Inspection·April 12, 2023

F 0582 Covid positive status and isolation. Level of Harm - Minimal harm or potential for actual harm A Physician order dated 01/04/2023 indicated Resident # 11 admitted to skilled services for Covid positive status and isolation, discharged from skilled services on 01/17/2023 and remained in the facility. The facility issued a NOMNC (Notice of Medicare Non-Coverage) on 01/15/2023 but facility failed to issue SNF ABN. Residents Affected - Few Record review of SNF Beneficiary Notice indicated Residents #3, Resident # 7, and Resident # 11 remained in the facility at the end of Medicare part A stay and did not receive the SNF ABN notification form. During an interview on 04/12/23 at 08:57 AM the Assistant Admin stated she was responsible for issuing the NOMNC and had never issued a SNF ABN for residents that remained in the facility. She stated she had been trained on the proper notifications but missed the need for a SNF ABN. She stated she was the only person at the facility that handled the discharges and issued the residents or responsible party their appropriate forms. She stated the risk could be resident not being aware of their full benefits. She stated she would see that going forward the correct forms are given at discharge and would participate in any trainings available for her to learn more. Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, revealed Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 2 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #11) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #11's oxygen nasal cannula tubing and prefilled humidifier was dated as specified in their policy. These deficient practices could place residents at risk of developing respiratory infections and complications. Findings: Record review of facility face sheet dated 04/12/2023 indicated Resident # 11 was admitted on [DATE] with diagnosis of senile degeneration of the brain (loss of brain function). Record review of Resident # 11's order summary report dated 04/12/2022 indicated an order for Oxygen 2 to 5 liters per nasal cannula as needed for shortness of breath with a start date of 07/10/2022. Record review of Resident # 11's significant change in status MDS dated [DATE] indicated oxygen therapy. Record review of Resident # 11's comprehensive care plan dated 01/04/2023 indicated resident was Covid positive and required intervention with oxygen therapy. During an observation on 04/10/2023 at 09:43 AM Resident # 11 was lying in bed with oxygen in place at 3 liters per nasal cannula. The oxygen nasal cannula and humidifier bottle was undated. During an interview on 04/10/2023 at 2:16 PM Resident # 11's family member stated Resident # 11 used oxygen daily. During an interview on 04/10/2023 at 03:04 PM LVN A stated the night shift changes out the oxygen tubing and bottles. She stated the tubing and humidifier bottle should be dated and when not in use it should be bagged for infection control purposes. She stated the risks could be malfunction, improper oxygen delivery, and infection control. During a phone interview on 04/12/2023 at 05:30 AM LVN B stated she had worked night shift at the facility for 3 years. She stated she was trained during orientation by LVN C. She stated that oxygen tubing is changed every Friday and is to be dated and humidifier bottles were changed monthly and dated. She stated that the nurse then signs the treatment record indicating it was changed. She stated she was not aware Resident # 11 did not have a treatment order to change their tubing weekly and humidifier monthly. She stated the risk could be respiratory infections. During a phone interview on 04/12/2023 at 08:00 AM LVN C stated she had worked night shift at the facility for 21 years. She stated she had been responsible for training new staff on hire on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 3 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 procedure for changing oxygen tubing and humidifier bottles. She stated the facility policy was to change oxygen tubing every Friday and date the tubing and change the humidifier botte monthly and date the bottle. She stated in the past the nurse would initial the treatment record that the task was completed but recently noticed the oxygen orders were no longer on the treatment record. She stated she thought she changed Resident # 11's oxygen tubing Friday 04/07/2023. She stated the risk could be infection control and oxygen not working properly. During an interview on 04/12/2023 at 08:35 AM the DON stated that the night shift nurse was responsible for changing out oxygen tubing on Fridays and that the tubing should be dated. She stated the humidifier bottles are changed out monthly on the 10th and should be dated as well. She stated the nurse should then sign out on the treatment administration record that the task was complete. She stated she was not sure why Resident # 11 did not have a treatment for changing out their tubing and humidifier but would see that it was corrected. She stated she was responsible for oversight and ensuring this process was followed. She stated she would provide retraining on the proper process for changing out oxygen supplies and expected the facility policy was followed. During an interview on 04/12/2023 at 08:33 AM the Assistant Admin stated the DON is responsible for nursing oversight but she would oversee that the nursing staff are trained on the facilities oxygen policy and procedure. She stated she expects that all staff are following the policy and procedure and oxygen tubing and humidifier bottles are dated. She stated the risk could be infection control. Record review of undated facility policy titled Oxygen Concentrator indicated' .3. Other c. each month the night charge nurse will change the humidifier bottle. a. write the date on the bottle. b. every Friday night charge nurse will change oxygen tubing with a new one, write date on tubing and discard old into the trash. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 4 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (treatment cart) reviewed for labeling and storage. The facility failed to remove expired glucose control solution and ensure the glucometer strips had an open date located on the nurse medication cart used for treatments. This deficient practice could place residents at risk for receiving improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings: During an observation on [DATE] at 11:00 AM the nurse treatment cart contained glucometer strips with no open date and directions on the bottle indicated to use within 3 months of opening. Glucose control solution was dated [DATE] and directions on the bottle indicated to use within 3 months of opening. During an interview on [DATE] at 01:57 PM LVN A stated the night nurses were responsible for the glucometer checks and maintaining the control solution and strips. She stated all nurses however are trained on use of glucometers and control monitoring. She stated she had not performed the task of checking glucometer controls in a long time and the risk of using expired strips and control solutions could be inaccurate blood sugar results. During a phone interview on [DATE] at 05:30 AM LVN B stated she had worked the night shift at the facility for 3 years. She stated that the night nurses are responsible for checking the glucometer controls and she has only followed the expiration date on the bottles. She stated she was unaware of the use within 3 months date for the control solution and glucometer strips. She stated she was trained on glucometer controls but that was a while ago. She stated the risk of using expired strips could be inaccurate blood glucose results. During a phone interview on [DATE] at 08:00 AM LVN C stated she had worked the night shift at the facility for 21 years. She stated she was not aware of the use within 3 months of opening instructions for glucometer control solution and test strips. She stated she was trained by the DON but that was years ago. She stated the risk could be incorrect blood glucose results. During an interview on [DATE] at 08:20 AM the DON stated the night nurses were responsible for monitoring the glucometer controls and they had all been trained at some point to date glucometer strips and glucose solution and dispose of after 90 days. She stated the risk could be inaccurate blood glucose results. She stated she would see that all nurses were retrained and expects all staff to follow the facility policy and product directions. During an interview on [DATE] at 08:30 AM the Assistant Admin stated the DON was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 5 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nursing oversight and she would ensure all nurses are trained on policy and procedure for glucometer checks and monitoring. She stated she was not aware of the risk but could be the glucometer not reading accurately. Record review of an undated facility policy titled Glucometer Control Test indicated, .#1 Check the expiration date of the control solution. Discard unused control solution 90 days after opening. Event ID: Facility ID: 676043 If continuation sheet Page 6 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure the pureed meat and corn were prepared in a form designed to meet individual needs for 1 of 1 lunch meal reviewed for food form and preparation. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: The pureed steak fingers and corn prepared on 04/11/23 for the noon meal was not pureed to a smooth pudding like consistency. During an observation and interview on 04/11/23 at 11:12 a.m., the DM was preparing the pureed meat and corn for the lunch meal. She said she had worked at the facility since June of 2022 and has been a DM for six years. She said she learned to puree at her previous job, the Registered Dietician came into the facility and demonstrate how to puree. The DM said she had three residents in the facility on a pureed diet. She placed the steak fingers in the Robot Coupe and added 1/2 cup of gravy and processed. She then poured the steak fingers into a serving pan to place on the steamtable. The pureed meat had the texture of chunky oatmeal. The surveyor requested to sample the puree for consistency, and it was not a smooth, pudding like consistency. The DM then placed the cream style corn into the Robot Coupe and processed. She then poured it into a pan and placed it on the steam table to serve. The corn was chunky with corn husk in it, and not a smooth pudding like consistency. During an interview on 04/11/23 at 11:30 a.m., the DM said the Robot Coupe just does not get the pureed smooth and it is not going to get any better than that. During an observation on 04/11/23 at 12:00p.m, of the test tray the pureed meat and corn was chunky and not of a smooth texture. During an interview with the Administrator on 04/11/23 at 2:00 PM, he said he would try sharpening the blade to see if that helped. He said he had the Robot Coupe a long time. During an interview on 04/12/23 8:00 AM, with the DM she said if the puree was not a pudding like consistency a resident could choke. During an interview on 4/12/23 at 8:15AM with the DON she said if there was any texture to the food resident #1 would spit it out. During an interview on 04/12/23 at 8:31 a.m., with the Assistant Administrator she said they bought a new blender. She said she expects the DM to pay attention to the consistency and texture of the food and make sure it purees to a smooth consistency. She said if they were serving something that was difficulty to puree, they could offer a substitute for the residents on a pureed diet. She said she expects the RD to come at lunch time and watch the puree process to make sure it being done correctly. She said not pureeing to a smooth consistency could cause the residents to choke. During an interview on 04/12/23 at 2:00 p.m., with the Administrator he said he expects the pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 7 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be of appropriate consistency. He said not pureeing to pudding consistency could cause the resident to choke. Record review of Nutrition Therapy for Pureed Food indicates. (undated) This diet consists of foods that can be are easy to swallow because they are blended, whipped, or mashed until they are a pudding-like texture. All foods on this diet should be smooth and free from lumps. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 8 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control. (Resident #21) Residents Affected - Few CNA D did not wash or sanitize her hands when changing gloves while performing incontinent care for Resident #21. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an admission record dated 4/12/2023 for # Resident # 21 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, dementia (memory loss), major depressive disorder (persistent feeling of sadness and loss of interest) and hypertension. Record review of a Quarterly MDS Assessment for Resident #21 dated 4/6/2023 indicated she was rarely/never understood. She was always incontinent of bowel and bladder. She was totally dependent with personal hygiene and required one-person physical assist. Record review of a care plan dated 11/21/2022 for Resident #21 indicated she had an ADL self-care performance deficit related to dementia and limited mobility with an intervention of personal hygiene that she was totally dependent on staff. She had bowel/bladder incontinence related to dementia with intervention for incontinence to check every 2 hours and prn. During an observation on 4/11/2023 at 8:57 AM, CNA D and CNA E were in the room of Resident #21 to provide incontinent care. Both CNA D and CNA E washed their hands in the bathroom and applied gloves. CNA E assisted CNA D with turning and repositioning Resident #21. CNA D provided incontinent care wiping from front to back. CNA D removed her gloves after cleaning the perineal area and placed them in the trash. CNA D applied clean gloves without washing or sanitizing her hands. CNA E rolled Resident #21 onto her right side and stool was present and CNA D cleaned Resident #21's rectal area. CNA D wiped Resident #21's rectum several times wiping from front to back. CNA D removed her gloves and placed them in the trash along with the soiled brief. CNA D applied clean gloves without washing or sanitizing her hands. Both CNA D and CNA E placed a clean brief underneath Resident #21 and secured it. Resident #21 was repositioned in bed. Both CNA D and CNA E removed their gloves and placed them in the trash and washed their hands in the bathroom. During an interview on 4/11/2023 at 9:06 AM, CNA D said she had been employed at the facility since 2010. She said the facility provided in-services on different topics such as safety, falls, dementia, incontinent care, handwashing monthly. She said she was taught when providing incontinent care to start with the front before moving to the back and before moving to the back to change gloves. She said after cleaning the resident she would change the resident into a clean brief and apply clean gloves. She said she was not told to do anything to her hands after changing gloves or before applying them. She said she was taught to change gloves when moving from clean to dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 9 of 10 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 676043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston County Nursing Home 100 N E Loop 304 Crockett, TX 75835 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 Residents Affected - Few During an interview on 4/11/2023 at 3:15 PM, the DON said it had been a while since the staff received any check offs on handwashing and hand hygiene. She said the last time it was done was before COVID. She said she had tried to instill to staff to perform a lot of handwashing prior to procedures and after they were completed. She said if staff washed or sanitized their hands between glove changes, it would take too long during the care to allow their hands to dry. She said their policy did not reflect to wash or sanitize hands between glove changes. She said she tried to give in-services to staff on incontinent care once a year. She said she was not aware of the regulation of infection control related to hand hygiene but would make changes to their policy and procedures. She said there could be a risk of cross contamination and risk for infection if staff did not wash or sanitize their hands between glove changes. She said she had been so consumed with COVID and just did not think about it. Record review of a facility in-service dated 12/26/2022 conducted by the DON on Handwashing indicated CNA D was in attendance. Record review of a facility policy titled Incontinent Care undated indicated, .To keep residents clean, dry, and comfortable and to retain the maximum amount of dignity. 1. Wash hands. 3. Put on gloves. 7. Change gloves. 12. Change gloves. 13. Pull clean linens. 14. Fasten brief, if applicable. 18. Remove gloves and wash hands . CDC Guidelines for Hand Hygiene dated January 30, 2020, indicated, .The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, immediately after glove removal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676043 If continuation sheet Page 10 of 10