Health inspection·May 10, 2023

F 0578 Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated 7-29-2022 Level of Harm - Minimal harm or potential for actual harm Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated 2-9-2023 Residents Affected - Few In the absence of b/p, pulse, respirations, CPR will not be initiated -date initiated 2-9-2023 Record review of the clinical record for Resident #4 revealed an Order Summary with active orders as of 5-9-2023 with the following order: DNR (with a start date of 7-29-2022) Record review of the clinical record for Resident #4 revealed a DNR dated 7-28-2022 (by Resident #4's adult child) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no second signature for the physician in the All person who have signed above must sign below, acknowledging that this document has been properly completed section. Resident #11 Record review of the face sheet dated 5-8-2023 in the clinical record for Resident #11 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), Parkinson's (a disorder of the central nervous system that affects movements to include tremors), malignant neoplasm of the right and left lung (a fast-growing cancer that spreads to other areas of the body), and malnutrition (lack of proper nutrition). Under the section Advanced Directives Resident #11 was listed as a DNR. Record review of the clinical record for Resident #11 revealed the last MDS completed was a quarterly dated 3-22-2023 with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring one to two-person assistance with activities of daily living. Record review of the clinical record for Resident #11 revealed a care plan (date initiated 2-9-2023) with an admission date 12-16-2022 with the following: Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated 2-9-2023 Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated 2-9-2023 Focus: Resident requires hospice as evidenced by terminal illness. She has been diagnosed with lung cancer. -Date initiated 2-15-2023 Interventions: -there were no interventions listed related to the DNR process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 2 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0578 Record review of the clinical record for Resident #11 revealed an Order Summary Level of Harm - Minimal harm or potential for actual harm with active orders as of 5-8-2023 with the following order: DNR (with a start date of 2-9-2023) Residents Affected - Few Admit to hospice services (with a start dated of 2-6-2023) Record review of the clinical record for Resident #11 revealed a DNR dated 2-8-2023 (by Resident #11's Medical Power of Attorney) with the following: Section-Two Witnesses-there was no information Section-All person who have signed about must sign below, acknowledging that this document has been properly completed-there was a signature on the Notary line and a notary stamp. Resident #13 Record review of the face sheet dated 5-8-2023 in the clinical record for Resident #13 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), malnutrition (lack of proper nutrition), Lymphoma (a cancer of the lymph system), and schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly. Under the section Advanced Directives Resident #13 was listed as a Full Code. Record review of the clinical record for Resident #13 revealed the last MDS completed was a quarterly dated 1-30-2023 with a BIMS of 6 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with all her activities of daily living. Record review of the clinical record for Resident #13 revealed a care plan with admission date 6-28-2022 with the following: Focus: Resident is a full code-Date initiated 6-29-2022 Intervention-Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMS -Date Initiated: [DATE] Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of 5-8-2023 with the following order: Full code (with an order date 0f 6-28-2022) Record review of the clinical record for Resident #13 revealed a DNR dated 5-3-2023 (by Resident #13's Medical Power of Attorney) that was completed correctly. During an interview on [DATE] at 02:36 PM LVN F reported that if a resident was a DNR and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 3 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessed that resident to not have a heart rate and/or pulse then she would not start CPR, she would notify the family, hospice if they were involved with the resident's care, and notify the physician. LVN F attempted to verify Resident #4, Resident #11, and Resident #13's DNR status by the markings placed on each Residents door. LVN F reported that a green sticker will be placed on the resident's door if that resident is a DNR, but the door markings were inconsistent and LVN F reported that she would have to verify each resident's DNR status by the resident information kept at the nurse's station. LVN F checked the master file at the nurse station and reported that the information had not been updated since [DATE] so she would have to check each resident's chart in the computer system. LVN F checked Resident #13's electronic record and reported that Resident #13 was listed as a full code and that she would immediately start CPR and have another staff member contact 911, Resident #11 and Resident #4 were both listed as a DNR on their face sheet in their electronic record and therefor LVN F would not start CPR and would notify family and the physician for Resident #4 and family, physician, and hospice for Resident #11. LVN F was asked to check each resident's DNR form in the electronic record. LVN F reviewed Resident #11's DNR form and reported that it was missing the witness's signature, therefore it was invalid, not a legal document, and that the resident would have to be changed to a full code until the DNR form could be corrected with the right document. LVN F then checked Resident #4 and reported that the DNR form did not have any physician information and therefore was not a legal document and would have to be handled the same as Resident 11's DNR. LVN F then checked Resident #13's electronic record and reported that Resident #13 was a full code. When asked to check the document section of Resident 13's electronic record LVN F found the DNR form, reported that it was filled out correctly as of 5-3-2023, and that Resident #13 would have to be changed to a DNR status. LVN F reported that it was the Social Workers responsibility to ensure that the DNR's were correct and that if the DNR's were not correct then the resident wishes would not be followed. During an interview on [DATE] at 02:52 PM the DON and CN verified that Resident #11 was missing the witness signatures and was not a valid DNR, Resident #4 was missing all the physician information and was not a valid DNR, and Resident #13 was listed as a full code with a valid DNR in her record. Both the DON and CN verified that the social worker was responsible for making sure the DNR's were correct. The DON reported that it would cause problems for the staff, and it could result in the resident, or the families wishes not being followed if the DNR process was not followed correctly. During an interview on [DATE] at 03:21 PM the SW went to the medical records office an pulled the original DNR form for Resident #11 and verified it was missing the witness signature, pulled Resident #4's DNR form and verified it was missing the physician information, and reported that she did not know why both DNR forms were not signed. The SW reported that she would try to do a monthly review of all resident DNR's, and she again reported that she did not know Resident #4 and Resident #11's DNR's were not signed. The SW did report that if the DNR form process is not complete and accurate then it can be a mess because the process will not be followed correctly. The SW reported that she would get both DNR forms corrected immediately. During an interview on [DATE] at 09:17 AM the CN reported that they did an audit of the original medical record charts kept in the medical records office the previous evening and was able to find the original DNR forms for Resident #11 that had the second witness signature that was a notary but when it was copied the witness signature did not copy correctly in the Resident #11's electronic chart or the hospice record which would be the records that staff would access when completing a code and they found the original DNR form for Resident #4 that when copied cut off the bottom of the form to include the physicians signature section and that is the reason why the physicians signature section was missing in the copy placed in Resident #4's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 4 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few electronic chart which would be the record that staff would access when completing a code. The CN reported that the facility was going to implement an immediate in-service with staff to reeducated on the DNR/Code process and implement a monthly audit of all DNR forms to ensure that they are complete and accurate. Record review of facility provided policy titled Do Not Resuscitate Order, revised 10-12-2013, revealed the following: Out of Hospital DNR Form The Out of Hospital DNR form was designed by the Texas Department of Human Services to comply with the requirement as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts. 5. In all cases the form must be signed and dated by two witnesses 11. All validly executed DNR orders will be honored by the facility. Record review of the facility provided policy titled Self Determination End of Life Measures and Advanced Directives, undated, revealed the following: 8. The residents right to execute and advanced directive or make changes to an existing advanced directive .will be recognized an applicable under Texas state law. 11. There are two witnesses required for all advance directive documents . Residents who have completed a valid OOH (Out of Hospital) DNR (Do Not Resuscitate) form will have their wishes be honored. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional Resident #4 Advance Directives FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 5 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #16) of 16 residents reviewed for respiratory care. Residents Affected - Few Resident #16 had orders for oxygen at 5 liters per minute and was receiving oxygen at lower concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organ), shortness of breath, and hypoxia (insufficient levels of oxygen in the tissues of the body for normal life functions). Findings included: Record review of Resident #16's face sheet, dated 05/09/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), anxiety disorder, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), emphysema (a lung disease which results in shortness of breath). Record review of Resident #16's Quarterly MDS, dated [DATE], revealed a BIMS score of 7 out of 15 which indicated severely impaired cognition. He required limited to extensive one-person assistance with bed mobility, transfer, bathing, walking, locomotion and personal hygiene. He was independent in eating and toilet use. The MDS documented a need for oxygen therapy while a resident. Record review of Resident #16's care plan, dated 03/13/23, revealed he had congestive heart failure, emphysema, and chronic obstructive pulmonary disorder with a history of low O2 [oxygen] saturations. The care plan listed an intervention of continuous oxygen at 2-5 liters per minute via nasal cannula. It further noted, Give oxygen therapy as ordered by the physician. The care plan noted the resident had oxygen therapy and medications were to be given as ordered by physician. The care plan noted hospice provided a second concentrator to be kept in the dining room for Resident #16 to use during meals. The care plan again noted the resident was to take oxygen at 2-5 liters per minute via nasal cannula. The care plan noted the resident had altered respiratory status/difficulty breathing/ shortness of breath. Record review of Resident #16's active orders revealed an order by his primary physician, dated 02/24/23, for oxygen via N/C [nasal cannula] at 5 LPM [liter per minute] continuously. Record review of Resident #16's oxygen saturation summary, dated 05/09/23 revealed his oxygen levels were checked between two and five times per day. His oxygen levels dropped below 90% 14 times in the last 3 months. Ten of those times Resident #16 was not receiving oxygen via nasal cannula as ordered but was breathing room air. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 6 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 05/08/23 at 12:26 PM Resident #16 was sitting at a table in the dining room taking oxygen via nasal cannula hooked to a concentrator near his table set at 4.5 liters per minute. He appeared alert and oriented as he ate his lunch. During an observation on 05/08/23 at 01:58 PM Resident #16 was observed sitting in his w/c in the hallway taking oxygen via nasal cannula from a tank on the back of his w/c set to 4 liters per minute. During an observation on 05/08/23 at 02:01 PM Resident #16 was sitting in his w/c in his room taking oxygen via nasal cannula at 4 liters per minute. He was fully dressed and appeared to be sleepy but willing to talk. During an observation on 05/08/23 at 02:25 PM Resident #16 walked from his room to the drink station in the hall without oxygen. During an observation on 05/09/23 at 12:06 PM Resident #16 stood in front of his closet with no oxygen looking for a new shirt to wear. During an observation on 05/09/23 at 12:21 PM Resident #16 was sitting in the dining room with his oxygen via nasal cannula hooked to the oxygen tank on the back of his w/c. The oxygen tank was set to 0 liters per minute. The oxygen concentrator near his table was not on. During an observation on 05/09/23 at 01:29 PM Resident #16 was sitting in his w/c in the hallway. He was taking oxygen via nasal cannula hooked to the tank on his w/c which was set to 3 liters per minute. During an observation on 05/09/23 at 02:42 PM Resident #16 was lying in his bed on his back under a blanket with his eyes closed taking oxygen via nasal cannula hooked to the concentrator near his bed which was set to 3.75 liters per minute. During an observation on 05/10/23 at 08:22 AM Resident #16 was sitting at a table in the dining room eating his breakfast taking oxygen via nasal cannula hooked to the concentrator near his table which was set to 4 liters per minute. During an interview on 05/10/23 at 09:32 AM CNA E stated the nurses were responsible for setting the oxygen concentration levels for residents. She stated if a resident complained to her or showed signs of struggling to breathe, she would get a nurse. During an interview on 05/10/23 at 09:32 AM LVN D stated the nurses were responsible to set the oxygen concentration levels for residents based on the physician's orders. She stated the physician's orders were found in the chart of the resident. LVN D stated a possible negative outcome of a resident taking oxygen at a lower concentration than ordered by the physician was the resident would not be able to breathe well, they would not get the right amount of oxygen. During an interview on 05/10/23 at 09:44 AM RN A stated the nurses were responsible for physically setting the oxygen concentration levels for residents. She stated she knew what level to set a resident's oxygen concentration to by reading the physician's orders in the resident's chart. She stated if a resident took oxygen at a lower concentration than ordered by the physician it could lead to shortness of break and decreased oxygen saturation. RN A stated she cared for Resident #16. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 7 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few why his oxygen concentration levels did not match his orders for 5 liters per minute, RN A got online and looked at Resident #16's orders. She stated he had a new order dated 05/10/23 for oxygen at 4 liters per minute. During an interview on 05/10/23 at 09:49 AM the DON stated the nurses were responsible for setting the oxygen levels for residents to the correct concentration. She stated the nurses found the physician's orders regarding oxygen in the resident's chart. The DON stated a resident receiving oxygen at a lower concentration than ordered by the physician might experience oxygen desaturation. She stated the nurses were responsible for entering physician's orders into the electronic health record. When asked why Resident #16 was not receiving oxygen at the concentration ordered she stated she changed his order that morning because he had an order for 2-5 liters per minute and she knew they were not allowed to have orders with ranges, so she changed it to 4 liters per minute. Record review of facility's policy titled Medication Orders and dated 2003 revealed the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Record review of a facility's policy titled Oxygen Administration and dated 2007 revealed the following: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. 7. Place nasal cannula .in the nares . 9. Turn on oxygen after properly setting volume . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 8 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in one of one kitchen reviewed for proper food storage. Residents Affected - Many 1. The facility failed to ensure refrigerated foods were properly labelled and dated. 2. The facility failed to ensure pantry foods were properly labelled, dated, and stored in airtight containers. 3. The facility failed to ensure expired foods and leftovers past the use by date were removed from the refrigerator, pantry, and spice shelf. These failures could place residents at risk for food-borne illness. Findings included: Observation of the upright refrigerator on 05/08/23 at 09:57 AM revealed the following: -a white plastic tub of chicken base with no date -a resealable plastic bag of what appeared to be slices of ham dated 04/28/23 -a bag of celery with no date -a resealable plastic bag of what appeared to be tortillas dated 02/16/23 -a resealable plastic bag of what appeared to be half a green pepper dated 03/28/23 -mango slices in rectangular plastic package with a use by date of 04/28/23 -a grocery store produce bag with what appeared to be two nectarines, one of which had two black fuzzy spots the size of dimes on one side -two kiwi in square plastic package dated 03/28/23 -a resealable plastic bag of what appeared to be half a red onion dated 04/21/23 -a resealable plastic bag of what appeared to be 4 limes dated 04/10/23 -a resealable plastic bag of what appeared to be 5 garlic cloves which were orange in color and slimy, dated 04/10/23 Observation of the spice shelf in the kitchen on 05/08/23 at 10:06 AM revealed a small opaque white storage tub with lid labelled caramel sauce with a use by date of 04/05/23. Observation of the pantry on 05/08/23 at 10:07 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 9 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0812 -a bag of powdered sugar with no date Level of Harm - Minimal harm or potential for actual harm -an open bag of chocolate chips with no date -a bag of chocolate chips with no date Residents Affected - Many -an open bag of grape drink mix with no date -a bag of lemon gelatin with no date -a 5-gallon opaque white storage tub with lid approximately ¼ full of a crumb-like substance no label or date -a large bag of Japanese breadcrumbs open to air with no date -three gallons of lemon juice with expiration dates of 04/26/23 -4 gallons of mustard in a box with no date -3 cans of cooking spray in a box with no date -2 large cans of mandarin orange slices with dents on the sides of the cans near the top During an interview on 05/08/23 at 10:18 AM [NAME] B stated pantry foods should be dated on the top of the packaging. Observation of the chest refrigerator on 05/08/23 at 10:20 AM revealed a gallon of lemon juice 2/3 full had an expiration date of 04/26/23. Observation of the freezer on 05/08/23 at 10:25 AM revealed a foil wrapped package labelled cilantro with a use by date of 12/08/22. During an interview on 05/09/23 at 02:21 PM the ADM stated canned goods that are not dented are assumed to be good for consumption indefinitely. During an interview on 05/09/23 at 03:24 PM the DM stated she and the cooks were responsible for throwing out expired food or food past it's use by date. She stated a possible negative outcome of not throwing out said food was residents could get sick or vomit. During an interview on 05/09/23 at 03:26 PM [NAME] C stated part of her job responsibility was to throw out expired food. She stated a possible negative outcome of serving expired food to residents was they could get food poisoning or get sick. During an interview on 05/10/23 at 09:54 AM the DM stated she and the cooks were responsible to label and date food that comes into the kitchen. She stated a possible negative outcome of having undated and unlabeled food was the food could be spoiled. She stated leftovers were to be dated the date they were made and the date they should be thrown away. The DM stated leftovers were to be thrown away 7 days after they were made. She stated produce was good for two to three weeks. The DM stated she had trained her staff on throwing away expired food and leftovers as well as labelling and dating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 10 of 11 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 675973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McLean Care Center 605 W Seventh St McLean, TX 79057 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 0812 food properly. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/10/23 at 09:50 AM [NAME] C stated the cooks were responsible for labelling and dating food. She stated a possible negative outcome of not labelling and dating food was, We wouldn't know when it was opened or if it is fresh to serve out and people could get sit from that. [NAME] C stated produce is good for 6-7 days. She stated leftovers are dated the date they were made and 7 days after that. [NAME] C stated she had been trained on how to date and label food as well as on throwing out expired food from the pantry, refrigerator, and freezer. Residents Affected - Many Record review of an in-service training report dated 05/08/23 listed the DM as instructor and revealed the following: Make sure everything it [sic] labeled and dated. Items in fridge must have labels and dates. When it was put in fridge and 7 days out. Record review of facility's policy titled, Storage Refrigerators and dated 2012 revealed the following: .5. Food must be covered, when stored, with a date label identifying what is in the container. Record review of facility's policy titled Dry Storage and Supplies and dated 2012 revealed the following: .3. Dry bulk foods are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of facility's policy titled Food Storage and Supplies and dated 2012 revealed the following: .8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil.If a food has developed such spoilage characteristics it should not be eaten.if possible food spoilage is observed prior to the best by date, the product will be discarded. 9. Perishable and non-perishable foods are classified based on their pH and water content.Perishable items that are refrigerated are dated once opened and used within 7 days .but non-perishable items that are refrigerated once opened should be dated when opened . Record review of facility's policy titled Food Safety and dated 2012 revealed the following: . 2. Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 11 of 11