN EE signed off she changed Resident #130's oxygen tubing and filter 01/14/2024 and 01/17/2024 on the 6p-6a shift. LVN DD signed off she changed Resident #130's oxygen tubing and filter 01/21/2024 on the 6p-6a shift. During an observation and interview on 01/22/2024 at 1:53 p.m., Resident #130 was lying in bed and oxygen was in use via nasal cannula. Resident #130's nasal cannula tubing was dated 01/11. Resident #130's oxygen concentrator filter had a thick, grey, fuzzy material. Resident #130 stated he wore oxygen due to respiratory problems. During an observation on 01/23/2024 at 8:16 a.m., Resident #130 was lying in bed and oxygen was in use via nasal cannula. Resident #130's nasal cannula tubing was dated 01/11. Resident #130's oxygen concentrator filter had a thick, grey, fuzzy material. During an observation on 01/24/2024 at 8:53 a.m., Resident #130 was lying in bed and oxygen was in use via nasal cannula. Resident #130's nasal cannula tubing was dated 01/11. Resident #130's oxygen concentrator filter had a thick, grey, fuzzy material. During an observation, interview, and record review on 01/24/2024 at 8:55 a.m., LVN Q stated she believed nurse staff on Wednesday nights were responsible for changing/labeling tubing and filter. LVN Q observed with the surveyor Resident #130's nasal cannula tubing dated 01/11 and the filter with a thick, grey, fuzzy material. After reviewing Resident #130 electronic medical records, LVN Q stated the filter and tubing should be changed on Wednesdays and Sundays. LVN Q stated she would go ahead (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 18 of 42 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 01/25/2024 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 0695 and change the tubing and filter. LVN Q stated this failure could potentially place residents at risk for respiratory infection. Level of Harm - Minimal harm or potential for actual harm An attempted telephone interview on 01/25/2024 at 10:09 a.m. with LVN EE, was unsuccessful. Residents Affected - Some An attempted telephone interview on 01/25/2025 at 3:03 p.m. with LVN DD, was unsuccessful. During an interview on 01/25/2024 at 2:16 p.m., Unit Manager FF stated the filters and tubing should all be changed on the Wednesday night shift by the charge nurse. Unit Manager FF stated the TAR should not have indicated the task was completed when in fact it was not. Unit Manager FF stated she monitored by weekly random rounds. Unit Manager FF stated her last round was done the week of 1/15/2024. Unit Manager FF stated she did not notice the filter and the tubing needed to be changed. Unit Manager stated it was important those tasks were completed because it went into the resident's respiratory tract and could possibly cause a respiratory infection. During an interview on 01/25/2024 at 4:21 p.m., the DON stated the charge nurses were responsible for ensuring the tubing was changed and dated weekly and PRN. The DON stated the charge nurses were responsible for ensuring the filters were cleaned or changed weekly and PRN. The DON stated the charge nurses were responsible for ensuring the oxygen was on the correct settings and his nebulizer was stored appropriately between each treatment. The DON stated the unit manager was ultimately responsible to ensure these duties were carried out weekly. The DON stated her and the Infection Control Preventionist also monitored by random spot checks. The DON stated there had not been a trend with non-compliance with the above-mentioned issues. The DON stated the facility also did grand rounds where the department heads went around on Monday morning to ensure compliance. The DON stated it was important to ensure the tasks were completed to prevent compromising the respiratory system. During an interview on 01/25/24 at 5:15 p.m., the Administrator stated he was deferring to the DON regarding nasal cannula tubing and oxygen concentrator filters. 4. Record review of Resident #81's face sheet, dated 01/25/2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included COPD,( a group of diseases that cause airflow blockage and breathing-related problems) End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning permanently leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and diabetes (a condition that happens when your blood sugar [glucose] is too high). Record review of Resident #81's quarterly MDS assessment, dated 11/09/2023, indicated Resident #81 understood and understood others. Resident #81's BIMs score was 04, which indicated he was severely cognitively impaired. Resident #81 required limited assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set up for eating. The MDS indicated he required oxygen. Record review of Resident #81's comprehensive care plan, dated 08/31/2023, indicated he was at risk for respiratory distress related to the diagnosis of COPD. Interventions were for staff to observe for adequate airway and comfort and check, clean, and/or replace oxygen filter weekly. During an observation on 01/22/2024 at 1:26 PM, Resident #81's oxygen concentration filter contained a brown-like substance. During an observation and interview on 01/24/2024 at 5:43 PM, LVN M said oxygen concentrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 19 of 42 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 01/25/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some filters should be changed every Wednesday night shift and they should be cleaned to prevent infection. LVN M looked at Resident #81's oxygen concentrator filter and said it was dirty. During an interview on 01/25/2024 at 2:52 PM, Unit Manager O said she looked at Resident #81's oxygen concentrator filter and said it was dirty, she said she tried to clean it before this interview. She said the nurses were responsible for ensuring oxygen filters were cleaned weekly and as needed. She said dirty filters could cause dust to go into the machine and place residents at risk of infection. During an interview on 01/25/2024 at 3:43 PM, the DON said she did not know why Resident #81's oxygen concentrator filter was dirty. She said the charge nurses were responsible for ensuring oxygen concentrator filters were cleaned on Wednesday nights and as needed. She said dirty filters could cause the machine not to work effectively therefore causing respiratory issues. During an interview on 01/25/2024 at 4:20 PM, the Administrator said he was not sure why Resident #81's oxygen concentrator filter was dirty. He said it was the responsibility of the nurses to clean or change the oxygen concentrator filters. He said nurse management was the overseer to ensure nurses were changing oxygen filters weekly or as needed. He said the risk for dirty oxygen filters was wear and tear on the machine and infection. Record review of the facility policy titled, Oxygen Administration, revised: February 2015, indicated The policy: Correct technique and standards of practice will be used with oxygen administration. Purpose: To administer oxygen to the resident with insufficient oxygen saturation. Procedure:1. Check the physician's order for the flow rate and the method of administration . 2c. Change the face mask weekly or as indicated . 5. a. Change the prefilled disposable humidifier bottles and tubing weekly. b. Clean the filters daily with soap and water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 20 of 42 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents (Resident #85) reviewed for medication administration. The facility did not ensure Resident #85's furosemide (diuretic), metoprolol tartrate (blood pressure medication), valproic acid (anticonvulsant), and lacosamide (anticonvulsant) labels from the pharmacy matched the orders placed in the electronic charting system. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings included: Record review of the face sheet, dated 01/25/2024, revealed Resident #85 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (long-term condition that develops over many years in people who have high blood pressure), conversion disorder with seizures or convulsions (condition where a mental health issue disrupts how your brain works causing physical symptoms), gastrostomy status (feeding tube is a device that's inserted into your stomach through your abdomen), and dysphagia (condition with difficulty in swallowing food or liquid). Record review of the significant change MDS assessment, dated 01/10/2024, revealed Resident #85 had unclear speech and was usually understood by staff. The MDS revealed Resident #85 was able to understand others. The MDS revealed Resident #85 had short-term and long-term memory problems. The MDS revealed Resident #85 had moderately impaired decision-making skills. The MDS revealed Resident #85 received more than half of his calories and fluid intake through a feeding tube while a resident. Record review of the comprehensive care plan, revised 08/23/2022, revealed Resident #85 was at risk for complications related to hypertension (high blood pressure). The interventions included: medication as ordered: metoprolol tartrate tablet enterally. The care plan revealed Resident #85 was at risk for complications related to seizure disorder. The interventions included: medication as ordered: lacosamide oral solution enterally and valproic acid solution 250mg/5mL enterally. The care plan revealed Resident #85 was at risk for fluid and electrolyte imbalance related to daily use of a diuretic. The interventions included: medication as ordered: furosemide tablet enterally. Record review of the order summary report, dated 01/25/2024, revealed Resident #85 had an order for the following: 1. Furosemide 20 mg - give 1 tablet enterally one time a day related to heart failure, which started on 07/04/2023. 2. Lacosamide oral solution 10mg/mL - give 15mL enterally two times a day related to conversion disorder with seizures, which started on 07/03/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 21 of 42 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm 3. Metoprolol tartrate tablet 25 mg - give 1 tablet enterally two times a day related to high blood pressure, which started on 07/03/2023. 4. Valproate sodium solution 250mg/5mL - give 25 mL enterally two times a day related to conversion disorder with seizures, which started on 07/03/2023. Residents Affected - Few Record review of MAR, dated January 2024, revealed Resident #85 received furosemide, lacosamide, metoprolol tartrate, and valproate sodium per the physician's orders. During an observation on 01/23/2024 beginning at 8:01 AM, LVN Q started preparing Resident #85's medications for administration. LVN Q placed the following into separate medication cups to administer enterally: 1. one furosemide 20 mg tablet 2. one metoprolol tartrate 25 mg tablet 3. 25 mL of valproic acid 250mg/5mL solution 4. 15 mL of lacosamide 10mg/mL solution. The medication labels from the pharmacy on the medications listed above stated by mouth for the route of administration. LVN Q crushed the medication and administered all medications enterally through his feeding tube. During an interview on 01/25/2024 beginning at 3:36 PM, LVN Q stated she had not noticed any labels from the pharmacy not matching the orders in the computer. LVN Q stated the person administering medications usually looked at the order in the computer on the MAR and compared it to the card. LVN Q stated she should have noticed the cards did not match the order. LVN Q stated that was only her second shift on the 300 Hall. LVN Q stated it was important to ensure the pharmacy labels matched the orders in the electronic charting system because if someone did not know Resident #85 and administered his medications by mouth, it could have caused aspiration or choking. During an interview on 01/25/2024 beginning at 3:39 PM, Unit Manager R stated charge nurses were responsible for ensuring medication labels matched the orders in the computer. Unit Manager R stated if a medication label did not match, a change of directions sticker should have been placed on the card or bottle, and the pharmacy should have been notified. Unit Manger R stated the Pharmacy Consultant completed monthly audits and had not identified or noticed the medication labels not matching the orders. Unit Manager R stated it was important to ensure medication labels from the pharmacy matched the medication orders in the computer to prevent a medication error. Unit Manager R stated Resident #85 could have aspirated, choked, or had an adverse reaction if the medication was given incorrectly. During an interview on 01/25/2024 beginning at 4:24 PM, the Pharmacy Consultant stated he performed monthly audits. The Pharmacy Consultant stated the audit was 10 -15% and was a small portion. The Pharmacy Consultant stated he had not identified any trends with medication labels not matching the orders. The Pharmacy Consultant stated the medications labels not matching the orders had happened a few times, but it was brought to the facilities attention, and it was fixed. The Pharmacy Consultant stated it was important to ensure medication labels from the pharmacy matched the medication orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 22 of 42 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 01/25/2024 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 0755 in the computer, so the medication was given properly and prevent medications errors. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2024 beginning at 5:14 PM, the DON stated the charge nurses were responsible for ensuring the pharmacy labels matched the orders in the computer. The DON stated it was monitored daily by the nurses administering the medications. The DON stated spot checks were completed by the pharmacy nurse. The DON stated it was monitored monthly by the pharmacy consultant. The DON stated it was important to ensure medication labels from the pharmacy matched the orders in the carting system to ensure residents received medications via the correct route. Residents Affected - Few During an interview on 01/25/2024 beginning at 5:31 PM, the Administration stated he expected nursing staff to ensure medication labels from the pharmacy matched the orders placed in the computer. The Administrator stated the charge nurses, then nursing management were responsible for monitoring to ensure medication labels from the pharmacy matched the orders in the electronic charting system. The Administrator stated it was important to ensure medication labels from the pharmacy matched the orders to decrease the risk of injury or adverse reactions from the medications. Record review of the General Dose Preparation and Medication Administration policy, revised 01/01/2022, revealed .facility staff should verify each time a medication is administered that it is the correct medication . at the correct route . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 23 of 42 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 01/25/2024 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 observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents reviewed for insulin administration. (Resident #300) Residents Affected - Few The facility did not ensure LVN A administered Resident #300's Novolog (insulin aspart) FlexPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 01/25/2024, revealed Resident #300 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar). Record review of Resident #300's MDS assessment revealed it was not due to have been completed yet. Record review of the comprehensive care plan, initiated on 01/16/2024, revealed Resident #300 was at risk for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) related to diagnosis of diabetes mellitus. The interventions included: insulin per sliding scale: Novolog Injection Solution. Record review of the order summary report, dated 01/25/2024, revealed Resident #300 had an order for Novolog Injection Solution 100 units/mL per sliding scale: if 150 - 200 = 2 units . Record review of the MAR, dated January 2024, revealed Resident #300 received insulin injections daily. Record review of the manufacturer's website, accessed on 01/25/2024 at 4:38 PM, revealed a video titled NovoLog FlexPen Instructions for Use. The video revealed at 2 minutes and 18 seconds, To avoid injection of air and ensure proper dosing perform an air shot. The video further revealed an air shot included dialing the insulin pen to 2 units, holding the pen upright and injecting the 2 units into the air to ensure all air bubbles were out. During on observation on 01/23/2024 beginning at 11:11 AM, LVN A prepared Resident #300's Novolog FlexPen. LVN A dialed the insulin pen to 2 units after comparing the blood sugar to the sliding scale order. LVN A then took the cap off the pen and went into Resident #300's room. LVN A wiped Resident #300's left lower abdomen with an alcohol prep pad. LVNA A then opened the needle and screwed it on to the tip of the insulin pen. LVN A then administered the insulin pen to Resident #300's left lower abdomen. LVN A did not prime the pen or perform an air shot prior to administration. During an interview on 01/23/2024 beginning at 11:17 AM, LVN A stated she normally prepared the insulin pen by dialing the amount and then applying the needle. LVN A stated she had not heard of priming the pen or performing an air shot. LVN A stated she was unaware of what the manufacturer's instructions were for the NovoLog FlexPen as she had not looked them up. LVN A stated it was important to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 24 of 42 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 01/25/2024 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 - Few ensure the manufacturer's instructions were followed to ensure residents received the correct dosage of insulin. During an interview on 01/25/2024 beginning at 4:02 PM, Unit Manager G stated she expected the charge nurses to follow the manufacturer's instructions when administering an insulin pen. Unit Manager G stated she expected the nurses to look up administration instructions if they were unsure how to administer an insulin pen. Unit Manager G stated it was important to ensure insulin was administered per the manufacturer's instructions because it puts the residents at risk to receive the incorrect dosage of insulin. Unit Manager G stated an incorrect dosage of insulin could have led to uncontrolled diabetes which could have caused a change in the organ systems. During an interview on 01/25/2024 beginning at 4:24 PM, the Pharmacy Consultant stated there was a lot of debate regarding the priming of the insulin pens. The Pharmacy Consultant stated if insulin pens were primed each time they were used, the resident would run out of medication. The Pharmacy Consultant stated the manufacture instructions for use was a guideline and they could have been used for off-label problems. During an interview on 01/25/2024 beginning at 5:14 PM, the DON stated medication and insulin should have been given per the physician's order and manufacturer's instructions or guidelines. The DON stated it was important to ensure insulin pens were administered according to manufacturer's instructions, so residents received the most effect dosage of medication. During an interview on 01/25/2024 beginning at 5:31 PM, the Administrator stated insulin should have been administered according to the manufacturer's instruction. The Administrator stated nursing management was responsible for monitoring to ensure insulin was administered correctly. The Administrator stated it was important to ensure insulin pens were given correctly so the residents received the full dosage. Record review of the General Dose Preparation and Medication Administration policy, revised 01/01/2022, revealed .follow manufacturer medication administration guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 25 of 42 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 01/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 3 residents (Resident #12) reviewed for medications at their bedside and 1 of 6 (500 Hall) medication carts reviewed for storage of medications. 1. The facility did not ensure Resident #48's Nystatin Powder was not unsecured in Resident #12's room. 2. The facility did not ensure LVN A kept the medication cart on 500 Hall locked or within her line of site, while administering medications. This failure could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings included: 1. Record review of Resident #48's face sheet, dated 01/25/2025, indicated Resident #48 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure). Record review of the physician order summary report dated 01/25/2024, indicated Resident #48 had an order for Nystatin External Powder 100000 unit/gm, apply to areas of moisture topically as needed for rash with a start date 10/23/2023. 2. Record review of Resident #12's face sheet, dated 01/25/2024, indicated Resident #12 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included paroxysmal atrial fibrillation (irregular rapid heart rate). Record review of the physician order summary report dated 01/25/2024 did not indicate Resident #12 had an order for Nystatin External Powder. Record review of Resident #12's annual MDS, dated [DATE], indicated Resident #12 understood others and made himself understood. The assessment indicated Resident #12 had a BIMS score of 15, which indicated her cognition was intact. During an observation and interview on 01/22/2024 at 2:05 p.m., Resident #12 was sitting in his recliner pouring himself a drink. There was a bottled labeled Nystatin 100000-unit topical powder on Resident #12 tv stand. The bottle prescription label had Resident #48 information on it. Resident #12 stated the medication was being used for his back because it itched. Resident #12 did not know who brought the medication in his room. During an interview and observation on 01/22/2023 at 2:10 p.m., LVN GG observed with the surveyor the bottled labeled Nystatin 100000-unit topical powder on Resident #12 tv stand. LVN GG removed the bottle from the tv stand. LVN GG stated when she did her rounds on 01/22/24 prior to surveyor intervention she did not notice the powder on his tv stand. LVN GG stated all staff were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 26 of 42 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 01/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some checking resident rooms to ensure safety. LVN GG stated it was important that other resident medications were not at bedside because this could potentially cause an allergic reaction. During an interview on 01/25/2024 at 2:16 p.m., Unit Manager FF stated all nursing staff were responsible for ensuring the resident rooms did not contain items that should not be in there such as the nystatin powder. Unit Manager FF stated that she felt like Resident #48's nystatin powder did not get transferred to the charge nurse on the other hall when he moved rooms. Unit Manager FF stated she had never had to reprimand a nurse for using other resident medications on another resident. Unit Manager stated it was important to ensure that other resident medications, treatment supplies, etc should not be entering other rooms to prevent errors and the possibility of adverse reactions. Unit Manager FF stated she monitored by random room rounds. Unit Manager FF stated her last round for Resident #12 was the week of 01/15/2024. Unit Manager FF stated the powder was not sitting out to where it could be visibly seen. During an interview on 01/25/2024 at 4:21 p.m., the DON stated all staff were responsible for ensuring medications were storage appropriately. The DON stated the unit managers should be monitoring by rounds and anything identified should be addressed. The DON stated she monitors by routine spot checks to ensure compliance. The DON stated she had not noticed a trend with medications being stored at bedside. The DON stated if there an issue it was corrected immediately, and the physician was notified if an order was needed. The DON stated grand rounds were done weekly on Monday morning. The DON stated it was important to ensure medications were not let at bedside for resident safety and to ensure they did not receive medications that could have an adverse reaction. During an interview on 01/25/24 at 5:15 p.m., the Administrator stated he was deferring to the DON regarding medication storage. 3. During an observation on 01/23/2024 beginning at 11:11 AM, LVN A went into Resident #300's room to obtain a blood sugar check. LVN A left the 500 hall nurses' cart unlocked in the hallway, which was not visible from Resident 300's room. LVN A returned to the 500 hall nurses' cart to prepare and administer insulin. LVN A went into Resident #300's room to administer the insulin. LVN A left the 500 hall nurses' cart unlocked in the hallway, which was not visible from Resident #300's room. During an interview on 01/23/2024 beginning at 11:17 AM, LVN A stated she should have kept the 500 hall nurses' cart locked when she was away from it. LVN A stated she was nervous with state watching her and she forgot. LVN A stated it was important to ensure the nurses' carts were kept locked to ensure residents did not obtain injuries or adverse reactions. During an interview on 01/25/2024 beginning at 4:02 PM, Unit Manager G stated she expected the medication carts to remain locked anytime the nurses stepped away. Unit Manager G stated it was monitored by random observation by nursing management. Unit Manger G stated it was important to ensure medication carts were remained locked to prevent a resident or another employee from getting into the cart. Unit Manager G stated if residents were able to get into the cart, they could obtain medications or supplies and become hurt. During an interview on 01/25/2024 beginning at 5:14 PM, the DON stated she expected the nursing staff to ensure their medication or treatment carts were remained locked when they stepped away out of sight. The DON stated it was monitored by random observation. The DON stated it was important to ensure the medication carts were kept locked to prevent injury to the residents or a drug diversion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 27 of 42 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 01/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2024 beginning at 5:31 PM, the Administrator stated he expected nursing staff to ensure the medication carts were kept locked when they stepped away out of sight. The Administrator stated it was the licensed staff member's responsibility to have kept it locked and anyone passing's responsibility to monitor it. The Administrator stated it was important to ensure medication carts were kept locked to prevent accidents or a drug diversion. Residents Affected - Some Record review of the Storage and Expiration Dating of Medications, Biologicals policy, revised 08/07/23, revealed Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Record review of the General Dose Preparation and Medication Administration policy, revised 01/01/2022, revealed 7. Facility should ensure that medication carts are always locked when out of sight or unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 28 of 42 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 01/25/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 assist residents in obtaining routine dental services to meet the needs of 1 of 2 (Resident #124) residents reviewed for dental services. Residents Affected - Few The facility failed to ensure Resident #124 received dental services when he had jagged, black teeth and missing teeth. This failure could place residents at risk of not receiving needed dental care, difficulty eating, toothaches, tooth infections, and a decreased quality of life. Findings included: Record review of a face sheet dated 01/25/2024 indicated Resident #124 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic diastolic congestive heart failure (the heart's main pumping chamber, left ventricle, becomes stiff an unable to fill properly) and atrial fibrillation (irregular often rapid heartbeat). Record review of the Comprehensive MDS assessment indicated Resident #124 was able to make himself understood and understood others. The MDS assessment indicated Resident #124's BIMS score was a 15, which indicated his cognition was intact. The MDS assessment indicated Resident #124 had no issues with swallowing. The MDS assessment indicated Resident #124 had obvious or likely cavity or broken natural teeth. The MDS assessment indicated Resident #124 did not require a mechanically altered diet. Record review of the Order Summary Report dated 01/25/2024 indicated Resident #124 had the following orders: regular diet with regular texture with a start date of 08/03/2023 dental care as needed with a start date of 02/23/2023 dental consult related to poor dentition with a start date of 03/06/2023. Record review of the care plan last reviewed 11/20/2023 indicated Resident #124 was at risk for mouth pain related to presence of carious broken teeth (tooth decay) and history of a jaw fracture with interventions which included a dental consult related to poor dentition (teeth). Record review of Resident #124's Dental Record with an effective date of 02/23/2023 indicated all his teeth on the top were broken off and several teeth on the bottom were black and broken. During an observation on 01/22/2024 at 2:34 PM, Resident #124 had missing teeth, and some were black and appeared jagged. During a group interview on 01/23/2024 at 3:30 PM, Resident #124 said he needed to see the dentist, and an appointment had not been made. Resident #124 said he would not know if he had pain because he took routine pain medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 29 of 42 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 01/25/2024 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/25/2024 at 9:30 AM, CNA H said she was responsible for scheduling appointments for the residents. CNA H said the nurses obtained a physician order from the doctor to refer the residents to the dentist, and then she made the appointments. CNA H said Resident #124 had asked her when he was going to be taken to the dentist, but CNA H said she never received a physician's order for a referral to the dentist for Resident #124. CNA H said Resident #124 had asked her sometime last year mid-summer. CNA H said whenever residents asked her about appointments, and she did not have a referral she should ask the nurse to get a physician's order so the referral could be made. CNA H said she could not remember if she had talked to the nurse about obtaining an order for a referral to the dentist for Resident #124. CNA H said it was important for the residents to be referred to the dentist because it could affect their health and chewing ability. During an interview on 01/25/2024 at 4:59 PM, the Administrator said the dental services they used were from an outside dental agency if the resident had dental services. The Administrator said it depended on the resident's insurance if they would be private pay or not. The Administrator said if the residents needed to go to the dentist, he expected for them to be taken. The Administrator said it was important for the residents to receive dental services because good dentition was key and they could have pain, it could affect their eating, and they could get an abscess. During an interview on 01/25/2024 at 5:55 PM, the DON said the process for residents to be referred to for dental care depended on their payer source. The DON said Resident #124 had not mentioned to her that he needed to go to the dentist. The DON said the nurses would put an order in the electronic health record, and then CNA H reviewed the orders for the referrals and made the appointments. The DON said the unit managers performed random audits on the orders to ensure appointments were not missed. The DON said it was important to ensure the residents were referred for dental care for their dental health, to avoid weight loss, infections, and so they could eat and maintain a healthy dental status. Record review of the facility's policy titled, Dental Services, last revised November 2017, indicated, . To ensure that the facility assist residents in obtaining routine (to the extent covered under the state plan) and 24-hour emergency dental care. Procedure: 1. Assist resident to make dental appointments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 30 of 42 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 01/25/2024 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 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 observations, interviews, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident's #30 and #299) reviewed for infection control practices related to droplet precautions and 4 of 11 facility staff members (MA C, LVN A, LVN F, and Speech Therapist D) reviewed for infection control practices related to medication pass and droplet precautions. The facility further failed to ensure facility personnel handled, stored, processed, and transported linens so as to prevent the spread of infection for 1 of 5 staff members (CNA N) reviewed for transportation of linens. Residents Affected - Many 1. The facility failed to ensure LVN A, MA C, Speech Therapist D wore the appropriate PPE when entering Resident #30's and Resident #299's room. 2. The facility failed to ensure LVN F removed her PPE prior to exiting Resident #30's and Resident #299's room. 3. The facility failed to ensure LVN A performed hand hygiene and changed her gloves during a blood sugar check and insulin administration. 3b. The facility failed to ensure LVN A cleaned the tip of Resident #300's insulin pen with an alcohol prep pad, prior to applying the needle. 4. The facility failed to ensure that CNA N did not carry linen next to her body. These failures could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: 1. Record review of a face sheet dated 01/25/2024, indicated Resident #299 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Post-Traumatic Stress Disorder (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it) and altered mental status. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #299 was usually able to make himself understood and understood others. Record review of the MDS assessment indicated Resident #299's BIMS score was 14, which indicated his cognition was intact. The MDS assessment indicated Resident #299 was independent with all his ADLs, including showers and personal hygiene. Record review of the care plan with date initiated 01/22/2024 indicated Resident #299 was diagnosed with influenza virus on 01/21/2024 with interventions for droplet precautions (a type of infection control measure used to prevent the spread of respiratory infections that are spread through droplets produced by coughing or sneezing). Record review of Resident #299's Order Summary Report dated 01/23/2024 indicated droplet precautions-influenza with a start date of 01/21/2024 and Tamiflu 75 mg give 1 capsule by mouth two times a day for Influenza- Flu A for 5 days with a start date of 01/22/2024 and an end date of 01/27/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 31 of 42 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #299's progress notes indicated a progress note dated 01/21/2024 at 9:45 PM, resident had returned from the hospital at 9:14 PM with diagnosis of Infuenza-Flu A with new medication orders received to start Tamiflu 75 mg by mouth twice daily for 5 days for treatment of Flu A, to give Motrin (ibuprofen) and Tylenol for fever/pain, resident quarantined upon arrival, droplet/contact precautions for 7 days signed by LVN Y. Residents Affected - Many 2. Record review of a face sheet dated 01/25/2024 indicated Resident #30 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke that caused weakness and paralysis of the right side of the body) and hypertensive heart disease without heart failure (complications of high blood pressure that affect the heart). Record review of Resident #30's Comprehensive MDS assessment dated [DATE] indicated he usually understood others and was usually understood by others. The MDS assessment indicated Resident #30 had a BIMS score of 3, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #30 required partial/moderate assistance with showering/bathing himself, set up or clean-up assistance for eating, independent for oral, toileting, dressing, and personal hygiene. Record review of the care plan last review completed on 01/22/2024 indicated Resident #30 was at risk for complications related to Influenza-Flu A and interventions included droplet precautions for 7 days. During an observation and interview on 01/22/2024 starting at 2:52 PM, a cart with PPE was outside Resident #30's and Resident #299's room, no sign indicating residents required special precautions was on the door and the door was open. Surveyor entered to screen Resident #30. Resident #30 was non-interviewable. While with Resident #30, Resident #299's privacy curtains were pulled around his bed, and Resident #299 came out from behind the curtains and told Surveyor not to come too close to him because he had the flu and had it since maybe Friday. During an interview on 01/22/2024 at 3:17 PM, LVN A said Resident #299 had the flu, but Resident #30 did not. LVN A did not indicate if any special precautions were being taken while providing care to either resident. During an observation on 01/23/2024 at 8:17 AM, MA C went in Resident #30's and Resident #299's room with only a mask, no gown, gloves, or face shield were worn. MA C did not remove/change her mask upon exiting the room and went into other residents' rooms. During an observation on 01/23/2024 at 8:22 AM, a sign was posted on the door indicating droplet precautions were required prior to entering Resident #30's and Resident #299's room. LVN A entered the room with only a mask on, no gown, gloves or face shield were worn. During an interview on 01/23/2024 at 8:29 AM, LVN A said she was new to the facility. LVN A said she was not sure what PPE was required when a resident required droplet precautions. LVN A then said she was sure she had to wear a mask and she though maybe a face shield, but only with Resident #299. LVN A said Resident #30 did not require any special precautions. LVN A did not know if she needed to change the mask when she exited the room. LVN A said she would go look but she was not sure if she had to wear a gown, gloves, and face shield. LVN A said she could ask the unit manager what PPE was required. LVN A said what PPE was required might just depend on how comfortable you were being around Resident #299. LVN A said she felt comfortable being around Resident #299 with just a face mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 32 of 42 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and she had washed her hands. LVN A said she could not answer why she should wear he appropriate PPE while in Resident #30's and Resident #299's room. LVN A said she thought the PPE was maybe because the flue was droplet, and it was more for the family and visitors. LVN A said because she had been vaccinated for the flu for herself, she should only wear a face mask. During an interview on 01/23/2024 at 8:34 AM, Nurse Aide B said she believed to go into Resident #30's and Resident #299's room a KN95 mask should be worn, no gown was required because it was not COVID. Nurse Aide B said gloves should be worn if touching the residents but other than that just a face mask was worn. During an interview on 01/23/2024 at 8:36 AM, MA C said she had gone into Resident #30's and Resident #299's room to give Resident #299 his Tamiflu. MA C said all she did was hand him his medication. MA C said no special PPE was required with Resident #30 she would just wear a face mask. MA C said Resident #299 required droplet precautions and she should have worn a gown gloves and face mask when giving him his medications. MA C said it was important to wear the appropriate PPE because Resident #299 could sneeze or breathe on you, and you could catch the flu. During an observation on 01/24/2024 at 10:10 AM, Speech Therapist D entered Resident #30's and Resident #299's room with only a face mask on. During an interview on 01/24/2024 at 10:48 AM, Speech Therapist D said she had gone in to see Resident #299. Speech Therapist D said she saw the sign on the door indicating droplet precautions were in place and she went ahead and when in there without the appropriate PPE. Speech Therapist D said there was no reason she did not put on the appropriate PPE she just did not think about it. Speech Therapist D said she had a face mask on, and she thought that was plenty. Speech Therapist D said Resident #299 had the flu, so droplet precautions were required, but she had not sat close to him. Speech Therapist D said it was important to wear the appropriate PPE to keep you safe and to keep you from carrying the virus. Speech Therapist D said she could carry the virus with her to other residents. During an interview on 01/24/2024 at 4:47 PM, Unit Manager G said when droplet precautions were required the nurses or nurse managers put in a physician order for droplet precautions, a sign was posted on the door and a cart with PPE was placed outside the door. Unit Manager G said the nurses should be passing on in report when a resident required special precautions to ensure all staff were aware. Unit Manager G said for droplet precautions the staff should wear a gown, gloves, face mask, and face shield, and the face mask should be changed when exiting the residents room. Unit Manager G said droplet precautions were not required with Resident #30 because he was only exposed, but they were required for Resident #299. Unit Manager G said it was important to wear PPE to stop the chain of infection. During an observation on 01/24/2024 at 5:00 PM, LVN F came out of Resident #30's and Resident #299's room with her PPE still on and removed it in the hallway. LVN F removed her gown and disposed of it on the trash can on the medication cart. LVN F did not remove her face mask and went into other resident rooms. During an interview on 01/24/2024 at 5:54 PM, LVN F said she had only been working at the facility about a week. LVN F said she really did not know when she was supposed to take off her PPE. LVN F said she guessed she was supposed to take it off before she came out of the room. LVN F said she should have changed her face mask prior to providing care to other residents, but she had not because she did not have another one to put on. LVN F said it was important to remove PPE prior to exiting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 33 of 42 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 01/25/2024 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 0880 room because of the germs on the PPE. Level of Harm - Minimal harm or potential for actual harm Record review of the Order Summary Report dated 01/25/2024 indicated Resident #30 had an order for Droplet Precautions for 7 days for Influenza/Flu A started on 01/25/2024. Residents Affected - Many During an interview on 01/25/2024 at 5:01 PM, the Administrator said he expected for the staff to use the correct PPE and correctly don it (put it on) and doff it (remove it). The Administrator said if a resident required special precautions a sign should be posted on the door. The Administrator said there should be a trash can inside the room for the staff to remove their PPE prior to exiting. The Administrator said it was important for PPE to be worn appropriately and discarded properly for infection control. During an interview on 01/25/2024 at 5:26 PM, the Infection Control Preventionist said the process when somebody required droplet precautions was a sign would be placed on the resident's door to alert staff and visitors what PPE was required and there would be a cart placed outside the door with the PPE required. The Infection Control Preventionist said the charge nurse was responsible for placing the sign on the door. The Infection Control Preventionist said if she was in the building, and she was notified she assisted them with putting the sign on the door and the PPE outside the door. The Infection Control Preventionist said for droplet precautions the staff should be wearing a gown, gloves, face mask and face shield, and the mask should be removed prior to leaving the residents room. The Infection Control Preventionist said she monitored to ensure the proper isolation precautions were in place for the residents, but she had been out herself with the flu and today was her first day back. The Infection Control Preventionist said since they did not have an extra room to move Resident #30 to and he had already been exposed to his roommate Resident #299 he would stay in the room with Resident #299 and the same droplet precautions applied to him. The Infection Control Preventionist said they did random education on putting on and taking off PPE and wearing the proper PPE. The Infection Control Preventionist said when the charge nurse set up PPE, she should provide education to the staff on the floor. The Infection Control Preventionist said the RN supervisor should have made sure the charge nurses and the staff were wearing appropriate PPE. The Infection Control Preventionist said the staff educator also provided education to the staff on wearing the appropriate PPE, but the staff educator was currently out with COVID. The Infection Control Preventionist said PPE should be removed prior to exiting a room. The Infection Control Preventionist said it was important for the staff to put on the appropriate PPE and remove the PPE properly to prevent the spread of infection. During an interview on 01/25/2024 at 6:00 PM, the DON said Resident #30 had remained in the room with Resident #299 because he had already been exposed, and there was no bed availability to move him out of the room. The DON said if they had the availability the resident would have been moved out of the room. The DON said droplet precautions were in place for both Resident #30 and Resident #299, and the staff should be wearing the appropriate PPE when entering the room. The DON said the charge nurse should have put the sign on the door to alert staff and visitors that droplet precautions were in place and the appropriate PPE to wear when entering the room. The DON said typically the Infection Control Preventionist ensured the sign was put up on the door the next day. The DON said the nurse managers also followed up to ensure the sign and PPE were in place. The DON said all PPE should be removed prior to exiting the room. The DON said the Infection Control Preventionist, and the nurse managers ensured the staff was wearing the appropriate PPE and removing it properly. The DON said it was important for PPE to be worn and removed properly to reduce the transmission of infection to the staff and other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 34 of 42 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm 3. Record review of the face sheet, dated 01/25/2024, revealed Resident #300 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar). Record review of Resident #300's MDS assessment revealed it was not due to have been completed yet. Residents Affected - Many Record review of the comprehensive care plan, initiated on 01/16/2024, revealed Resident #300 was at risk for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) related to diagnosis of diabetes mellitus. The interventions included: insulin per sliding scale: Novolog Injection Solution. Record review of the order summary report, dated 01/25/2024, revealed Resident #300 had an order for Novolog Injection Solution 100 units/mL per sliding scale: if 150 - 200 = 2 units . Record review of the MAR, dated January 2024, revealed Resident #300 received insulin injections daily. During an observation and interview on 01/23/2024 beginning at 11:11 AM, LVN A prepared to check Resident #300's blood sugar level using a glucometer (machine that measures blood sugar). LVN A applied her gloves, went into her nurses' cart and grabbed the lancet (pricks the finger), test strip bottle, and an alcohol prep pad. LVN A gathered all her used supplies and carried them to the nurses' cart located in the hallway. LVN A disposed of the lancet in the sharps container and placed all other used supplies in the trashcan. LVN A entered Resident #300's blood sugar into her laptop using the same gloves. LVN A revealed Resident #300 was getting 2 units according to the sliding scale. LVN A opened her nurses' cart, with the same gloved hands, obtained the insulin pen, an alcohol prep pad, and a needle for the insulin pen. LVN A dialed the insulin pen to 2 units, then went into Resident #300's room. LVN A wiped Resident #300's left lower abdomen with an alcohol prep pad. LVNA A then opened the needle and screwed it on to the tip of the insulin pen. LVN A then administered the insulin pen to Resident #300's left lower abdomen. LVN A did not wipe the tip of the insulin pen with alcohol prior to applying the needle. LVN A then disposed of the needle into the sharps container and the alcohol pad into the trashcan. LVN A then recovered the insulin pen and opened the drawer to place the insulin pen back into the drawer. LVN A did not change her gloves or perform hand hygiene during the observation. During an interview on 01/23/2024 beginning at 11:17 AM, LVN A stated she normally changed her gloves and performed hand hygiene while obtaining blood sugars and administering insulin. LVN A stated she was nervous because the state was watching, and she was new to the facility. LVN A stated she normally wiped the tip of the insulin pen with an alcohol prep pad prior to placing the needle on the tip. LVN A stated again she was nervous. LVN A stated it was important to ensure hand hygiene, glove changes, and wiping the tip of the insulin pen with an alcohol prep pad to prevent the spread of infection. During an interview on 01/25/2024 beginning at 4:02 PM, Unit Manager G stated nursing staff was expected to follow infection control policy and procedures when performing blood sugar checks and administering subcutaneous injections. Unit Manager G stated it was monitored through competencies that were completed upon hire and annually. Unit Manager G stated the Infection Control Preventionist was responsible for ensuring the competencies were completed. Unit Manager G stated it was important to follow infection control policy and procedures when performing blood sugar checks and administering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 35 of 42 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 01/25/2024 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 0880 subcutaneous injection to prevent the spread of infection. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/25/2024 beginning at 5:08 PM, the Infection Control Preventionist stated she expected the nursing staff to follow infection control policy and procedures when performing blood sugar checks and administering subcutaneous infections. The Infection Control Preventionist stated infection control policy and procedures were monitored by random rounds and observations to determine how blood sugar checks and injections were completed. The Infection Control Preventionist stated she had some infection control problems with agency staff (staff hired by an outside agency that signed up for shifts at the nursing facility, they were non-routine staff) at times but nothing routine. The Infection Control Preventionist stated competencies were completed upon hire and annually. The Infection Control Preventionist stated the Staff Educator was currently out sick, but she was responsible for completing the competencies. The Infection Control Preventionist stated it was important to follow infection control policy and procedures when performing blood sugar checks and administering subcutaneous injection to prevent the spread of infection. The Infection Control Preventionist stated she would attempt to find LVN A's competencies. The competencies were not provided upon exit of the facility. Residents Affected - Many During an interview on 01/25/2024 beginning at 5:14 PM, the DON stated she expected the nursing staff to follow infection control guidelines when obtaining blood sugar checks and when administering insulin. The DON stated this was monitored by completing competencies upon hire and annually, frequent education, and random observation. The DON stated if problems were observed then it would have been addressed individually and retraining was provided. The DON stated it was important to ensure infection control policy and procedures were followed to reduce the risk of infection. During an interview on 01/25/2024 beginning at 5:31 PM, the Administrator stated he expected nursing staff to follow infection control guidelines while performing a blood sugar check and administering insulin. The Administrator stated it was everyone's responsibility to ensure infection control guidelines were followed, and the Infection Control Preventionist was responsible for monitoring. The Administrator stated it was important to ensure infection control policy and procedures were followed for infection control. 4. 4. During an observation and interview on 01/23/2024 at 8:14 AM, CNA N was getting linen off the hall D cart with gloves on her hands, and she then proceeded to walk down the hallway with the linen next to her body and gloves on. CNA N went into Resident #32's room in which the bed was unmade. CNA N said she was supposed to carry linen in a bag and not against herself and was not supposed to wear gloves in the hallway related to infection control issues. During an interview on 01/25/2024 at 2:52 PM, Unit Manager O said linen should be carried in a trash bag from the linen cart. She said all staff should be aware of how to carry linen and know not to wear gloves while in the hallway. She said when staff leave an area, they should remove their gloves and perform hand hygiene. She said staff clothes could be contaminated and could cause infection control issues. During an interview on 01/25/2024 at 3:43 PM, the DON said linen should be carried away from the body and covered. She said gloves should not be worn down the hallway. She said nurse managers should correct a staff member if they see that happening and re-educate them. She said carrying linen next to your clothes and/or wearing gloves in the hallway could place residents at risk of infection. During an interview on 01/25/2024 at 4:20 PM, the Administrator said linen should be carried away (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 36 of 42 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many from the body or in a plastic bag. He said gloves should never be worn in the hallway. He said the unit managers, or any staff should be able to correct a staff member if they see them carrying linen next to their body or wearing gloves in the hallway. He said the staff member was being careless and could cause infection control issues. Record review of the facility's policy revised April 2020, titled, Droplet Precautions, indicated, Purpose: It is the policy of this facility to comply with CDC standards related to infection control practices for the resident requiring droplet precautions Responsibility: All Staff Purpose: To provide an environment that protects against droplet disease transmission and is safe for the health care worker. Procedure: Droplet precautions shall be used in addition to Standard Precautions for residents with infections that can be transmitted by droplets. Droplet transmission involves contact of the conjunctiva or mucous membranes of the nose or mouth of a susceptible person with largeparticle droplets containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets may be generated by the resident coughing, sneezing, talking, or during the performance of procedures. Resident Placement: 1. Resident may be placed in private room. If a private room is not available/not needed, the resident may be placed in a room with a resident(s) who has an active infection with the same organism but with no other identified infection. 2. When a private room is not available and cohorting is not an option, consider the organism and resident population when determining placement. A decision will be made on a case-by-case basis regarding the safety of placing the resident in a room with another resident. 3. The green Droplet Precautions sign will be placed on the door . 2. Gloves should be worn when entering the room and while providing care. 3. Gloves should be changed after having contact with potential infectious material. 4. Gloves should be removed before leaving the resident's room and hands should be washed immediately. Gowns: 1. Gowns should be used by staff entering the resident's room and removed prior to exiting the room. Eye protection/Face shield: 1. Eye protection/face shield should be worn upon entering the resident's room and removed prior to exiting the room. Masks: 1.A mask should be worn upon entry into the resident's room and removed prior to exiting the room . Record review of the facility's policy titled, Infection Prevention and Control, revised October 2022, indicated It is the policy of this facility to comply with all of CDC guidelines related to infection prevention and control practices. The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.#4 Standard Precautions: staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services and hand hygiene shall be performed in accordance with facilities' established hand hygiene procedures. Staff shall use personal protective equipment (PPE) according to established facilities governing the use of PPE when providing resident care. #9 Equipment Protocol: reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with recommended CDC guidelines. Equipment will be cleaned prior to returning to storage. #11 Linen: Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. #15 Staff Education: Staff shall receive training relevant to their specific roles and responsibilities regarding the facility's infection prevention and control program including policies and procedures related to their job function staff shall demonstrate competency in relevant infection control practices. Record review of the facility's policy titled, Glucometer Use and Cleaning, Revised: March 2019, indicated, The Policy: To comply with CDC guidelines and procedures for use and cleaning of glucometers. Procedure: 1. Follow the manufacturers' directions and recommendations for glucometer use and cleaning.2. Wash or sanitize (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 37 of 42 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many your hands. 5. Wash or sanitize your hands and apply gloves. 6. Following the fingerstick procedure dispose of the lancet and glucometer strip into a sharp's container. 7. Place the glucometer on a designated dirty barrier. 8. Remove gloves and wash or sanitize your hands. Apply gloves. 9. Disinfect the glucometer between each use with a 1:10 bleach disinfectant wipe. Wipe the glucometer, wrap it in a bleach wipe, and allow it to air dry according to the manufacturer's recommendations. 11. Return the glucometer to the clean barrier.12. Remove gloves and wash or sanitize your hands. Record review of the manufacturer's website, accessed on 01/25/2024 at 4:38 PM, revealed a video titled NovoLog FlexPen Instructions for Use. The video revealed at 1 minute and 43 seconds, to wipe the tip of the insulin pen with an alcohol swab. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 38 of 42 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 01/25/2024 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 0926 Have policies on smoking. 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 follow their own established smoking policy for 3 of 4 residents (Resident #62, Resident #6, and Resident #127) reviewed for smoking. Residents Affected - Some The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #62, Resident #6, and Resident #127. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #62's face sheet, dated 01/25/24 indicated Resident #62 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Involuntary movements (a group of uncontrolled movements that may manifest as a tremor), Blindness to left eye and diabetes (a condition that happens when your blood sugar (glucose) is too high). Record review of Resident #62's quarterly MDS assessment, dated 12/21/23, indicated Resident #62 was understood and understood by others . Resident #62's BIMs score was 15, which indicated he was cognitively intact. Resident #62 required limited assistance with dressing and was independent with toileting, personal hygiene, transfer, eating, and bed mobility. Record review of Resident #62's comprehensive care plan, dated 09/19/22 indicated Resident #62 was a supervised smoker per facility policy. The interventions of the care plan were for staff to provide Resident #62 with a smoking assessment routinely and as needed. Record review of Resident #62's Smoking Screen Assessment, which was last dated 09/19/23, revealed he required supervision for smoking. During an observation on 01/23/24 at 3:42 p.m., Resident #62 was outside smoking with staff. 2.Record review of Resident #6's face sheet, dated 01/25/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Macular degeneration (a disease that affects a person's central vision), Chronic obstructive pulmonary disease, or COPD, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and seizures (when too many of your brain cells become excited at the same time). Record review of Resident #6's quarterly MDS assessment, dated 11/16/23, indicated Resident #6 understood and understood by others . Resident #6's BIMs score was 13, which indicated he was cognitively intact. Resident #6 required limited assistance with bathing, set up with eating, and independent with toileting, personal hygiene, transfer, dressing, and bed mobility. Record review of Resident #6's comprehensive care plan, dated 05/27/22 indicated Resident #6 smoked and used snuff products. The interventions of the care plan were for staff to provide Resident #6 with a smoking assessment routinely and as needed. Record review of Resident #6's Smoking assessment, which was last dated 09/19/23 revealed he needed supervision for smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 39 of 42 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 01/25/2024 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 0926 During an observation on 01/23/24 at 3:42 p.m., Resident #6 was outside smoking with staff. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #127's face sheet, dated 01/25/24 indicated Resident #127 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Chronic obstructive pulmonary disease, or COPD, (refers to a group of diseases that cause airflow blockage and breathing-related problems), diabetes (a condition that happens when your blood sugar (glucose) is too high), and high blood pressure. Residents Affected - Some Record review of Resident #127's quarterly MDS assessment, dated 11/23/23, indicated Resident #127 understood and understood others . Resident #127's BIMs score was 15, which indicated he was cognitively intact. Resident #127 required limited assistance with toileting, transfer, bed mobility bathing, and set up for eating and personal hygiene. Record review of Resident #127's comprehensive care plan, dated 08/11/23 indicated Resident #127 was a supervised smoker per facility policy. The interventions of the care plan were for staff to provide Resident #127 with a smoking assessment routinely and as needed. Record review of Resident #127's Smoking assessment, which was last dated 09/19/23, revealed he required supervision for smoking. During an observation on 01/23/24 at 3:42 p.m., Resident #127 was outside smoking with staff. During an interview on 01/25/24 at 2:52 p.m., Unit Manager D said the nurses were responsible for completing the smoking screen assessment on admission, quarterly, or any changes. She said she was not aware the smoking assessments were not being completed. She said she talked with the regional nurse consultant and she explained that the smoking assessment was not triggering in the computer hardware system they were using. She said Cooperate would get the smoking assessments implemented for all residents in the hardware system. She said since the smoking assessments were not being done, residents were at risk of being burned. During an interview on 01/25/24 at 3:43 p.m., the DON said the social worker was responsible for doing the smoking assessments but a nurse could do a smoking assessment as well. She said she believed there was some confusion about who was supposed to do the smoking assessments. She said they had a system in place for checking on smoking assessments but since some of the smoking assessments did not trigger, they were not aware they were not being done. She said since the smoking assessment was not being done it could place the residents at risk for burns. During an interview on 01/25/24 at 4:20 p.m., the Administrator said he had been at the facility for about 2 weeks and could not say what the policy read on smoking assessment. He said if the smoking assessment were not being done then it could potentially place a resident at risk for injury. Record review of the facility Policy titled Resident Smoking, revised date of April 2018, indicated, The purpose: To allow residents who smoke the privilege of smoking while maintaining a safe environment. Procedure: I. Residents are permitted to smoke only in the designated area(s). 2. Residents will be screened by using the Smoking Screen form on admission, significant change, and quarterly thereafter FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 40 of 42 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 01/25/2024 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 21 employees (ADON) reviewed for required annual trainings. Residents Affected - Few The facility failed to ensure the ADON received required restraint training annually in January 2023. The facility failed to ensure the ADON received required HIV training annually in January 2023. This failure could place residents at risk for inappropriate restraints and exposure to HIV. The Finding included: Record review of the Facility Personnel file undated indicated, ADON was hired 01/23/18 and the HIV training was last completed on 3/27/23. The facility did not complete ADON's HIV training in January of 2023. The HIV training for the ADON was 2 months late. Record review of the Facility Personnel file undated indicated, ADON was hired 01/23/18 and the restraints training was last completed on 3/27/23. The facility did not complete ADON's restraints training in January of 2023. The restraints training for the ADON was 2 months late. During an interview on 1/25/23 at 2:30 p.m., the HR Director stated, HIV and restraints training should be completed intially and the month of hire for annual checks. The HR director stated staff development was responsible for completing the annually HIV and restraints training but the staff development staff member was off work due to medical issues. The HR director stated she was responsible to making sure staff completed HIV and restraints upon hire. The HR director stated the process for monitoring that the HIV and restraints training was completed annually was by verifying the new hire checklist upon hire and she made sure everything had been checkoff the new hire checklist prior to staff leaving orientation. The HR director stated she had created calendar reminders to remind her of when annual HIV and restraints training were due for staff members. The HR Director stated she did not realize that the ADON HIV and restraints training was completed late. The HR Director stated it was important to the resident for staff to complete HIV and restraints training annually an upon hire to make sure staff was educated. During an interview on 1/25/23 at 2:35 p.m., the Administrator stated, he has been employed as the Administrator for two weeks at the facility. The Administrator stated he did expect the HIV and restraints to be completed annually and on time. The Administrator stated there was no reason why the HIV and restraints training for the ADON was not completed during the ADON hired month of January 2023. The Administrator stated he was not sure what the process was for monitoring the HIV and restraints trainings for staff but, he would be speaking to the HR Director and ADON to make sure everyone was completing his or her HIV and restraints training timely. The Administrator stated he was not aware that the ADON was late on HIV and restraints training. The Administrator stated it was important for staff to complete the HIV and restraints training annually and upon hire because ,We deal with blood pathogen every day and to ensure the employees are aware the facility is restraint free. Record Review of the abuse and neglect policy revised dated on November 2019 indicated, (4) The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 41 of 42 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 01/25/2024 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 0940 Level of Harm - Minimal harm or potential for actual harm facility will ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. A request for the facility policy regarding Required Training policy was requested from to the Human Resource Director on 1/25/2024 at 4:40p.m. A policy was not received prior to exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675873 If continuation sheet Page 42 of 42