Health inspection·August 8, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 07/19/2023 at 1:43 PM the Administrator stated she expected that all residents' concerns be addressed and followed up on. The Administrator stated the facility had a grievances process and the person receiving the resident's complaint should be the one to ensure it was given to the person responsible for concerns and follow should be conducted to ensure all concerns are resolved. Review of the facility's policy Filing Grievances/ complaints dated June 2005 reflected Our facility will help residents .file grievances or complaints when such requests are made .Grievances and or complaints may be submitted orally or in writing .Upon receipt of a grievance and or complaint the administrator and/or designee will investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint .The resident, or person filing the grievance and/or complaints on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems . Event ID: Facility ID: 675903 If continuation sheet Page 2 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for one (Resident #34) of nine residents reviewed for accidents resulting in injury. The facility failed to report the injuries sustained by Resident #34 to HHSC as required. This deficient practice could place all 47 residents in the facility with the potential to be abused, neglected, exploited, or mistreated, or have injuries of unknown source to be at risk for compromised protection from abuse, neglect, exploitation or mistreatment. The findings included: Record review of Resident #34 face sheet, generated at time of admission on [DATE], revealed that Resident #34 was [AGE] years old and was admitted to the facility on [DATE]. Resident #34 face sheet listed Resident #34 as her own Responsible Party (she can make decisions on her own and has not been declared incompetent). Resident #34 diagnosis list included: Chronic Obstructive Pulmonary Disease (a condition which produces difficulty breathing), cachexia (muscle loss), spinal stenosis (narrowing of the canal through which the spinal cord travels), lack of coordination, anxiety disorder, Chronic Pain Syndrome, and neuropathy (condition causing numbness and/or weakness, tingling, and/or burning sensation usually affecting the hands and feet), nicotine dependence, among other diagnoses. Record review of Resident #34 MDS (an assessment tool required of nursing facilities receiving Medicare/Medicaid funds) dated 05/04/23 revealed a BIMS (cognition screening tool) score of 15, which indicated intact cognition (awareness of person, place, time, and situation with no memory deficit). Under Section G of the MDS dated [DATE], Functional Status, it was indicated that Resident #34 required a level of Supervision to One-person Physical Assistance with eating (which also included drinking in the description). Under Section GG of the MDS dated [DATE], Functional Abilities and Goals, it was indicated that Resident #34 required Set-up Assistance and/or Clean-up Assistance in order to eat and drink. Record review of Resident #34's Care Plan dated 04/25/23 revealed that Resident #34 had a terminal illness, Chronic Obstructive Pulmonary Disease, and is under care of Hospice Provider. Record review of Resident #34's Care Plan dated 04/25/23 revealed an addition of Impaired Skin Integrity related to Burn added on 05/27/23; interventions which were care-planned included safety evaluation for handling hot liquids, identifying and educating Resident #34 on causative factors, wound management, and encouraging good nutrition necessary for wound healing. Record review of Facility Incident Report written by LVN A, dated 05/27/23 at 07:53 a.m., revealed that while Resident #34 was sitting up in bed, she spilled coffee in her lap as she attempted to take the lid off a coffee cup. As described in the 05/27/23/7:53 a.m. Facility Incident Report, no injury was initially seen by LVN A and RN on duty, but cool moist wash cloths were applied and Resident #34 was instructed by LVN A to call for assistance with her coffee and to leave the lid off so a spill wouldn't occur if the lid needed to be removed. Incident Report of 05/27/23/07:53 a.m. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 3 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Primary Physician was notified of the incident at 11:25 a.m. by LVN A. Review of Facility Incident Report written by LVN A also included interventions, added by RN on 05/29/23, to prevent recurrence and included: checking of coffee temperature logs with ongoing monitoring for unspecified duration of time, replacing electric coffee urn with standard drink dispenser in dining room, and replacing glass mugs with lighter-weight plastic mugs. Incident Report addendum dated 05/29/23 by RN also included that Resident #34 had demonstrated safe use of coffee cup and that temperatures of coffee were all within range when temperature log checked. Record review of facility Safety of Hot Liquids Policy dated October 2014 revealed that interventions would be implemented to minimize the risk from burns and included: maintaining hot liquids at a serving temperature of no more than 180 degrees Fahrenheit, serving hot beverages in a cup or insulated cup, encouraging residents to sit at a table when drinking hot liquids, and staff supervision or assistance with hot beverages. Record review of facility Coffee Log Temperature Inservice, dated 05/29/23, was done and included the staff from the Dietary Department with a sign-in sheet; instructions given in the in-service included twice daily coffee temperature checks with documentation of that temperature and keeping coffee temperature between 160 and 180 degrees Fahrenheit. Record review of facility Coffee Temperature Log from 05/27/23 to 07/20/23 revealed that the coffee had been kept at temperatures consistently between 160 and 180 degrees Fahrenheit. Record review of Skin assessment dated [DATE] by LVN A revealed redness to bilateral inner thighs from spilled coffee with no blistering at time of incident. Additional record review of weekly Skin Assessments dated 05/30/23, 06/06/23, 06/13/23, 06/20/23, 06/27/23, 07/04/23, 07/11/23, 07/18/23 by facility nursing staff indicated ongoing monitoring and documentation of burn wounds to Resident #34's thighs. There were no other concerning wounds to Resident #34 appearing on the weekly Skin Assessments. Record review of Resident #34's electronic medical record revealed that Resident #34 was first seen by Wound Care MD on 05/31/23 at the request of Primary Physician. Record review of Wound Care MD's Initial Wound Evaluation and Management Summary, dated 05/31/23, stated Focused Wound Exam Site 1: Burn wound of the left, medial thigh, partial thickness, with an area of 9.0 x 7.0 x 0.1 cm and with a light serosanguineous exudate (thin and watery fluid that is pink in color due to the small amount of red blood cells; not indicative of infection). Record review of Wound Care MD's 05/31/23 Focused Wound Exam Site 2 note revealed: Burn wound of the right, medial thigh, partial thickness, with an area of 9.0 x 9.0 x 0.1 cm and having a light serous exudate (thin, watery drainage). Wound care notes dated 05/31/23 from Wound Care MD's Initial Wound Evaluation and Management Summary listed Dressing Treatment Plan as: Petroleum-impregnated gauze applied once daily for 30 days with a bordered gauze dressing over it once daily for 30 days. Record review of Wound Care MD notes reveal that Resident #34 was seen again by Wound Care MD on 06/07/23, 06/16/23, 06/28/23, 07/05/23, and 07/12/23. Record review of Wound Care MD notes for these dates indicated that same type dressings as originally ordered daily for the facility wound care were reordered on each visit to continue after the initial 30-day period was complete; as time passed and the wounds showed improvement, the wound care frequency was changed to three times weekly but the process and wound care supplies used were unchanged. Record review of 06/28/23 Wound Care MD notes indicated that Wound Care MD had resolved (healed to a point where the wound no longer required treatment) the Left Thigh/Site 1 burn wound for Resident #34; after 06/28/23 Wound Care MD orders for the facility nurses applied only to Site 2, Right Thigh. Record review of Wound Care MD notes dated 06/28/23, 07/05/23, and 07/12/23 indicated that the Wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 4 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care MD had performed clean surgical debridement procedures (a process where dead tissue is removed using a scalpel, allowing healthier tissue to grow) at each visit on Site 2, right thigh, under the topical anesthetic benzocaine (a spray that numbs the area of skin or tissue to be worked on). Record review of Wound Care MD notes stated for each visit (05/31/23, 06/07/23, 06/16/23, 06/28/23, 07/05/23, 07/12/23) that there was no indication of pain associated with this condition in Resident #34. Record review of MD Wound Care orders, Hospice Provider orders, and Primary Care Physician orders during the time period of 05/27/23 through 07/20/23 did not reveal that an additional analgesic, added to the analgesics which Resident #34 took for Chronic Pain Syndrome, was ordered as a pre-medication prior to nurses performing wound care or Wound Care MD performing wound care debridement procedures. Observation was done on 07/20/23 at 09:50 a.m. with Resident #34 regarding the burn injuries; pink scarring in areas which approximated the sizes detailed on Wound Care MD's notes were observed to both upper thighs of Resident #34 after Treatment Nurse removed dressing from right thigh. Tissue appeared to be intact and there was no drainage when observed on 07/20/23 at 09:50 a.m. in Resident #34's room as she lie in bed. Interview with Resident #34, on 07/20/23 at 09:50 a.m., revealed that she had been told by Wound Care MD that her burns from the hot coffee were second degree burns (burns which affect the epidermis layer and the dermis layer of skin). Resident #34 stated that Wound Care MD had been coming weekly since the hot coffee incident on 05/27/23. Resident #34 stated that the burn wounds initially hurt but now the pain is under control. Resident #34 stated it hurt like the dickens initially and for a period of time; resident did not clarify how long the period of increased pain to her thighs lasted. Resident #34 stated that she currently experienced a lot of itching as the skin continued to heal. Resident #34 stated that the hot coffee burn incident happened at the end of May when she was getting ready to eat breakfast in bed. Resident #34 stated that nurse aide who assisted her that morning had poured her coffee into her personal mug for her, which Resident #34 preferred, rather than drinking it out of the facility cup. Resident #34 stated that she did not think that the nurse aide who helped her that morning, 05/27/23, put the lid on well on her personal mug. Resident #34 believed this as she stated that on the morning of 05/27/23, she did not hear the lid make a popping sound as it went into place on the mug when the nurse aide put the lid on. Resident #34 did not remember who her nurse aide was on the morning that the incident occurred. Resident #34 did say that she was sure it was not a Hospice Provider nurse aide who helped her on the morning of the incident, 05/27/23, as she remembered that it was someone who was very familiar to her and provided regular care to her; she stated that she is not as familiar with the hospice staff. Treatment nurse was interviewed on 07/20/23 at 10:00 a.m. and removed the dressing over the right thigh burns for observations. Treatment nurse was able to give the wound care directions as cleaning the wound with Normal saline and covering with petroleum-based gauze and then covering (with additional wound care supply) three times weekly. Treatment nurse was able to give summary of orders which were consistent with most recent MD Wound Care orders of 07/13/2023 and stated that the dressings are changed by facility nurses after resident takes a shower with the Hospice Provider nurse aide three times weekly. Treatment nurse stated during 07/20/23/10:00 a.m. interview that she expected Wound Care MD to resolve (complete treatment of) the left thigh wound during his next visit. LVN A, primary nurse for Resident #34, on day of coffee burn, was interviewed on 07/20/23 at 10:15 a.m. LVN A stated that on 05/27/23 at breakfast time, Resident #34 was either in bed or in her wheelchair when the coffee sloshed out of her cup and into her lap. LVN A stated during interview on 07/20/23 at 10:15 am that Resident 34's skin was immediately assessed after 05/27/23 incident and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 5 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the skin was reddened to upper thighs but was not blistering. LVN A stated that she put cool compresses on the reddened sites after the burn injury on 05/27/23 and continued to monitor the burn sites for the remainder of her shift, noticing blistering to burn sites to be occurring a few hours after the initial burns. LVN A stated that she then notified the Primary Care Physician and the Hospice Provider, on the morning of 05/27/23. LVN A stated that Primary Care Physician stated, in their conversation of 05/27/23, that he would ask the Wound Care MD to see Resident #34 on his next visit to the facility. LVN A stated that she did not notify a family member of Resident #34 of the incident of 05/27/23 as Resident #34 is her own Responsible Party. CNA D was interviewed on 07/20/23 at 11:00 a.m. CNA D was the primary nurse aide for Resident #34 on 05/27/23 during the time of the incident, which occurred during breakfast. CNA D stated that she was not in the room when the burn injuries to Resident #34 occurred. CNA D stated that she was passing breakfast trays and drinks out during the incident of 05/27/23 a.m. CNA D reported hearing Resident #34 calling out for help and when CNA D responded, Resident #34 told her 'I dumped coffee on my legs!' CNA D stated that Resident #34 had been eating breakfast in bed on 05/27/23. CNA D stated that she asked Resident #34 if she was okay and then went to get LVN A on the morning of 05/27/23 after the coffee burns occurred and when it was brought to her attention by Resident #34. CNA D stated that after the incident occurred on 05/27/23 she observed redness to Resident #34's legs. When asked how the burns happened, CNA D stated that she believed that Resident #34 spilled it out of her personal coffee mug as she liked to drink her coffee from that particular mug; CNA D stated that she did not remember if it was her (CNA D) who gave Resident #34 her coffee and was unsure if it was herself or a different nurse aide who may have put coffee in Resident #34's cup. CNA D stated that Resident #34 liked to be as independent as possible and Resident #34 may have poured coffee from the facility cup on her breakfast tray into the personal mug. Wound Care MD was interviewed on 07/20/23 by phone at 11:05 a.m. Wound Care MD stated that he was initially consulted by facility to manage wound occurring to Resident #34 on approximately May 29, 2023. Wound Care MD stated that when he first saw Resident #34 on the day of 5/31/23, the burns to Resident 34's thighs were blistered. Wound Care MD stated that he believed that Resident #34 missed the table with her coffee mug and spilled the coffee on to her thighs to cause the burns on 05/27/23. Wound Care MD, during his interview on 07/20/23, stated that initially petroleum-based gauze dressing was applied for wound care to the burns and eventually debridement was done. Wound Care MD stated that no premedication prior to burn wound care treatment as been required by Resident #34. Wound Care MD stated that he did not believe there was any neglect or abuse involved in the burn incident affecting Resident #34 on 05/27/23. Wound Care MD stated that the burns were classified as second degree burns (burns which damage the outer layer of skin, epidermis, and the second layer of skin, dermis). The DON was interviewed on 07/20/23 at 11:25 a.m. DON stated that an investigation was not conducted into the burn incident of 05/27/23 as Resident #34 is cognitively intact so she is able to tell others that she spilled the coffee on herself. DON stated that there was no reason to suspect abuse or neglect after Resident #34 stated that she had spilled the coffee on herself. DON stated that she did an assessment to ensure that Resident #34 is safe to use her personal mug after the incident of 05/27/23 which resulted in the burn. DON stated that the electric coffee pot was changed to one which would help prevent possible overheating of the coffee as an intervention to prevent recurrence. DON stated that the coffee temperature log has been ongoing twice daily since 05/27/23 to ensure that coffee is not too hot to serve to residents, and there has been no indication of coffee that is served too hot (over 180 degrees) since the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 6 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADM was interviewed on 07/20/23 at 11:45 a.m. ADM stated I think there was an investigation and I did interventions. Resident has a BIMS of 15 and was just trying to take the lid off and spilled it (the coffee). We do temperature checks several times daily on the coffee and are never out of range. We took out the electric coffee pot and put out an urn to prevent overheating. ADM also stated during 07/20/23 interview that facility had recently purchased insulated cups with bigger handles as a safety precaution for the resident coffee drinkers. ADM stated that Wound Care MD was brought in to assist with assessment and treatment of Resident #34's wounds. ADM stated that she believed that DON had completed in-service to prevent a reoccurance but was unable to state the topic of the in-service, the date it was given, or which facility staff participated. ADM stated that she did not report incident involving burn injury from coffee because Resident #34 was able to explain what happened to cause the burns, so there was no evidence of abuse or neglect. ADM stated that the root cause of the burn injury was the lid being removed from the coffee by Resident #34 instead of someone doing it for her. ADM stated during interview that she felt that burn injury could have been a serious injury. ADM was unable to provide a written facility investigation when she was asked during the interview on 07/20/23 at 11:45 am. Review of the facility's policy Abuse Investigations dated 06/2005 reflected Policy Interpretation and Implementation; NFs must report abuse allegations immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 7 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility filed to ensure assessments accurately reflected the status of 1of 15 residents reviewed for assessments (Resident #7) Residents Affected - Few The facility failed to ensure Resident #7's assessment was properly coded for his Gastrostomy-tube status. These failures could place residents at risk of not having individual needs met. Finding included: Review of Resident #7's Face sheet dated 07/18/2023 reflected Resident #7 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Cerebrovascular Disease (a range of conditions that affect the flow of blood through the brain. This alteration of blood flow can sometimes impair the brain's functions on either a temporary or permanent basis.), mild intellectual disabilities (someone with a low IQ score (around 70) as well as poor adaptive behaviors that cause them to have educational problems.), Gastrostomy Status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage.) Review of Resident #7's Comprehensive Care plan reflected a focus area dated 07/27/2015 and revised on 10/09/2019 Resident #7 requires tube feeding related to diagnoses of dysphagia secondary to CVA. Interventions included .check for tube placement and gastric content .the resident is dependent with tube feeding and water flushes . Further review of Resident #7's Comprehensive Care Plan reflected a focus are dated 07/27/2015 and revised on 04/11/2023 Resident #7 has a potential nutritional problem related to NPO status. Receives all nutrition via G-Tube by nurse. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #7 was assessed to require extensive assist with ADLs. Further review reflected Resident #7 was assessed to not have a feeding tube. Observation on 07/18/2023 at 10:30 AM revealed Resident #7 in his room in bed. Resident #7 was observed to have a gastrostomy tube inserted into to his abdomen. Review of Resident #7's Consolidated physician orders reflected an order dated 11/14/2018 NPO diet, g-tube feeder. Further review reflected an order dated 10/24/2022 enteral feed order every 6 hours flush g-tube with 100 mg water every six hours In an interview on 07/20/2023 at 8:54 AM the MDS Coordinator stated after reviewing Resident #7's Annual MDS dated [DATE] she stated the MDS should have been coded for Resident #7's G-Tube status since he has had a G-Tube for years and receives all his nutrition through the G-Tube. The MDS Coordinator stated she was not sure why she missed it and stated it was an entry error. Review of the facility's policy Resident Assessments dated 11/2019 reflected A comprehensive assessment of every resident's needs is made at intervals .The results of the assessment are used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 8 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 develop, review, and revise the residents comprehensive care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 9 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 interview observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 15 residents (Residents #14) reviewed for care plans. Resident #14's comprehensive care plan did not address the resident's smoking. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. The findings were: Review of Resident #14's face sheet, dated 07/20/2023, revealed an 65year-old female was re-admitted to the facility on [DATE] with diagnoses including sepsis (body's extreme response to an infection), pure hypercholesterolemia (inherited disorder associated with elevated low density lipoprotein cholesterol levels and premature coronary heart disease), urinary tract infection (infection when bacteria, often from the skin or rectum enters the urethra and infect the urinary tract), and secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes (cancer cells spread to the lymph nodes from cancer that started somewhere else in the body). Review of Resident #14's MDS, dated [DATE]. Revealed Resident 14's BIMS score was 15 (Out of 15) which indicated resident 14 is cognitively intact. Review of Resident #14's Care Plan, dated 07/09/2023, did not address smoking. Review of the facility's smoking listed, not dated, revealed Resident 14 was not on the smoking list. Review of Resident #14's safe smoking assessment, dated 07/20/2023, revealed Resident 14 was assessed for smoking and was identified as a safe smoker. Observation on 07/19/2023 9:45 AM of Resident 14 outside in the designated smoking area. Interview with Resident #14 on 07/19/2023 at 11:25 AM Resident #14 stated she is a smoker and has been smoking for a long time. Resident 14 doesn't remember when she started smoking but stated it was before she moved into the facility. Resident 14 stated that she has been assessed for smoking. Resident 14 stated she has smoked at the facility in the past and has not had any smoking accidents. Interview with DON on 07/20/2023 at 9:05 AM the DON stated that if a resident was a smoker, then they should be care planned to ensure they have been assessed appropriately. DON stated that if a resident was not care planned for smoking the resident could potentially injury themselves by burning themselves while smoking or they may not be notified of the facility's smoking schedule. Interview with MDS Coordinator on 07/20/2023 at 9:30 AM the MDS Coordinator stated that residents that are smokers should be care planned for smoking. MDS Coordinator stated that residents should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 10 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 care planned for smoking, so they receive a smoking assessment. MDS Coordinator stated if a resident was not care planned for smoking, then the staff may not notify the resident of smoking times, or they resident could possibly injure themselves from smoking. MDS Coordinator stated that Resident 14 was a smoker. A record of review of the facility's Care Plans, Comprehensive Person-Centered dated 12/16 stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 11 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 the resident. Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Few Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process; b. Identify individuals or roles to be included; c. Request meetings; d. Request revisions to the plan of care; e. Participate in establishing the expected goals and outcomes of care; f. Participate in determining the type, amount, frequency and duration of care; g. Receive the services and/or items included in the plan of care; and h. See the care plan and sign it after significant changes are made. 5. The resident will be informed of his or her right to participate in his or her treatment. 6. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 12 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 7. Level of Harm - Minimal harm or potential for actual harm The care planning process will: a. Residents Affected - Few Facilitate resident and/or representative involvement; b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 13 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 Incorporate identified problem areas; Level of Harm - Minimal harm or potential for actual harm h. Incorporate risk factors associated with identified problems; Residents Affected - Few i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 14 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 The resident's physician (or primary healthcare provider) is integral to this process. Level of Harm - Minimal harm or potential for actual harm 11. Residents Affected - Few Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 15 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 16 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 16 residents reviewed with limited range of motion (Resident #7), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #7 had interventions in place for his right-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in his right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #7's Face sheet dated 07/18/2023 reflected Resident #7 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Cerebrovascular Disease (a range of conditions that affect the flow of blood through the brain. This alteration of blood flow can sometimes impair the brain's functions on either a temporary or permanent basis.), mild intellectual disabilities (someone with a low IQ score (around 70) as well as poor adaptive behaviors that cause them to have educational problems.), Gastrostomy Status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage.) Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #7 was assessed to require extensive assist with ADLs. Further review reflected Resident#7 was assessed to have limitations of ROM on upper and lower extremities with impairment on one side. Review of Resident #7's Comprehensive Care plan reflected a focus area dated 07/27/2015 and revised on 11/20/2019 Resident #7 has limited physical mobility related to weakness, contractures, CVA history. Resident currently has right arm contracture. (The plan of care did not address a right-hand contracture). Interventions included: Monitor/ document/ report to MD PRN of immobility; contractures forming or worsening .skin-breakdown .Further review reflected no right-hand specific interventions. Observation on 07/18/2023 at 9:30 AM revealed Resident #7 in bed. Observation of Resident #7's right hand revealed his right hand was in a closed position. Resident #7 was able to open his right hand slightly moving his index and middle finger to reveal long finger nails. Resident #7 was not able to move his right ring finger or pinky finger. Observation and interview on 07/20/2023 at 8:50 AM the DON stated Resident #7 did have contractures she stated she was not sure abut his hand. The DON went down to Resident #7's room and observed Resident #7's hand and stated yes, his hand was contracted and stated she would trim his fingernails. The DON then started trimming Resident #7's fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 17 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 07/20/2023 at 8:55 AM the MDS Coordinator stated after reviewing Resident #7's care plan that he was not care planed for a right-hand contracture. She stated if his hand is contracted it should be care planed and he should have interventions in place. Review of Resident #7's Physical Therapy Treatment Encounter Notes dated from 06/19/2023 through 07/17/2023 reflected no treatment or interventions for Resident #7's right hand contracture. In an interview on 07/20/2023 at 9:08 AM The COTA RD stated she was not sure if Resident #7's right hand contracture was being addressed. She further stated that therapy was in the building, and she would go with them to check Resident #7's hand. In an interview on 07/20/2023 at 9:21 AM the RCDO stated she went down to Resident #7's room [ROOM NUMBER]/20/2023 at 9:10 AM and put a contracture device in his hand (a carrot) she stated Resident #7 took it out. The RCDO stated she instructed staff to document the intervention and to update his care plan. In an interview on 07/20/2023 at 10:30 AM the COTA RD stated she examined Resident #7's right hand. She stated his hand was not a fixed contracture but was high tone (High tone or hypertonia is increased tension in the muscles which makes it difficult for them to relax and can lead to contractures and loss of independence with everyday tasks.). The COTA RD stated she performed a recertification for Resident #7 to continue therapy and he would be getting treatment for his right hand. She stated without treatment for his decreased ROM it could lead to increased contractures and or skin breakdown. Review of the facility's policy Resident Mobility and Range of Motion dated 07/2017 reflected Residents will not experience an avoidable reduction in range of motion. Residents with limited range of motion will receive treatment and services to increase and /or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .The care plan will include specific intervention, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 18 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 - Immediate jeopardy to resident health or safety 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 interview, and record review the facility failed to ensure residents were free of accidents/hazards for one of twenty residents (Resident #34) reviewed for Quality of Care. Residents Affected - Few A) The facility failed to ensure Resident #34 had been assessed for hot liquid safety prior to serving her two cups of hot coffee on 05/27/2023. Resident #34 spilled the hot coffee on her thighs resulting in 2nd degree burns. B) The facility failed to ensure all residents had safety evaluations for handling hot liquids prior to serving them hot liquids. An IJ was identified on 08/07/2023. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 08/08/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed all residents at risk for injuries, pain, and mental anguish. Findings include: Record review of the undated Face Sheet for Resident #34 reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (a condition which produces difficulty breathing), Cachexia (general state of ill health involving marked weight loss and muscle loss), Spinal Stenosis (narrowing of the canal through which the spinal cord travels), lack of coordination, Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety or fear strong enough to interfere with one's daily activities), Chronic Pain Syndrome (persistent pain that lasts longer than 12 weeks despite medication or treatment), and Neuropathy (condition causing numbness and/or weakness, tingling, and/or burning sensation usually affecting the hands and feet), and nicotine dependence. Record review of Resident #34's quarterly MDS assessment dated [DATE] reflected a BIMS (cognition screening tool) score of 15, which indicated intact cognition (awareness of person, place, time, and situation with no memory deficit). Section G of the MDS dated [DATE], Functional Status, reflected Resident #34 required a level of Supervision to one-person Physical Assistance with eating (which also included drinking in the description). Section GG - Abilities and Goals, reflected Resident #34 required Set-up Assistance and/or Clean-up Assistance in order to eat and drink. Record review of the Care Plan for Resident #34 dated 04/26/2023 and revised on 4/28/2023 reflected she used anti-anxiety medication, the goal was to be free from discomfort or adverse reactions. Interventions included: Monitor/document side effects. Antianxiety side effects: Drowsiness, lack of energy, clumsiness, slow reflexes, impaired thinking, and judgment. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 19 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 - Immediate jeopardy to resident health or safety Residents Affected - Few cognitive impairment. Monitor for safety. The Resident has actual skin impairment to skin related to burn. Was taking a lid off her coffee. Dated 05/27/2023 and revision on 07/20/2023. Interventions/Tasks: Resident evaluated for safety and hot liquids and able to demonstrate safe handling. RN. Review of an Initial Wound Evaluation and Management Summary for Resident #34 dated 5/31/2023 reflected the burn wound of the left medial (inner) thigh partial thickness measured 9.0 X 7.0 X 0.1 cm. the surface area was 63 cm2. The exudate was light serosanguineous (fluid leaking out of a wound that is yellowish with small amounts of blood). The burn wound of the right medial thigh partial thickness was 9.0 X 9.0 X 0.1 cm with a surface area of 81 cm 2. There was light serous drainage. (clear to yellow drainage that leaks out of a wound). The treatment plan wound care order for both areas was xeroform (petrolatum) dressings and a gauze island dressing for 30 days. The left medial thigh wound was resolved on 6/28/2023. The right medial thigh wound required a surgical excision and debridement (cutting to remove dead tissue) on 06/28/2023 and was resolved on 07/21/2023. Record review of a facility in-service Training report dated 07/21/2023 for the nursing department conducted by the ADON on the topic of Hot Liquid Safety reflected Monitor residents at risk for accidental burns and related complications. Encourage residents to sit at a table while drinking or eating hot liquids. Supervise and assist residents with hot liquids. The in-service was signed by 6 nursing staff out of 23. In an interview on 07/20/2023 at 9:50 AM, Resident #34 stated she had been told by Wound Care MD that her burns from the hot coffee were second degree burns (burns which affect the epidermis (top) layer and the dermis (second) layer of skin). Resident #34 stated Wound Care MD had been coming weekly since the hot coffee incident on 05/27/2023. She stated the burn wounds initially hurt like the dickens however the pain was under control. In an interview on 07/20/2023 at 10:00 AM CNA D stated she was the nurse aide for Resident #34 on 05/27/2023 but was not in the room when the burn injuries to Resident #34 occurred. She stated Resident #34 called for help and told her she had dumped coffee on her legs. CNA D stated she observed redness to Resident #34's thighs and she thought Resident #34 spilled the coffee out of her personal coffee mug. In an interview on 07/20/2023 at 11:25 AM, the DON stated an investigation was not conducted into the burn incident of 05/27/2023 as Resident #34 was cognitively intact so she was able to tell others that she spilled the coffee on herself. DON stated that there was no reason to suspect abuse or neglect after Resident #34 stated that she had spilled the coffee on herself. DON stated she did an assessment after her 9:00 AM stand up meeting to ensure Resident #34 was safe to use her personal mug for hot coffee. She further stated the electric coffee pot in use had been changed to one which would help prevent possible overheating of the coffee as an intervention to prevent recurrence. DON stated the coffee temperature log had been ongoing twice daily since 05/27/2023 to ensure that coffee was not too hot to serve to residents, and there had been no indication of coffee that was served too hot (over 180 degrees) since the incident. In an interview on 07/20/2023 at 11:45 AM, the ADM stated she thought there had been an investigation into the burn incident involving Resident #34. and she had put in place some interventions to prevent any further injuries. She stated Resident #34 was cognitively intact and was trying to take the lid off of her coffee and spilled it. She stated temperature checks were performed several times daily on the coffee after the incident and were never out of range . ADM further stated she believed the DON had completed an in-service to prevent a reoccurrence but was unable to state the topic of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 20 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 - Immediate jeopardy to resident health or safety Residents Affected - Few the in-service, the date it was given, or which facility staff participated. ADM stated she felt that the burn injury could have been a serious injury. ADM was unable to provide a written facility investigation. In an interview on 08/07/2023 at 12:50 PM, LVN A stated she was the charge nurse in the facility when Resident #34 spilled coffee on her thighs. She stated if residents had cognition issues, they would not give them hot liquids but there was no official evaluation for the charge nurse to complete for hot liquids safety. She stated she was hired at the end of February 2023 and did not remember reading a policy regarding Safety of Hot Liquids. In an interview on 08/07/2023 at 1:30 PM, CNA K stated Resident #34 had spilled coffee again all over her bed that morning between 8-10 am while trying to move her overbed table. She stated it was cold coffee and the resident was not injured. In an interview on 08/07/2023 at 1:48 PM, CNA D stated she had not received any in-services on hot liquid safety. In an interview on 08/07/2023 at 2:31 PM, the DON stated the Hot Liquid Safety in-service was conducted on 08/02/2023 not 07/21/2023 as documented and only Resident #34 had received a hot liquid safety evaluation. She further stated she had used paperwork for the evaluation from her previous employer as she knew this evaluation should be conducted. She stated hot liquid safety evaluations had been completed on all 51 residents on 08/07/2023. In an interview on 08/07/2023 at 3:00 PM with the Regional Clinical Director, stated the Hot Liquid Safety Evaluation had been used by the DON at a previous facility. When asked how residents had been evaluated for hot liquid safety, she stated the nurse would do it by observation, but she didn't know if they documented anything. She stated they had decided, at the corporate level, that the charge nurse will start to do it on admission and it will be part of the admission process. Record review of facility Safety of Hot Liquids Policy dated October 2014 reflected the potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition and nerve or musculoskeletal conditions. Residents with these conditions may suffer from accidental burns. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk form burns. Such interventions may include: maintaining hot liquids at a serving temperature of no more than 180 degrees Fahrenheit, serving hot beverages in a cup or insulated cup, encouraging residents to sit at a table when drinking hot liquids, and staff supervision or assistance with hot beverages. References: Related documents Hot Liquids Safety Evaluation. This was determined to be an Immediate Jeopardy (IJ) on 08/07/2023 at 4:50 PM. The ADM and DON were notified, and the ADM was provided with the IJ template on 08/07/2023 at 4:50 PM. The Plan of Removal was accepted on 8/08/2023 at 10:22 AM and included the following: The following is a plan of removal, which has been immediately implemented at [facility], to remedy the immediate jeopardy which was imposed 8/7/23 at 4:50 pm. All listed items will be completed by 8/8/23 with continued follow up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 21 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 1. Level of Harm - Immediate jeopardy to resident health or safety All staff will be in-serviced by the Regional Director of Operations/Regional Director of Clinical on Accident and Incident policy and procedure starting on 8/7/2023. Any staff not present, or new hires, will be in-serviced prior to starting their first shift. Residents Affected - Few 2. Dietary staff will be in-serviced by the DON/ or designee in conjunction with the Dietary Manager on ensuring temperature of hot liquids/ coffee is tested and documented twice daily to ensure within range and no hotter than 180 degrees on 8/7/2023. Any staff not present, or new hires, will be in-serviced prior to starting their first shift. 3. Resident #34 was provided a head-to-toe skin assessment by the Treatment Nurse, and no negative findings were found. Resident #34 was assessed for emotional distress by the Regional Clinical Director relating to the burn caused by spillage of resident's coffee, and no negative findings were found. 4. All nursing staff will be in-serviced by the nursing administration on coffee temperatures not to exceed 180 degrees, and policy and procedure relating to hot liquids starting on 8/7/2023. Any staff not present, or new hires, will be in-serviced prior to starting their first shift. 5. All nursing staff will be in-serviced by nursing administration on [NAME] use, and where to locate, to determine assistance needed for hot liquids based off hot liquid assessment starting on 8/8/2023 and on-going. Any staff not present, or new hires, will be in-serviced prior to starting their first shift. 6. The DON/ or Designee in conjunction with Rehab Director/ or Designee will complete and review a hot liquid safety assessment on all residents to identify risk factors and possible interventions starting on 8/7/2023. 7. All residents identified as a risk for hot liquids have been care planned by the MDS coordinator/ or designee for any changes related to hot liquid assessment findings and action/intervention changes. These have been completed on 8/7/2023. 8. Administrator, DON, and ADON to review every incident report pertaining to hot liquids during stand-up meeting daily to ensure interventions and documentation appropriate for resident safety and resident needs as applicable to prevent re-occurrence and provide protection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 22 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 9. Level of Harm - Immediate jeopardy to resident health or safety Items pertaining to Abuse/Neglect and Accident and Incidents referred to QAPI committee for weekly review to ensure current practice, interventions, and investigations are enforced with no negative findings. Any negative findings will be corrected immediately and reviewed for changes as identified. Residents Affected - Few 10. Any Agency Staff will receive in-service on all related in-services before being permitted to work by the DON/ or Designee. All residents who drink hot liquids have the potential to be affected by this alleged deficient practice. The Medical Director was made aware of the immediate jeopardy 8/7/23 at 5:15 PM and has been involved in the development of the plan to removal. The Medical Director initially made aware of this hot liquid finding on 6/7/2023 for QAPI compliance. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all Accident/Incident reports daily and follow up accordingly. The IDT will review and assess the Accident/Incident to determine what further actions if needed are necessary weekly. To monitor for compliance the administrator or designee will review hot liquid temperatures twice a day as served in the kitchen (i.e coffee) to ensure acceptable temperatures. The Administrator and/or Designee will also review and monitor hot liquid temperatures other than coffee that may be served outside of normal dietary practice daily. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QAPI committee for immediate correction. This plan was initially implemented 8/7/2023 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 8/8/2023. Monitoring for Plan of Removal was completed from 08/08/2023 through 08/11/2023 as follows: In an interview on 08/08/2023 at 11:00 with MA J, stated she had received a new in-service regarding hot liquid safety and that hot liquids could not be hotter than 160 degrees. She did not state how she would know the temperature of the liquid. She stated she was instructed to notify the charge nurse, DON and ADM for any accidents. Interviews were conducted with two nursing staff and three CNAs who were able to articulate and demonstrate use of the [NAME] to access hot liquid safety information. Record reviews reflected the facility documented hot liquid safety assessments on all residents on 08/07/2023. Record reviews reflected all staff were in serviced on the safety of hot liquids on 08/07/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 23 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review reflected a new hot liquid monitoring sheet was initiated for the kitchen staff and the ADM or their designee was to review the coffee temperatures twice daily. An IJ was identified on 08/07/2023. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 08/08/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Event ID: Facility ID: 675903 If continuation sheet Page 24 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #30) of 4 residents reviewed for respiratory care, in that: Residents Affected - Few The facility failed to: A.) date the oxygen tubing for Resident #30. B.) bag resident #30's oxygen tubing when not in use. These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident #30 Record Review of Resident #30's admission record dated 07/18/23 revealed the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses were acute respiratory failure (when lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), heart failure (a group of signs and symptoms, caused by an impairment of the heart's blood pumping function, and diabetes (a group of diseases that result in too much sugar in the blood. Record review of Resident #30's clinical physician orders dated as of 07/18/23 revealed: 1. an order to change and date O2 tubing and mask every Sunday and PRN. 2. an order for Albuterol Sulfate inhalation Nebulization Solution (2.5 mg/ml) 0.083% (Albuterol Sulfate) 1 vial inhaled orally every 4 hours as needed for cough/congestion/wheezing. 3. an order that stated may apply O2 per NC, mask or non-rebreather at needed rate not to exceed 10L/min to keep O2 saturation above 90% in emergent situation as needed for SOB/low O2 saturation. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 25 of 26 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 675903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mexia Ltc Nursing and Rehab 601 Terrace LN Mexia, TX 76667 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 SOB: Does resident have shortness of breath every shift for monitoring. Level of Harm - Minimal harm or potential for actual harm Record review of resident #30's quarterly MDS dated [DATE] revealed the resident's BIMS was 14 indicating she was cognitively intact. The MDS indicated the resident required extensive assistance during mobility in bed, transferring, personal hygiene, and dressing and required the assistance of one person while performing activities of daily living (dressing and toileting). The MDS revealed resident received oxygen therapy while being a resident of the facility and within the last 14 days. Residents Affected - Few Record review of resident #30's care plan dated 06/06/2023 read in part: Resident #30 is resistive to care r/t DX of Schizophrenia - Resident #30 has a dx of acute respiratory failure with hypoxia, O2 saturation is to be maintained above 90%. Interventions: Oxygen therapy as ordered. During and observation on 07/18/23 at 10:09 AM Resident #30's oxygen tubing, which was not in use and was not dated, was observed on the upper area of resident's bed with nasal canula stuck in between mattress and bed rail. Oxygen humidifier bottle, which was on concentrator was dated 06/11/23 and empty oxygen tubing bag was dated 06/11/23. In an interview on 07/18/23 at 10:11 AM with Resident #30, she stated things were alright and the staff treated her well. She stated the staff changed her oxygen tubing out, but she did not know how often. She stated she used oxygen sometimes but not every day. In an interview on 07/18/23 at 10:48 AM with RCD, she stated oxygen tubing and concentrators should be changed and dated every week on Sundays. She stated resident # 30's oxygen tubing storage bag was dated for 06/11/23 but that did not mean the tubing was from the same date and the bag was empty. She stated the oxygen tubing looked new, but it was not dated, and the humidifier bottle was dated 06/11/23. In an interview on 07/19/23 at 10:14 AM with DON, she stated oxygen tubing should be changed every Sunday night by the overnight nurse. She stated the oxygen tubing should be dated when changed and tubing should be placed in the bag when not in use. She stated the staff had been in-serviced on changing, dating, and placement of oxygen tubing. She stated a potential outcome if oxygen tubing is not changed or placed properly could be risk of exposure to germs or dirty tubing. Record review of facility policy Administration of Oxygen and Maintenance of Tubing and Equipment received from RCD and dated: 10/2017 revealed: Administration of Oxygen 1) Oxygen will be administered per physician order. Maintenance of Tubing and Equipment 1) Tubing will be kept in a bag when not in use. 2) Tubing will be dated and will be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675903 If continuation sheet Page 26 of 26