Health inspection·July 9, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. -Medication cart for the facility revealed the following:-The facility failed to discard Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -The facility failed to have an open date on Resident #19's Novolog 100units/ml. -The facility failed to discard Resident #16's Lantus 100units/ml with open date of 06/03/2025. -The facility failed to discard Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-The facility failed to have an open date on Resident #3's Novolog 100units/ml. -The facility failed to have an open date on Resident #3's Glargin-YFGN Injection pen. -The facility failed to have an open date on Resident #24's Novolog FlexPen. -The facility failed to discard Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -The facility failed to have an open date on Resident #22's Novolog FlexPen. -The facility failed to have an open date on Resident #9's Trelegy inhaler. -The facility failed to discard 1 bottle of Zyrtec with no expiration date on bottle. -The facility failed to store medications appropriately, 7 loose pills were found in the bottom of medication cart drawers. Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 1 medication carts (Medication cart) and 6 of 13 residents (Resident #3. #9, #16, #19, #22, and Resident #24) reviewed for medication storage. -Medication cart for the facility revealed the following:-The facility failed to discard Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -The facility failed to have an open date on Resident #19's Novolog 100units/ml. -The facility failed to discard Resident #16's Lantus 100units/ml with open date of 06/03/2025. -The facility failed to discard Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-The facility failed to have an open date on Resident #3's Novolog 100units/ml. -The facility failed to have an open date on Resident #3's Glargin-YFGN Injection pen. -The facility failed to have an open date on Resident #24's Novolog FlexPen. -The facility failed to discard Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -The facility failed to have an open date on Resident #22's Novolog FlexPen. -The facility failed to have an open date on Resident #9's Trelegy inhaler. -The facility failed to discard 1 bottle of Zyrtec with no expiration date on bottle. -The facility failed to store medications appropriately, 7 loose pills were found in the bottom of medication cart drawers. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included:During an observation on 07/07/25 at 9:43 AM the medication cart for the facility revealed the following:-Resident #19's Novolog 100units/ml with an open date of 06/06/2025. -Resident #19's Novolog 100units/ml with no open date on bottle or box. -Resident #16's Lantus 100units/ml with open date of 06/03/2025. -Resident #16's Novolog 100units/ml with an open date of 06/04/2025.-Resident #3's Novolog 100units/ml with no open date on bottle or box. -Resident #3's Glargin-YFGN Injection pen with no open date. -Resident #24's Novolog FlexPen with no open date written on pen. -Resident #22's Glargin-YFGN Injection pen with an open date of 06/04/2025. -Resident #22's Novolog FlexPen with no open date. -Resident #9's Trelegy inhaler had no open date written on inhaler. -1 bottle of Zyrtec with no expiration date on bottle. -7 loose pills found in the bottom of medication cart drawers. During an interview on 07/07/25 at 10:05 AM ADON stated that a negative outcome for medications not having an expiration date on them was that staff would be unsure when medication expired, and the medication will not be effective for the residents. During an interview on 07/07/25 at 11:32 AM DON stated the negative outcome (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 2 of 8 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 07/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete for having loose pills in the bottom of the medication cart drawers would be that the resident would miss a dose, and the staff doesn't know what the medication would be. DON stated the negative outcome for not having open dates on medications that require one would be the medication could be expired and not effective for the resident. Record review of the facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened.(fluticasone)-expires 6 weeks (50mcg strength) or 2months (100 and 250mcg strengths) after initial use.Novolog and Novolog MixInsulin Glargin (Lantus)Insulin Glargin (Apidra)-Refrigerate until initial use-Expires 28 days after initial use regardless of product storage (refrigerated or room temperature). Event ID: Facility ID: 675973 If continuation sheet Page 3 of 8 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 07/09/2025 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food.B. The facility failed to ensure personal items were not in the kitchen prep area. *This tag was written by [NAME]. However, she is out of the office at this time, so I am placing it here to get it turned into Enforcement timely. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. B. The facility failed to ensure personal items were not in the kitchen prep area. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an observation of the kitchen food prep area on 7/7/25 at 9:15 am revealed a pair of sunglasses, 2 cell phones, keys and papers on the kitchen counter prep table in the kitchen. In an observation of the kitchen food prep area on 7/7/25 at 11:30 am, a pair of sunglasses, 2 cell phones, keys and papers on the kitchen counter prep table in the kitchen. Lunch preparations were under way and resident drinks were being prepared on the same counter. In an observation on 7/7/25 at 11:35 am, the DM was observed preparing pork chops for lunch. The DM washed hands and changed gloves then picked up a large stainless bowl and took the bowl to the counter. The DM picked up pork chops, placed the chops into the bowl containing flour, breaded the pork chops with the flour coating, then picked up the stainless bowl with both hands and walked over to the fryer. The DM then shifted the stainless bowl to her hip and placed each pork chop into the fryer with her hands. In an observation on 7/7/25 at 11:40 am the DM was observed to have washed hands and changed gloves. The DM picked up the blender pieces and set up the blender for use. The DM then carried the container of pork chops to the blender table and picked up a knife. The DM began to cut the pork chops with a knife using her gloved hands to hold the meat. The DM touched the meat pieces to see if she had missed any bones then put the meat into the blender with her gloved hands. The DM used her gloved hands to put the pork chops into the blender. The DM then put the lid on the blender and started the blender. During the blending a bone was caught in the blender. The DM took the lid off the blender and took out the bone with her gloved hands, took out the bone and put the lid back on the blender. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 4 of 8 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 07/09/2025 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 Residents Affected - Some The DM started the blender again and continued blending the meat. The DM did not change her gloves or wash her hands. The DM stated she realized she had touched the food and should have washed her hands and changed her gloves during the meal preparations. She stated the consequences of the food contamination were cross contamination and could make the residents sick. In an observation of the kitchen food prep area on 7/8/25 at 10:00 am revealed a cell phone on top of a box of trash can liners on the counter of the food prep counter in the kitchen. Next to the personal phone sitting on trash bag liners was a crock pot cooking food for lunch. In an interview on 7/9/25 at 9:30 am, the Registered Dietician (RD) stated she had spoken to the DM about glove changes and hand washing. She stated she had trained staff on hand hygiene and glove changes recently. She stated she had not seen many issues since she had started monitoring the facility in April. She stated she had discussed personal items not being on the counter each time she had gone to the facility. She stated she expected personal items would be put away and would not be on the counter. She stated if the phones were out the staff were probably looking at them and touching them and then touching the food. She stated that would cause cross contamination. She stated she would address all issues with the DM on her next visit. In an interview on 7/9/25 at 10:25 am, the DM stated she did have her phones out on the kitchen prep table. She stated she was not aware she could not have her phone out. She stated she thought that was just for personal drinks. She stated the sunglasses and keys were [NAME] D's. She stated of the glove changes and hand hygiene she would in-service the staff on hand hygiene again. She stated personal items could cause cross contamination and food borne illness in residents. In an interview on 7/9/25 at 12:40 PM, [NAME] D stated those were his sunglasses on the counter and he was not aware personal items could not be on the kitchen counter. He stated the consequences of personal items in the kitchen would be cross contamination. Record review of the policy dated 2012 titled, Dietary Food Service Personnel Policy and Procedures revealed: All personal belongings (papers, cell phones, purses, etc.) must be kept out of the food preparation area.Do not handle food with bare hands. Remember to change gloves after touching anything that should not contact food. Wash your hands. Before starting work, after coughing.Touching something that is not clean and then handling food can cause food poisoning. All employees receive instruction in sanitation during orientation and thorough in-service training. Record review of the policy dated 2012 titled, Food Safety revealed we will ensure all food items shall be prepared in compliance with all State, Federal and local laws and regulations. Food shall be handled in a safe manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 5 of 8 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 07/09/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records.The facility failed to ensure Resident #15 had orders for his catheter.Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #15) of 13 residents reviewed for accuracy of medical records.The facility failed to ensure Resident #15 had orders for his catheter.These failures could place residents at risk of not receiving necessary care/treatment due to inaccurate medical records.Findings Included:Record review of Resident #15's admission record dated 07/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull), obstructive and reflux uropathy (urine cannot drain through the urinary tract). The onset date for the obstructive and reflux uropathy diagnosis was 06/10/25.Record review of Resident #15's significant change MDS completed on 05/13/25 revealed a BIMS of 2 which indicated severely impaired cognition. Resident #15 was not coded as having a catheter.Record review of Resident #15's care plan revealed he had a catheter due to his obstructive uropathy diagnosis. This focus area was initiated on 06/12/25 and revised on 06/17/25. The goal was, The resident will be/remain free from catheter-related trauma through review date [sic] The goal was revised on 07/01/25 Interventions listed included, Change the catheter as ordered. Monitor and document intake and output . Monitor/record/report to MD for s/sx UTI: . The interventions were initiated on 06/12/25. The intervention to Change the catheter as ordered. was revised on 07/01/25.Record review of Resident #15's active orders dated 07/08/25 revealed no mention of his catheter. He did have the following order with start date of 07/07/25: Macrobid Oral Capsule (Nitrofuratoin Monohyd Macro) Give 100 mg by mouth two times a day for UTI for 7 days.Record review of Resident #15's discontinued, struck out, and/or completed orders revealed the following orders with start date of 06/10/25 and end date of 06/15/25: Change Foley Catheter using 16 fr 10 ml bulb one time a day every 30 day(s)Empty drainage bag every shiftMonitor F/C q shift for leakage, blockage, sediment buildup, or low outputUrinary Catheter 16 F to gravity drainageEnsure foley bag is in privacy bag while in bed or w/c every shiftEnsure catheter strap in place and holding every shift . change as needed.Record review of Resident #15's MAR and TAR for June and July 2025 revealed no mention of a catheter.During an observation and attempted interview on 07/07/25 at 09:31 AM Resident #15 was reclined in a geri chair in his room. He was dressed in a T-shirt and a brief was visible on his left hip. A blanket covered his legs and right hip. No catheter or tubing was visible. He was unable or unwilling to answer when asked if he had a catheter.During an observation on 07/07/25 at 12:39 PM Resident #15 was seated in the dining room in a geri chair. No catheter or tubing was visible.During an interview on 07/09/25 at 09:21 AM RN A stated she worked for the facility PRN. She stated Resident #15 had a catheter and she and CNAs were responsible for doing catheter care. She stated only nurses were responsible to change a catheter. RN A stated nurses would know when to change Resident #15's catheter by referring to his physician orders. She stated the information would be in the TAR regarding catheter care. RN A stated a resident with a catheter and no physician's orders regarding the catheter could get a catheter associated infection due to lack of catheter care. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 6 of 8 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 07/09/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated nurses could put orders in a Resident's chart and inaccurate medical records could negatively affect resident care.During an observation and interview on 07/09/25 at 09:56 AM DON stated Resident #15 had a catheter. She stated she, ADON, and charge nurses were responsible for changing his catheter. DON stated nurses would know when to change a catheter and what size to use because they would refer to the order. She stated nurses were not trained regularly on catheter care as it is part of nursing school. DON searched her computer for orders for Resident #15's catheter. She stated, I don't see some (orders). She stated Resident #15 had his catheter out for a little while and then it was placed back in by hospice nurses and the orders were never put back into his chart. She stated she, ADON, and charge nurses were responsible for entering orders into resident charts. She stated inaccurate medical records could negatively affect residents. DON stated without orders for catheter care a resident could be negatively affected because you wouldn't be able to know when to change or document that you were changing it (the catheter).During an interview on 07/09/25 at 10:04 AM MDS LVN stated Resident #15 had a catheter. She stated inaccurate medical records, such as a resident with a catheter and no orders for the catheter could negatively affect residents. She stated without orders for a catheter in the chart, staff would not know when to change the catheter, would not document urine output, might not recognize s/sx of UTI, or know if the catheter was kinked or the resident was having trouble with the catheter. She stated nurses and CNAs were responsible for catheter care.During an interview on 07/09/25 at 10:09 AM ADM stated nurses were responsible for changing catheters. He stated residents might not receive needed treatment if their medical records were inaccurate.Record review of facility policy titled Documentation and dated 2003 revealed the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Event ID: Facility ID: 675973 If continuation sheet Page 7 of 8 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 07/09/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm -ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 of 13 residents (Resident #1) reviewed for infection control. -ADON did not use PPE to perform a glucose check on Resident #1, who was on contact precautions for MRSA. -ADON did not clean glucose strip container after coming out of Resident #1's room. -ADON did not use PPE to administer IV medications via PICC line for Resident #1. These deficient practices could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 07/07/25 at 11:37 AM ADON was observed going into Resident #1's room to perform a blood glucose check and did not don a gown to perform this task. ADON placed the container of glucose strips on the bedside table of Resident #1 who was on contact precautions for MRSA. ADON did not wipe glucose strip bottle when she removed it from Resident #1's room and placed it back in the medication cart. During an observation on 07/08/25 at 08:18 AM ADON went into Resident #1's room to administer IV medications and did not don a gown. During an interview on 07/08/25 01:32 PM ADON stated the negative outcome for not cleaning the glucose strip container and not donning a gown was I can spread whatever they (Residents that are on EBP) have to other residents. During an interview on 07/09/25 at 11:03 AM DON stated the negative outcome for not donning a gown during prolonged care for a resident who was on EBP could lead to the spread of infection to other residents. DON stated the negative outcome for not cleaning equipment properly would also lead to cross contamination. Record review of facility provided policy titled, Enhanced Barrier Precautions, dated 04/01/2024, revealed the following:.Donning PPE for Residents on EBP based on activity provided/assistance while in resident room.Device care or use: central line, .Any other high-contact activity that includes close bodily contact or coming into contact. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675973 If continuation sheet Page 8 of 8