Inspection·February 12, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cough without mucus or phlegm, shortness of breath, and fatigue), dementia (a group of thinking and social symptoms that interferes with daily functioning), and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 3 which indicated severely impaired cognition. Record review of Resident #2's progress notes revealed the following: A note from 02/12/24 at 01:02 AM written by LVN E which stated Resident #2 had been complaining of not feeling well (nausea, uncontrolled shaking) and when Resident #2 was tested for COVID he tested positive. A note from 02/12/24 at 01:21 AM written by LVN E which stated Resident #2 was placed in quarantine. During an observation on 02/12/24 at 10:05 AM LVN A and PTA D were sitting at the nurses' station not wearing masks. During an observation on 02/12/24 at 10:16 AM LVN A was sitting at the nurses' station wearing a surgical mask. During an observation and interview on 02/12/24 at 10:17 AM ADM was wearing a surgical mask. She stated staff wore surgical masks in the building during a COVID outbreak and wore N95 masks when caring for COVID positive residents. She stated the facility was amid a COVID outbreak that started on 02/05/24 with two residents complaining of not feeling well. The residents tested positive for COVID as did a third resident and one staff member. ADM stated one of the positive residents had tested negative twice in 48 hours and was off isolation but Resident #1 and Resident #2 were still isolated in their rooms. ADM stated she and DON were the infection preventionists for the facility. During an interview on 02/12/24 at 10:23 AM LVN A stated she had worked for the facility for 2 years. When asked about the surgical mask she was wearing LVN A stated staff wore surgical masks when COVID was in the building. When asked why she was not wearing a mask earlier she stated, I kinda forgot to grab one. LVN A said when staff are caring for a COVID positive resident they wear a gown, gloves, an N-95 mask, and shoe covers. She stated staff put the PPE on outside the resident's room and take it off and throw it away inside the resident's room before exiting the resident's room. During an observation and interview on 02/12/24 at 10:34 AM Resident #1 was lying on her bed on her back with her TV on. She stated her throat hurt so bad she had trouble swallowing and talking. She stated staff come into her room wearing PPE. There was a clear trash bag with it's top tied shut sitting on the floor with what appeared to be a yellow PPE gown and some white gloves inside the bag. There was no other trash bag or trash can in the room. When asked what staff do with their PPE after they take it off before leaving her room, Resident #1 stated, They sit it on that chair there (Resident #1 gestured to an upholstered chair near the door of her room). During an observation and interview on 02/12/24 at 10:54 AM Resident #2 was lying on his back in bed with his TV on and his eyes closed receiving O2 via nasal cannula. CNA C arrived in the room wearing a gown, gloves, and an N-95 mask. She asked Resident #2 how he was feeling. He opened his eyes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675954 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 675954 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Perryton 3101 S. Main St Perryton, TX 79070 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 and asked, What are you girls doing? He did not respond to any other questions. There was a balled up yellow PPE gown sitting on top of a nightstand near the bathroom door in Resident #2's room. CNA C stated that was where staff left their used PPE when they were exiting Resident #2's room. CNA C was in the process of emptying the trash can near Resident #2's bed. She took the bag of trash and added the PPE from the top of the nightstand to the bag of trash. Residents Affected - Few During an observation on 02/12/24 at 11:00 AM CNA C exited Resident #2's room with a clear bag of trash tied together at the top. She placed the trash into a covered receptacle on a rolling cart in the hall. During an observation and interview on 02/12/24 at 11:11 AM PTA D was wearing a surgical mask. He said he had worked for the facility for 3 months. He stated he was supposed to wear a surgical mask in the facility when COVID was in the building. When asked why he was not wearing one earlier in the day he stated, I thought our patients were off quarantine today, but I guess they have to test two times negative in two days and I wasn't sure if they had or not. During an observation on 02/14/24 at 12:18 PM CNA C was observed standing in the hall with her surgical mask hooked under her chin, thereby not covering her mouth or her nose. During an interview on 02/14/24 at 01:27 PM ADM stated she expected her staff to wear surgical masks in the building during a COVID outbreak. She stated a possible negative outcome of staff not wearing surgical masks was a possibility of contracting COVID. She stated there should be receptacles in each COVID positive resident's room for staff to discard their used PPE into. When asked a possible negative outcome of staff sitting used PPE on surfaces in the resident's room ADM stated the surfaces could be contaminated. ADM stated DON did the COVID, PPE, HH in-service on 02/05/24. She stated the information in the blue binder she provided was what was covered in the in-service. On 02/12/24 at 01:38 PM a voicemail message was left for DON asking her to return the call. DON did not return the call. Record review of staff in-services for the past three months revealed in-services covering COVID, PPE, and HH were done on 02/05/24, 12/27/23, and 11/27/23. Record review of the sign-in sheet for the in-service on 02/05/24 revealed ADM, LVN A, PTA D, and CNA C all three attended the in-service. Record review of material covered in the in-service on 02/05/24 revealed the following topics on separate sheets of paper: Prevention Actions to Add as Needed There are some additional prevention actions that may be done at any level, but CDC especially recommends considering in certain circumstances or at medium or high COVID-19 hospital admission levels. Wearing Masks . Standard Precautions for Infection Control . Personal protective equipment (PPE) .Before leaving the patient's room or cubicle, remove and discard PPE. HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucus membranes with potentially infectious materials. Remove all PPE before exiting the patient room . 1. GLOVES . Discard gloves in a waste container .3. GOWN . Fold or roll into a bundle and discard in a waste container. 4. MASK OR RESPIRATOR . Discard in a waste container . EXAMPLE 2 . 1. GOWN AND GLOVES . Place the gown and gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675954 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 675954 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Perryton 3101 S. Main St Perryton, TX 79070 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 into a waste container . 3. MASK OR RESPIRATOR . Discard in a waste container . Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Policies and Practices-Infection Control and dated 2001 revealed the following: Residents Affected - Few . The objectives of our infection control policies and practices are to: a. Prevent . and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; . Record review of facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures and dated May 2023 revealed the following: . This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Record review of CDC Infection Control Transmission Based Precautions dated 2016 revealed the following: . Contact Precautions Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. properly discarding before exiting the patient room is done to contain pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675954 If continuation sheet Page 4 of 4