Health inspection·August 17, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few immediately. He said a deficiency in food handling was evident in the kitchen and he would be organizing an in-service with the support of the Diet to address this issue. Record review of the Dietary Services- Departmental Operations policy revised on August, 2010, revealed . 6. Dry foods that are stored in bins will be removed from original packaging, labelled and dated ('used by' date). Such food will be rotated using a 'first in- first out system'. 7. All foods stored in the refrigerator or freezer will be covered, labeled, dated ('use by' date) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675884 If continuation sheet Page 2 of 4 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 675884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Teague Nursing and Rehabilitation 884 Hwy 84 W Teague, TX 75860 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents reviewed for medication administration (Residents #23). Residents Affected - Few Licensed Vocational Nurse (LVN) failed to properly wash or sanitize her hands when moving from Resident to Resident when administering medications to resident # 23. This deficient practice placed all residents identified at risk for cross contamination and the spread of infection. Findings include: Review of Resident #23's face sheet reflected Resident #23 was a [AGE] year-old female with an admission date of 10/01/21. Resident #23's diagnoses included anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), muscle wasting and atrophy (when muscles waste away), and hypokalemia (a low level of potassium in the blood serum). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact and able to complete an interview. During an observation on 08/15/2022 at 11:37 AM, LVN was observed passing medication to Residents #10 and #23 without sanitizing hands in between. LVN prepared and administered medications to Resident #10 and then without washing or sanitizing hands, prepared and administered Resident #23's medications. During an interview on 08/15/2022 at 11:41 AM, LVN stated no, she did not sanitize her hands in between passing medication to the 2 residents. She stated she just forgot to sanitize her hands in between the 2 residents. She stated she normally sanitized her hands in between residents, and it was their policy to do so. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she was aware that not sanitizing her hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. During an interview on 08/16/2022 at 11:22 AM, MA stated she either washed or sanitized her hands in between every resident when passing medications. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she believed that not sanitizing hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. She stated no matter what department or title someone was, whether they are in management or working on the floor, everyone should wash or at least sanitize their hands when going from one resident to the next. During an interview on 08/16/2022 at 12:52 PM, ADON stated she washed or sanitized her hands in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675884 If continuation sheet Page 3 of 4 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 675884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Teague Nursing and Rehabilitation 884 Hwy 84 W Teague, TX 75860 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 between every resident no matter what task she was performing and always in between administering medications. She stated she had been in-serviced on handwashing/sanitizing hands when going from one resident to another and performing any task. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. Residents Affected - Few During an interview on 08/16/2022 at 1:00 PM, the DON stated it was her expectation that all staff washed or sanitized their hands when going from resident to resident when passing medications or performing any task. She stated she in-serviced staff on handwashing or sanitizing hands when going from resident to resident when performing any task including administering medications. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. During an interview on 08/16/2022 at 1:12 PM, the ADM stated it was his expectation that all staff washed or sanitized their hands in between every resident when passing medication or performing any task. He stated he is in-serviced staff regularly on handwashing or sanitizing hands when going from resident to resident during any task including medication administration. He stated he believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. Review of the Handwashing/Hand Hygiene policy (revised August 2019), provided by the ADM, titled revealed the following: policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections; # 2. stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7 stated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications. Review of the Administering Medications policy (revised April 2006) provided by the DON revealed the following: Policy Interpretation and Implementation; # 2. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. Review of the Policies and Practices - Infection Control policy (revised September 2005) provided by the DON, revealed the following: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation; # 4. All personnel will be informed of our infection control policies and practices, including where and how to find and use pertinent procedures. Review of documents dated 07/11/2022, 07/20/2022, and 08/03/2022 revealed staff was in-serviced frequently on handwashing and policies and practices of infection control. Review of documents 07/11/2022 on handwashing and policies and procedures - infection control, revealed LVN attended these in-services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675884 If continuation sheet Page 4 of 4