Health inspection·August 22, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 5 employees (Administrator Q and ADON E) reviewed for employability.The facility failed to follow written policy of completion of criminal history check and an initial EMR/NAR check for ADON E prior to offering employment.The facility failed to follow written policy of annual EMR verification was completed for Administrator Q. These findings placed residents at risk of receiving care by someone that was unemployable.The findings included:Record review of ADON E's employee file revealed a hire date of 06/08/2025 and no evidence of criminal history or an EMR/NAR check were completed prior to offering employment. Record review of Administrator Q's employee filed revealed a hire date of 09/17/2021 and no evidence of annual EMR check completed. During an interview on 08/20/2025 at 10:30 AM, Administrator Q stated his expectation was criminal history and EMR checks were to be completed upon hire and annually. Administrator Q stated the facility did not have a policy for annual EMR/NAR checks. Administrator Q stated the Business Office Manager was responsible to complete criminal and EMR checks. Administrator Q stated he was ultimately responsible for ensuring checks were completed. Administrator Q stated what led to failure was improper training of the Business Office Manager. Administrator Q stated the negative effect to residents could have been at risk of receiving improper care. During an interview on 08/20/2025 at 1:15 PM the Business Office Manager H stated she had been working for the facility for a few months. Business Office Manager H stated she had been running the criminal history checks for new employees but had not been told to run EMR checks for new employees or annually for all employees. Record review of facility policy titled, Background Screening investigations dated March 2019, revealed: Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents.The Director of Personnel, or designee, conducts background checks, reference checks and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer or employee or contract agreement and completed prior to employment. Residents Affected - Some Page 1 of 21 676053 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 2 (Resident #1, Resident #2) of 24 residents reviewed for allegations of neglect. 1. The facility failed to report when Resident #1 ingested harmful chemicals and was hospitalized on [DATE] to the State Survey Agency. 2. The facility failed to report when Resident #2 left the facility unaccompanied on 07/04/25 to the State Survey Agency and to the police. These failures could affect the residents in a decrease in physical health, injuries, additional hospitalizations, or death. Findings included: A record review of the facility policy Abuse Investigation and Reporting, dated as revised July 2017, revealed the following [in part]: Policy Statement: All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility.e. Local enforcement officials. A record review of the facility policy Emergency Procedure - Missing Resident (Code Green) not dated, revealed the following [in part]: Report the incident to the State Licensing and Certification Agency according to regulation. A record review of Provider Letter No. 17-18, dated May 3, 2017, provided by the facility, revealed the following [in part]: I. Reporting Resident Abuse, Neglect, Exploitation and other Incidents to DADS Consumer Rights and Services (CRS).1. Abuse: A NF must report incidents or alleged abuse and all situations in which it has caused to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse caused by another person, to DADS. 1. Record review of Resident #1's Face Sheet, dated 08/08/25, revealed an [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Pneumonitis due to inhalation of other solids and liquids (lung inflammation caused by inhaling a foreign substance other than those with specific codes, such as food [aspiration] or oils and essences), GERD (a chronic digestive disorder where stomach contents flow back into the esophagus, causing symptoms like heartburn, regurgitation, and chest pain), Respiratory failure, unspecified with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood [hypoxia]), Other contact with exposures hazardous to health (situation where someone has been exposed to substances or conditions in the environment that pose a risk to their health, but are not infectious diseases or specific chemical toxicities), Dementia in other diseases classified elsewhere (dementia that arises as a secondary condition from a different underlying disease, rather than as a primary condition), unspecified severity, with agitation, Anxiety disorder (a mental health condition characterized by excessive and uncontrollable worry, fear, or panic that interferes with daily life) due to know physiological condition, Mild cognitive impairment of unknown etiology (a person experiences cognitive decline that is not severe enough to be diagnosed as dementia, but the underlying cause of this decline is not clear, and Essential (Primary) Hypertension (high blood pressure with no known, identifiable cause). Record review of Resident #1's Quarterly MDS, dated [DATE], 676053 Page 2 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed Resident #1's BIMS score was 00, which indicated severe cognitively impaired response. Section C - Cognitive Patterns, C0100 revealed Resident #1 was rarely/never understood in interview to conduct assessment. Record review of Residents #1's Event Note, dated 07/30/25, completed by LVN O, revealed Resident #1 had ingested (drank) Hibiclens [hazardous antimicrobial cleanser] as reported by CNA A. Further documentation revealed CNA A entered Resident #1's room at approximately 5:30 p.m. and observed Resident #1 in her recliner. Upon observation, Resident #1 was throwing up and coughing. CNA A noticed Resident #1 had Hibiclens. The nurse was notified immediately. Record review of progress notes dated 07/30/25 revealed emergency medical personnel were contacted, and Resident #1 was transported to the hospital. Record review of Resident #1's hospital records, dated 07/30/25, revealed she developed facial flushing with wheezing, distressful bouts of coughing, and was found hypoxic with O2 saturation of 87% on room air. Resident #1 was admitted to the hospital on [DATE]. Record review of hospital records dated 08/05/25 revealed Resident #1 remained hospitalized until discharged on 08/05/25 with the diagnoses of Aspiration pneumonitis, Hypoxia, and Accidental ingestion of substance. Record review of Resident #1's hospital admission Sheet, dated 07/30/25 at 7:01 p.m., revealed Resident #1 arrived at the emergency room and was admitted with diagnoses of Accidental ingestion of substance, Aspiration pneumonitis, and Hypoxia. Record review of Resident #1's hospital History and Physical, dated 07/30/25 at 9:50 a.m., revealed Resident #1 was admitted to the hospital and had a background medical history of prior heavy alcohol consumption as obtained from Resident #1's family member. Record review revealed, Patient had accidentally ingested unspecified amount of Hibiclens brand chlorhexidine antiseptic cleanser at the nursing home this evening. Volume of ingested Hibiclens could not be ascertained. Resident #1 developed interval facial flushing with wheezing. EMS was called. With patient given a dose of Benadryl 50mg IM and a run of DuoNeb with 125 mg of IV Solu-Medrol. Poison control was reportedly contacted from the nursing home with recommendation to have patients sent to the ER for observation and symptomatic management. Arrival to the ED, patient was having stressful bouts of coughing and was found hypoxic with O2 saturation at 87% on room air. She was placed on 2 L of supplemental oxygen to bring her O2 stat. Into the mid-90s. Test at 3 done in the ED did not show any acute cardiopulmonary process. Lab draw was only remarkable for borderline leukocytosis white count at 11. Beside auscultation reveals very coarse breath sounds with continued distressful coughing. Patient was admitted for telemetric observation and symptomatic management with the need for supplemental oxygen therapy. [sic] Record review of Resident #1's hospital discharge instructions, dated [DATE], revealed Resident #1 was admitted into the hospital on [DATE] for complaint of cough with shortness of breath. Resident #1 was admitted to the hospital with diagnosis of accidental ingestions of antiseptic cleansing agent as well as aspiration pneumonitis. Discharge diagnoses included Dysphagia (difficulty swallowing) and Aspiration pneumonitis. Record review of the Incident Investigation Report, not dated, provided by DON C on 08/08/2025, revealed the following [in part]: Incident Description: Only July 30, 2025, during meal service, staff member [CNA A] discovered resident [Resident #1] vomiting red-colored substant while delivering food trays. Initial concern was potential hematemesis (blood in vomit). Upon closer examination, staff determined the red substance appeared consistent with the Hibiclens antiseptic skin cleaner that had been inadvertently left in the resident's room. The resident was observed coughing and appeared to have ingested an unknown quantity of red-colored Hibiclens cleansing solution.Plan of Correction: Incident Summary: On 07/30/2025, [Resident #1] ingested skin cleaning solution, resulting in immediate hospitalization due to high levels of toxicity. The Resident survived but required emergency medical intervention and hospitalization. During an interview on 08/08/25 at 4:01 p.m., Owner D said she was not sure why the incident 676053 Page 3 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that Resident #1 who ingested the Hibiclens [hazardous antimicrobial cleanser] was not reported to the state. Owner D said the incident with Resident #1 was investigated by the facility that included measures to prevent future occurrences. Confirmation of the measures to prevent future occurrences were implemented was requested for verification but never was provided. Owner D said staff in-services were completed immediately or within the first 24-hours after the incident but were informal. Confirmation of the in-services were requested for verification but never was provided. Owner D said there was no documentation or sign-in sheets for the in-services. Owner D said Administrator Q and Administrator-in-Training F left after the incident occurred to go on vacation and did not return until 08/11/25. Owner D did not state her expectation of Administrator's leaving immediately after an incident rather than conducting a thorough investigation to report to State Agency. During an interview on 08/11/25 at 9:58 a.m., Administrator-in-Training F said she was notified Resident #1 ingested chemicals the day the incident occurred by text from the ADON E and LVN O. Administrator-in-Training F said the incident was not reported because the facility waited to see if Resident #1 had received a negative outcome when she ingested the cleansing chemical and the extent of the negative outcome was unknown at that time. Administrator-in-Training F said she had not read the hospital records, but was aware the incident had caused some respiratory issues and Resident #1 required the assistance of oxygen when she was transported to the emergency room on 7/30/25 after she ingested. Administrator-in-Training F said she was focused on immediate action of situation and took steps to address the incident and reporting the incident slipped her mind. Record review of the Material Safety Data Sheet for product identifier Hibiclens, dated 06/13/2012, revealed - irritating to eyes; should be kept out of the reach of children; Other hazards: may cause irritation of respiratory tract. 2. Resident #2 was an [AGE] year-old male, admitted to the facility on [DATE]. Primary diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominate side (stroke characterized by paralysis and weakness on one side of the body) and unspecified dementia (a decline in cognitive function without a clear underlying cause). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment, Section GG revealed Resident #2 had lower extremity impairment to one side and ambulated using a walker. He required supervision or touching assistance when walking. Record review of the Wander Risk assessment dated [DATE] revealed Resident #2 was scored at risk of wandering. Record review of progress note, dated 07/04/25 at 1:20 pm, revealed Resident #2 was found unsupervised by a family friend on 07/04/25 walking down the street, in front of a flower shop, and was returned to the facility by the family friend. Record review of Resident #2's Care Plan, dated as reviewed on 07/04/25 revealed: Focus 7/4/25: Today he eloped from the facility, he was found about a mile away. In an interview on 08/11/25 at 9:58 am, Administrator Q was asked how he was notified of the missing Resident #2, the Administrator-in-Training F who was in the room said she was the one that notified Administrator Q of the missing resident and was not aware it needed to be reported to the state. In an interview on 08/12/25 at 12:41 pm, Resident #2 said he lives about 8 blocks away and wanted to go home. He learned the code from watching other staff exit the facility and was going to walk home. He said he was about halfway there before he was brought back. In an interview on 08/12/25 at 2:40 pm, CNA I said on 07/04/25 she brought Resident #2's lunch tray to his room and left it in his room on his bedside table. She could not recall the specific time but said lunch generally starts around 11:30 pm. She said the light was on and door was closed to the bathroom, and she thought the resident was in the bathroom. In an interview on 08/13/25 at 11:06 am, LVN L said 07/04/25 at approximately 12:20 pm, it was reported to her during lunch they could not find Resident #2. A head count was completed, and it was determined that 676053 Page 4 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #2 was missing. She did not contact the police. At 12:40 pm, she got into her car to go search for the resident and as she was driving down the street, she saw the resident in a family friends car bringing him back to the facility. She said the resident was returned to the facility at 12:50 am. She said lunch was usually served starting at 11:30 am. In an observation on 8/13/25 at 12:30 pm of the area outside of the facility revealed the street in front of the facility had a speed limit of 45 miles per hour, no sidewalks, and an active railroad track adjacent to the road. In an interview on 08/13/25 at 3:00 pm with Administrator Q and Administrator-in-Training F, the Administrator-in-Training F said she was being supervised by Owner D of the facility who also was a licensed Administrator. The Administrator-in-Training F said she was notified by the facility charge nurse of Resident #2' missing from the facility after he had been already found and returned to the facility which was approximately around 12:45 pm. The Administrator-in-Training F then notified Owner D of the incident. Administrator-in-Training F said she did not know a missing resident was a reportable event to the State at that time. Administrator-in-Training F said the police were not notified. Administrator Q was present during the conversation but did not add any additional information about the incident. In an interview on 08/21/25 at 10:50 am, Owner D said she was the supervisor of Administrator-in-Training F and was notified of the incident. She was not aware the State had not been notified of the incident. In an interview on 08/21/25 at 2:00 pm, Administrator-in-Training F said the importance of reporting the incident was accountability, resident safety, and in hindsight, the incidents should have been reported. Administrator-in-Training F said her expectation was to follow the facility's abuse and neglect policy to ensure the safety of all residents that resided in the facility. 676053 Page 5 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of all investigations to administrator and to other officials in accordance to State law, including to the State Survey agency, within 5 working days after the incident, and if the alleged violation is verified appropriate corrective action must be taken for 3 of 3 incidents reviewed. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not submitting the results of all investigations to the State Survey agency, within five (5) working days after the incident was reported, for: 1. The self-reported incident that involved Resident #9 when she suffered a mildly displaced fracture of the ankle on 07/23/2025.2. The self-reported incident that involved Resident #8 when she suffered a fall that required stitches to her left forehead on 07/08/2025. 3. The self-reported incident that involved Resident #3 when she suffered alleged abuse from a nurse at the facility 04/28/2025. These failures could place residents of not having their complaints of abuse/neglect thoroughly investigated and the result reported to the proper authorities to ensure the safety of all residents who reside in the facility. The findings included: Record review of Resident #9's Face Sheet, dated 08/13/2025, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #9's diagnoses included Encephalopathy (a group of brain conditions that cause brain dysfunction), unspecified, Intervertebral Disc Degeneration, and Chronic Diastolic (Congestive) Heart Failure. Record Review of Resident #9's Annual MDS, dated [DATE], revealed Resident #9's BIMS score was 04, which indicated severe cognitive impairment. Record review of the self-report intake revealed Resident #9 suffered a fall on 07/23/2025 at 3:15 a.m., and the incident was reported to the State Survey Agency. Further record review revealed the Provider Investigation report and results of the investigation were not submitted with the required five (5) time frame or at any time after. Record review of Resident #8's Face Sheet, dated 08/14/2025, revealed an [AGE] year-old female who was admitted on [DATE]. Resident #8's diagnoses included Unspecified Dementia, Type 2 diabetes, and Essential (Primary) Hypertension. Record Review of Resident #8's Annual MDS, dated [DATE], reveals Resident #8's BIMS was 15, which indicated intact cognitive response. Record review of the self-report intake revealed Resident #8 suffered a fall on 07/08/2025 at 12:24 p.m., and the incident was reported to the State Survey Agency. Further record review revealed the Provider Investigation report and results of the investigation were not submitted with the required five (5) time frame or at any time after. Record review of Resident #3's Face Sheet revealed she was an [AGE] year-old female, admitted to the facility on [DATE]. The resident had a primary diagnosis of cerebral infarction due to thrombosis of right middle cerebral artery (stroke related to a blood clot in the brain). The resident had additional diagnoses of constipation (having difficulty passing stool), hypertensive chronic kidney disease (a progressive disease where high blood pressure causes damage to the kidneys) with stage 5 kidney disease or end stage renal disease (kidney failure). Record Review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 12, which indicated moderate cognitive impairment. Record review of the facility's self-report intake revealed on 04/28/2025, Resident #3 had a reported incident of abuse that was reported to the State Survey Agency. Further record review revealed the Provider Investigation report and results of the investigation were not submitted with the required five (5) time frame or at any time after. During an interview on 08/21/2025 at 10:08 a.m., the Administrator-in-Training F said she reported the incidents as required and investigated them to determine if abuse/neglect had occurred. The Administrator-in-Training F said she did not submit the Provider Investigation Report as evidence of her investigation. The Administrator-in-Training F said she was under the impression that she had completed the report but was not Residents Affected - Some 676053 Page 6 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some familiar or aware of the form that generated the Provider Investigation Report (3613-A). The Administrator-in-Training F said she had received training on the reporting procedures but did not reference the actual training material when she reported an allegation to the State Survey agency. She said she had received her training from Owner D. The Administrator-in-Training F said she thought she had the process memorized and failed to bring a paper copy out each time she reported a self-reported incident. During an interview on 08/21/2025 at 10:38 a.m., Owner D said she was not aware the Administrator-in-Training F did not know how to submit the Provider Investigation Report. Owner D said this did not meet her expectation and the negative outcome had the potential to not be reported correctly or accurately. Owner D said she trained the Administrator-in-Training F on the reporting procedures but apparently the training did not sink in. Record review of the facility's policy, Abuse Investigations, not dated, revealed the results of the investigation will be recorded on the Resident abuse Investigation Report Form and would be reported to the state licensing agency within two (2) days of the results of the completion of the investigation. 676053 Page 7 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 24 residents (Resident #1 and Resident #2) whose records were reviewed for quality of care. 1. The facility failed to ensure Resident #1 was supervised to prevent the ingesting of chemical. 2. The facility failed to ensure Resident #2 received adequate supervision to prevent the resident from leaving the facility. An Intermediate Jeopardy (IJ) was identified on 08/14/2025. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 08/20/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, diminished quality of life, and serious physical harm. The findings included: 1. Record review of Resident #1's Face Sheet, dated 08/08/2025, revealed an [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Pneumonitis due to inhalation of other solids and liquids (lung inflammation caused by inhaling a foreign substance other than those with specific codes, such as food (aspiration) or oils and essences), GERD (a chronic digestive disorder where stomach contents flow back into the esophagus, causing symptoms like heartburn, regurgitation, and chest pain), Respiratory failure, unspecified with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood [hypoxia]), Other contact with exposures hazardous to health (situation where someone has been exposed to substances or conditions in the environment that pose a risk to their health, but are not infectious diseases or specific chemical toxicities), Dementia in other diseases classified elsewhere (dementia that arises as a secondary condition from a different underlying disease, rather than as a primary condition), unspecified severity, with agitation, Anxiety disorder (a mental health condition characterized by excessive and uncontrollable worry, fear, or panic that interferes with daily life) due to know physiological condition, Mild cognitive impairment of unknown etiology (a person experiences cognitive decline that is not severe enough to be diagnosed as dementia, but the underlying cause of this decline is not clear, and Essential (Primary) Hypertension (high blood pressure with no known, identifiable cause). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 00, which indicated severe cognitively impaired response. Section C Cognitive Patterns, C0100 revealed Resident #1 was rarely/never understood in interview to conduct assessment. Record review of Resident #1 Care Plan did not have an intervention addressing ingesting non edible's until after the incident on 08/05/2025. Record review of Residents #1's Event Note, dated 07/30/2025, completed by LVN O, revealed Resident #1 had ingested (drank) Hibiclens [hazardous antimicrobial cleanser] as reported by CNA A. Further documentation revealed CNA A entered Resident #1's room at approximately 5:30 p.m. and observed Resident #1 in her recliner. Upon observation, Resident #1 was throwing up and coughing. CNA A noticed Resident #1 had Hibiclens. The nurse was notified immediately. Review of progress notes dated 7/30/2025 revealed medical personnel were contacted, and Resident #1 was transported to the hospital. Record review of Resident #1's hospital records, dated 7/30/2025, revealed she developed facial flushing with wheezing, distressful bouts of coughing, and was found hypoxic with O2 saturation of 87% on room air. Resident #1 was admitted to the hospital on [DATE]. Record review of hospital records dated 08/05/2025 revealed Resident #1 remained hospitalized until discharged on 08/05/2025 with the diagnoses of Aspiration pneumonitis, Hypoxia, and Accidental ingestion of substance. Record review of Resident #1's hospital 676053 Page 8 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admission Sheet, dated 07/30/2025 at 7:01 p.m., revealed Resident #1 arrived at the emergency room and was admitted with diagnoses of Accidental ingestion of substance, Aspiration pneumonitis, and Hypoxia. Record review of Resident #1's hospital History and Physical, dated 07/30/2025 at 9:50 a.m., revealed Resident #1 was admitted to the hospital and had a background medical history of prior heavy alcohol consumption as obtained from Resident #1's family member. Record review revealed, Patient had accidentally ingested unspecified amount of Hibiclens brand chlorhexidine antiseptic cleanser at the nursing home this evening. Volume of ingested Hibiclens could not be ascertained. Resident #1 developed interval facial flushing with wheezing. EMS was called. With patient given a dose of Benadryl 50mg IM and a run of DuoNeb with 125 mg of IV Solu-Medrol. Poison control was reportedly contacted from the nursing home with recommendation to have patients sent to the ER for observation and symptomatic management. Arrival to the ED, patient was having stressful bouts of coughing and was found hypoxic with O2 saturation at 87% on room air. She was placed on 2 L of supplemental oxygen to bring her O2 stat. Into the mid-90s. Test at 3 done in the ED did not show any acute cardiopulmonary process. Lab draw was only remarkable for borderline leukocytosis white count at 11. Beside auscultation reveals very coarse breath sounds with continued distressful coughing. Patient was admitted for telemetric observation and symptomatic management with the need for supplemental oxygen therapy. Record review of Resident #1's hospital discharge instructions, dated [DATE], revealed Resident #1 was admitted into the hospital on [DATE] for complaint of cough with shortness of breath. Resident #1 was admitted to the hospital with diagnosis of accidental ingestions of antiseptic cleansing agent as well as aspiration pneumonitis. Discharge diagnoses included Dysphagia (difficulty swallowing) and Aspiration pneumonitis. Record review of the Material Safety Data Sheet for product identifier Hibiclens, dated 06/13/2012, revealed - irritating to eyes; should be kept out of the reach of children; Other hazards: may cause irritation of respiratory tract. Record review of the Incident Investigation Report, not dated, provided by DON C on 08/08/2025, revealed the following [in part]: Incident Description: Only July 30, 2025, during meal service, staff member [CNA A] discovered resident [Resident #1] vomiting red-colored substant while delivering food trays. Initial concern was potential hematemesis (blood in vomit). Upon closer examination, staff determined the red substance appeared consistent with the Hibiclens antiseptic skin cleaner that had been inadvertently left in the resident's room. The resident was observed coughing and appeared to have ingested an unknown quantity of red-colored Hibiclens cleansing solution.Plan of Correction: Incident Summary: On 07/30/2025, [Resident #1] ingested skin cleaning solution, resulting in immediate hospitalization due to high levels of toxicity. The Resident survived but required emergency medical intervention and hospitalization. During an interview on 08/08/2025 at 2:54 p.m., CNA A said she was the first one to find Resident #1 and contact as she was passing out dinner trays. CNA A said she walked into Resident #1's room and witnessed her as she threw up red vomit and coughed profusely. CNA A said she saw a red bottle on her rolling table, the label had Hibiclens on the bottle, and the bottle was empty. CNA A said she reported the incident to the charge nurse on duty on 07/30/2025, but the nurse was no longer employed with the facility. CNA A said the nurse called 911 and poison control. CNA A said the resident was taken to the hospital by ambulance. CNA A said prior to the incident, she had last seen the resident an hour prior at approximately 4:30pm, and said the bottle of Hibiclens was on her table next to her recliner approximately 1/4 full of liquid. During an on interview on 08/10/2025 at 3:11 p.m., NA B said she was on duty with Resident #1 ingested the chemical Hibiclens. NA B said she went into her room after CNA A reported the incident to the nurse and witnessed Resident #1 coughing up red stuff. NA A said she saw a plastic bottle, labeled Hibiclens on Resident #1's bed side table and the bottle was 676053 Page 9 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some empty. NA A said Resident #1's vomit was bright red, and Resident #1 was coughing profusely and loudly. During an interview on 08/10/2025 at 3:34 p.m., ADON E said she was not aware how the Hibiclens was brought into the facility as it was not used by the facility on a regular basis. She said Resident #1 would ambulate by wheelchair, pushing the chair with her feet and wander up and down the hall and into other residents' rooms. During an interview on 08/11/2025 at 9:58 a.m., the Administrator-in-Training F said she was notified Resident #1 ingested chemicals the day the incident occurred by text from ADON E and LVN O. The Administrator-in-Training F said she had not read the hospital records, but was aware the incident had caused some respiratory issues and Resident #1 required the assistance of oxygen when she was transported to the emergency room on 7/30/2025. The Administrator-in-Training F said the incident was investigated, and the facility could not determine how the chemical was brought into the building. The Administrator-in-Training F said Resident #1 ingested the skin cleanser and she interviewed the staff on duty the day of the incident. The Administrator-in-Training F said she would in-service staff on the need to keep chemicals locked and out of reach of residents on 08/29/2025 even though the incident occurred 07/30/2025. The Administrator-in-Training F said the facility scheduled all-staff in-services on a monthly basis. The Administrator-in-Training F said the facility had difficulty getting all staff together at one time so monthly in-services worked best for the staff. During an interview on 08/12/2025 at 10:45 a.m., the Primary Care Doctor G said he was aware Resident #1 ingested antibacterial skin cleanser and the dangers of ingesting the chemical depended on the amount ingested. The Primary Care Doctor G said Resident #1 ingested enough to cause excessive coughing and vomiting that required hospitalization. The Primary Care Doctor G said the fact that Resident #1 ingested skin cleanser, that can cause nausea, vomiting, and diarrhea, was serious because a person does not typically ingest skin cleanser. The Primary Care Doctor G said the skin cleanser Resident #1 ingested was typically used on the skin prior to surgery. The Primary Care G Doctor said the skin cleanser would act as a deterrent as it can cause the throat and skin to become irritated and reflux can cause the chemical to come back up and irritate the esophagus and throat. During a follow-up interview on 08/13/2025 at 1:19 p.m., CNA A said when she entered Resident #1's room, she observed Resident #1 sitting in her recliner. CNA A said Resident #1 was throwing up dark red vomit and coughing profusely. CNA A said she observed an empty bottle of antibacterial skin cleanser on Resident #1's bed side table approximately 12 inches from where Resident #1 was sitting. CNA A said the vomit was on the inside of the recliner between her arm of chair and Resident #1's lap on the right side and bright enough that she thought the vomitus was blood. CNA A said she immediately notified LVN O of the incident. 2. Resident #2 was an [AGE] year-old male, admitted to the facility on [DATE]. Primary diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominate side (stroke characterized by paralysis and weakness on one side of the body) and unspecified dementia (a decline in cognitive function without a clear underlying cause). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment, Section GG revealed Resident #2 had lower extremity impairment to one side and ambulated using a walker. He required supervision or touching assistance when walking. Record review of Resident #2's Care Plan, dated as reviewed on 07/04/2025 revealed: Focus 7/4/25: Today he eloped from the facility, he was found about a mile away. The care plan revealed no evidence addressing at risk elopement status prior to the incident. Record review of the Wander Risk assessment dated [DATE] revealed Resident #2 was scored at risk of wandering. Record review of progress note, dated 07/04/2025 at 1:20 p.m., revealed Resident #2 was found unsupervised by a family friend on 07/04/2025 walking down the street, in front of the flower shop, and was returned to the facility by the 676053 Page 10 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some family friend. In an interview on 08/12/2025 at 12:41 p.m., Resident #2 said he lives about 8 blocks away and wanted to go home. He learned the code from watching other staff exit the facility and was going to walk home. He said he was about halfway there before he was brought back. In an interview on 08/12/25 at 2:40 pm, CNA I said on 07/04/25 she brought Resident #2's lunch tray to his room and left it in his room on his bedside table. She could not recall the specific time but said lunch generally starts around 11:30 pm. She said the light was on and door was closed to the bathroom, and she thought the resident was in the bathroom. In an interview on 08/13/25 at 11:06 am, LVN L said 07/04/25 at approximately 12:20 pm, it was reported to her during lunch they could not find Resident #2. A head count was completed, and it was determined that Resident #2 was missing. She did not contact the police. At 12:40 pm, she got into her car to go search for the resident and as she was driving down the street, she saw the resident in a family friends car bringing him back to the facility. She said the resident was returned to the facility at 12:50 am. She said lunch was usually served starting at 11:30 am. In an observation on 08/13/2025 at 12:30 pm of the area outside of the facility revealed the street in front of the facility had a speed limit of 45 miles per hour, no sidewalks, and an active railroad track adjacent to the road. In an interview on 08/13/2025 at 1:04 pm, DON C said she was not employed at the time of incident. She said Resident #2 was currently not on any precautions for elopement nor was he at the time of the incident. When asked if there were any interventions in place in Resident #2's care plan addressing his high elopement risk, she did not know and was not able to access the resident's care plan due to not being able to get into Point Click Care, the electronic charting system due to password settings. In an interview on 08/13/2025 at 1:12 pm, ADON E said when Resident #2's family comes to visit, he gets agitated wanting to go home. In an interview on 08/13/2025 at 1:15 pm, Activity Director M said she had observed Resident #2 expressing to his family when they visit that he wants to go home. In an interview on 08/13/2025 at 3:00 pm, the Administrator-in-Training F said before the incident, Resident #2 would sit in the lobby area watching the birds. The resident's family told her Resident #2 memorized the code from watching people and staff leave the facility. She said Resident #2 eloped during lunch time, at the time there were no staff in the lobby area as they were assisting the other residents with eating. In an interview on 08/13/2025 at 3:10 pm, LVN N said Resident #2 did express to her about 2 weeks ago that he wanted to go home. She said Resident #2 was not on any type of elopement precautions, but she keeps an eye on him. A record review of the facility policy Safety and Supervision of Residents, dated as revised July 2017, revealed the following [in part]: Policy Statement: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation:Facility-Orientated Approach to Safety:2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.Individualized, Resident-Centered Approach to Safety:1. Our individualized, resident-centered approach to safety addresses safe and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices. Systems Approach to Safety:1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then 676053 Page 11 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risks and Environmental Hazards:1 Due to the complexity and scope, certain residents risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environments hazards include:e. Unsafe Wandering;f. Poison control. A record review of the facility policy Wandering and Elopements, dated as revised March 2019, revealed the following [in part]: Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Policy Interpretation and Implementation:1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an Immediate Jeopardy that was called on 08/14/2025 at 4:50 p.m. The Administrator was notified on 08/14/2025 at 5:00 p.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 08/14/2025 5:00 p.m. and the plan of removal was requested. The facility's plan of removal was accepted on 08/18/2025 at 11:15 a.m. and included the following: Plan of Removal of Immediacy of the lack of adequate supervision F689 - Quality of Care - Accidents Hazards and Adequate Supervision Date of Survey: August 8-13, 2025 Administrator: [Administrator Q] Date of POR: August 14, 2025 CITATION SUMMARY The facility failed to ensure residents' environment remained free of accident hazards and that each resident received adequate supervision to prevent accidents for 2 of 2 residents reviewed, specifically: 1. Resident #1 ingested hazardous antimicrobial cleanser (Hibiclens) resulting in hospitalization. 2. Resident #2 eloped from facility undetected for approximately 1 hour. ROOT CAUSE ANALYSIS UNDERLYING CAUSES IDENTIFIED PRIMARY UNDERLYING CAUSES: 1. Inadequate Chemical Storage Protocols * Root Cause: Need for strengthened chemical management procedures to optimize secure storage practices facility-wide * Contributing Factor: Need for expanded training protocols to ensure consistent identification of products requiring specialized handling procedures * System Optimization: Establishment of documentation protocols needed to ensure comprehensive tracking of environmental safety assessments 2. Insufficient Cognitive Assessment and Care Planning * Root Cause: Development of systematic protocols required to align BIMS assessments with individualized supervision requirements * Contributing Factor: Care plans were updated to include ingestion risk for residents with cognitive impairment (BIMS 0-10) * System Development: Need for automated supervision protocol implementation utilizing cognitive assessment score parameters 3. Inadequate Elopement Prevention System * Root Cause: Need for structured documentation system to formalize headcount verification and tracking processes * Contributing Factor: Resident demonstrated capability to obtain and implement facility security protocols, resulting in unsupervised egress * System Enhancement: Documentation protocols to be established for systematic visual monitoring of high wandering risk residents RESIDENTS AT RISK IMMEDIATE SAFETY ASSESSMENT COMPLETED Administrator and DON completed comprehensive risk assessment on August 15, 2025 HIGH-RISK RESIDENTS IDENTIFIED (Immediate Enhanced Supervision Required): Chemical Ingestion Risk: * All residents with BIMS scores 0-7 AND history of pica or inappropriate ingestion behaviors- 1 resident * All residents with moderate to severe dementia (regardless of BIMS if documented swallowing of non-food items)-13 residents * Residents on psychotropic medications affecting judgment- 11 residents. Elopement Risk * All residents with BIMS scores 0-10 AND documented wandering behaviors- 1 resident * Residents with documented exit-seeking behaviors in past 90 days- 1 resident * Residents with new admission or recent medication changes affecting cognition- 2 residents Environmental Safety Risk * All 676053 Page 12 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents requiring substantial assistance or total dependence for decision-making- 14 residents * Residents with combination of mobility and cognitive impairment- 14 residents IMMEDIATE PROTECTED MEASURES FOR AT-RISK RESIDENTS(Implemented August 15, 2025): For Chemical Hazard Risk Residents: * ADON implemented daily room sweeps to remove any hazardous items * Charge Nurse updated care plans to include CHEMICAL HAZARD RISK alert For Elopement Risk Residents: * Administrator implemented 15-minute visual checks with documented log * DON assigned specific staff member responsibility for location verification each shift For Environmental Safety Risk Residents: * IDT completed emergency care plan updates with specific safety interventions * DON assigned enhanced supervision levels based on individual risk factors * Charge Nurse implemented buddy system pairing high-risk residents with specific CNAs PLAN OF CORRECTION IMMEDIATE CORRECTIVE ACTIONS TAKEN Chemical Safety (Resident #1): - chemical products immediately removed from resident room in common areas by DON on 07/321/2025. - charge nurse, LVN O contacted poison control to ensures next steps immediately after assessing Resident #1 on 07/30/2025. - charge nurse, LVN O stayed with Resident #1 and continued to monitor her for safety while awaiting for the ambulance on 07/30/2025. Elopement Prevention (Resident #2): - door access code changed facility-wide on 07/09/2025 by [contracted fire vendor]. - Charge Nurse, LVN R, updated elopement risk assessment on 07/10/2025 to reveal a high risk for elopement (Resident #2). - provided one-on-on supervision by aide to resident for five (5) hours on 07/04/2025 upon return to the facility and ended when DON determined there was no immediate risk for elopement and staff on duty had been in-serviced on what to do in case of elopement. - contact MD and facility obtained a UA order on 07/10/2025, UA results came back positive for UTI on 07/14/2025, give [antibiotics] oral tablet 500mg from 07/14/2025 - 07/21/2025. [ADON] verified function of exit alarms on 07/04/2025 by pushing crash bar without the code entered and secured egress points by checking if the locks were working when the door was pulled on both sides. SYSTEMIC CORRECTIVE ACTIONS 1. CHEMICAL SAFETY PROGRAM OVERHAUL Target Completion: August 14, 2025, at midnight STEP-BY-STEP IMPLEMENTATION: August 14 by Midnight 1. Administrator assigns DON to lead chemical safety team 2. Team consisting of DON, ADON, maintenance supervisor, and administrator conducts room-by-room audit using standardized checklist: * document all chemical locations (name, quantity, storage method) * remove ANY chemical found in resident areas immediately 3. Maintenance Supervisor create master inventory list of all facility chemicals 4. Maintenance supervisor designate secure storage areas: housekeeping closet (main), medication room (antiseptics), maintenance room (industrial chemicals) 5. Maintenance supervisor find secure area to store shower supplies. 6. Administrator create chemical access log sheets for each storage location 7. Administrator post AUTHORIZED PERSONNEL ONLY signs on all chemical August 14 by midnight 1. DON conduct mandatory staff training for staff BEFORE they are able to return to work 2. DON Training content: chemical hazards, proper storage, never leave unattended rule, emergency procedures 3. Each staff member signs competency form stating they have completed the in-service before they can return to work. Staff will complete a quiz about the training. Staff failing the quiz will be required to receive one-on-one training from a member of the chemical safety team Clarification We do not take things away from residents. Our Approach: We provide oversight and monitoring of products that could hurt people. For resident person care items (soap, lotion, perfume, cologne): * We keep items safe through proper storage * Staff help residents use items safely * Items are secured immediately after use * We ensure residents with cognitive impairment cannot access items unsupervised Accountability: Our facility takes responsibility for keeping everyone safe while respecting resident preferences and autonomy. 2. ELOPEMENT PREVENTION PROGRAM Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: 1. Administrator meets with maintenance to assess current door security by 676053 Page 13 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some testing alarms, faulty mechanisms, and codes. 2. Maintenance supervisor inventory all exterior doors and windows accessible to residents 3. Maintenance supervisor retest door alarms on all exterior exits: * Front entrance (main priority) * Emergency exits * Patio/courtyard door 4. DON implement immediate visual check system: * Post visual check sheets at the nurses' station * Assign specific staff for 15-minute checks of high wandering risk residents * Create accountability system with signatures and timestamps 5. DON/designee update resident care plans for ALL residents with cognitive impairment to add that they are higher risk for chemical hazards 6. ADON/designee conduct headcount procedure training for all nursing staff BEFORE they can return to work. 7. Administrator create and laminate emergency elopement response cards for all staff. 8. Administrator provide local police non-emergency number by all unit phones. 9. DON/designee conduct mock elopement drill with each shift the first shift they work. 10. Administrator post updated elopement response procedure at nurses' stations 11. Staff will complete an elopement in-service with a final quiz to determine competency. Any staff found incompetent in elopement procedures will be required to complete one-on-one training with the administrator. Ongoing Daily Process: * Every 15 minutes: Hall aid visual checks of high wandering risk residents (documented) * Every 2 hours: Charge nurse facility-wide headcount (all shifts). * Once a day: Charge nurse test door alarms and review high wandering risk resident list. Responsible Person: Administrator Monitoring: Administrator monthly elopement drill logs and quarterly policy compliance checks 3. ENHANCE SUPERVISION PROTOCOLS Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: August 14 by midnight 1. IDT begins reviews all current care plans for residents with BIMS scores 0-10. 2. DON create priority list of residents requiring enhanced supervision. 3. ADON assign designated CNA responsibility per shift for each resident with BIMS score between 0-10. 4. IDT update care plans for Resident #1 and #2 immediately. Add specific interventions: * Resident #1: Visual supervision during all activities, especially meals. No chemicals/cleaning products in room or within reach * Resident #2: 15-minute visual checks, escort for all outdoor activities The ADON/DON will be responsible for ensuring that the interventions on the care plan will be completed. A log of checks will be established, requiring initials. The chemical log will keep up with documentation for resident #1's interventions with logs for supervision checks and sweeps of the room. 5. ADON/designee communicate changes to all shifts via shift huddles. By August 15, IDT review ALL resident care plans 1. DON document new supervision requirements in nursing notes 2. Administrator create daily assignment sheets that specify which staff monitors which high-risk (BIMS 0-10) residents. 3. ADON conduct supervision training for all nursing staff BEFORE they return to work: 4. Staff will complete a quiz to determine competence. Any staff that does pass the quiz will receive one-on-one training with the ADON 5. ADON/designee implement daily huddles at start of each shift to review high-risk residents Ongoing Daily Process * Shift report: Charge nurse specific handoff for all enhanced supervision residents * Weekly: IDT meeting to assess effectiveness of supervision plans * Monthly: IDT full care plan reviews for all enhanced supervision residents Responsible Person: Director of Nursing Monitoring: Administrator daily supervision logs and weekly care plan effectiveness reviews. 4. ENVIRONMENTAL SAFETY PROGRAM Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: Administrator assigns Safety Committee (DON, Maintenance Director, one floor nurse from each shift) 1. Maintenance supervisor create standardized safety checklist covering: * Chemical storage verification * Door alarm functionality * Resident room hazard assessment * Common area safety check * Exit security verification 2. DON implement three (3) daily safety rounds: * 6-2: Day charge nurse - focus on overnight incidents and morning setup * 2-10: Evening charge nurse - focus on mealtime safety and visitor activities * 10-6: Night charge nurse - focus on sleep safety and security 676053 Page 14 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Daily Process: 1. Each safety round documented by charge nurse on 24-hour report. 2. Any hazards noted must be corrected by DON within 2 hours (non-urgent) or immediate (urgent) 3. Charge nurse reports finding to DON within one (1) hour of discovery 4. DON/designee reviews all safety forms and trends issues weekly Monthly System Setup: 1. Administrator schedule monthly safety committee meeting with QAA/QAPI 2. IDT create safety suggestion system for staff and families 3. Maintenance supervisor set up quarterly comprehensive facility safety audit schedule 4. Each department supervisor conduct a safety walkthrough Ongoing Daily Process: * Daily: Charge nurse conduct a chart safety round findings * Weekly: DON analyzes trends and reports to Administrator, document corrective actions * Monthly: Safety Committee reviews all incidents and updates protocols; all incidents will be reported by the QAA/QAPI committee. Responsible party: Administrator Monitoring: Daily safety logs, weekly trend reports, monthly committee reviews Ensuring Safety of Other Residents ADON will complete a BIMS and Wandering Risk assessment on all residents to determine which residents need higher levels of supervisions, including 15-minute safety checks for residents with a high risk to wander and 1 hour safety checks for residents with cognitive impairment. Administrator will create a log for initials that checks were completed. QUALITY ASSURANCE MEASURES 1. MONITORING SYSTEM * Daily safety round with written documentation * Weekly QA meetings with IDT to review safety incidents * Administrator monthly trend analysis of safety-related occurrences * Administrator quarterly external safety audit 2. STAFF ACCOUNTABILITY * DON/designee mandatory safety competency testing every six (6) months * Administrator progressive discipline policy for safety violations * Administrator [TRUNCATED] 676053 Page 15 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 Dietary Manager (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility had a certified DM from July 21, 2025, until August 20, 2025. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses.Findings included: Record review of the employee files revealed no evidence of a dietary manager. During an interview on 08/18/2025 at 11:30 AM DA R stated the facility currently did not have a DM. DA R stated that on July 21, 2025, the DM called in sick, and they had not heard anything else from the DM. DA R stated the facility had not hired another DM. During an interview on 08/18/2025 at 12:00 PM the Administrator in Training F stated the previous DM had left without putting in notice. Administrator in Training F stated she had been trying to hire a new DM but had not been able to hire one at this time. During an interview on 08/19/2025 at 1:24 PM the Dietician stated she was notified on her last visit, 8/12/25, that the facility did not have a DM. The Dietician stated she visited the facility once per month. The Dietician stated she did not think there had been a negative effect to residents for not having a DM. The Dietician stated her expectation was for the facility to have a dietary manager. The Dietician stated what led to the failure of not having a DM was that it was difficult to find certified DM's.During an interview on 08/20/2025 at 10:30 AM Administrator Q stated his expectation was to have a full time DM. Administrator Q stated ultimately, he was responsible for ensuring there was a DM in place. Administrator Q stated negative affect on residents could have been lack of communication. Administrator Q stated what led to the failure was possibly not having appropriate job postings posted. Administrator Q stated they did not have a policy for having a DM. 676053 Page 16 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, Resident #3) of 24 residents. 1. Resident #1 ingested harmful chemicals and was hospitalized on [DATE].2. Resident #2 left the facility unaccompanied and without facility knowledge on 07/04/2025.3. Resident #3 reported an allegation of abuse and the facility administration failed to follow internal policies.4. The facility's administrative personnel did not ensure the facility was administered by a full-time licensed administrator who was knowledgeable of regulations, facility policies, and procedures.5. The facility's administrative personnel did not ensure the Administrator In Training was being provided oversight. These failures placed residents at risk of physical and psychological harm due to lack of oversight by facility administration.Findings included: Review of AIT's personnel file revealed a hire date of January 2025. Review of the Texas Unified Licensure Information Portal (TULIP) accessed on 08/15/2025 at https://txhhs.my.site.com/TULIP/s/public-search revealed AIT had a Prospective NFA License Status. In an interview on 8/13/25 at 3:00 pm, the Administrator-in-Training F stated she was supervised by Owner D who was also a licensed administrator. In an interview on 8/8/25 at 4:01pm with the Owner D, she stated she was not sure why the incident with Resident #1 regarding ingestion of harmful chemical and hospitalization was not reported and in-services were done informally. Owner D stated Administrator-in-Training F left for vacation the next day (8/01/25) after the incident and did not return until 8/12/25. In an interview on 8/11/25 at 9:58 am, the Administrator-in-Training F stated she was made aware of the incident with Resident #1 ingestion of harmful chemical and hospitalization on 7/30/25 and contacted Owner D. She then implemented safety checks on all rooms. The nurse had contacted the doctor and Resident #1 had already been sent to the ER. Administrator-in-Training F stated she did not report it because they were waiting to see what would happen, what the outcome would be, the extent of it. Administrator-in-Training F stated she was the facility investigator. She stated they made sure there were no more chemicals, investigated and we're unable to determine where it came from, and the in-service was scheduled for 8/29/25. Administrator-in-Training F stated she was focused on the action and taking care of immediate steps and reporting the incident slipped her mind. The Administrator-in-Training F stated that Resident #2 was missing from the facility but by the time she was notified the facility had found him, and he had been returned to the facility. She stated she notified her supervisor. Policy said to call the police, but the police were not called per policy because Resident #2 had already been found. Administrator-in-Training F stated she called the facility to make sure interventions were put in place such as placing Resident #2 on one-on-one supervision, and the family had been contacted. Administrator-in-Training F stated at the time, she did not know to report to the State Agency of a missing resident and a resident ingesting harmful chemicals that required hospitalization. In an interview on 8/15/25 at 12:50 pm Administrator-in-Training F stated that in the investigation with Resident #3 alleging she was abuse, she interviewed other residents for signs and experiences of abuse, but she did not document it, and she did not know she needed evidence to support her investigation. In an interview on 8/16/25 at 11:08am with NA K, she stated she witnessed an incident with Resident #3 where a nurse performed an exam that Resident #3 refused. NA K stated she went to Activity Director M, and she went to Administrator Q. NA K stated she also encouraged Resident #3 to go to Administrator Q and report the incident. LVN J was a bully, and stated she was worried about retaliation. She stated the nurse was terminated. NA K stated she had Residents Affected - Many 676053 Page 17 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many been trained on abuse and neglect and Administrator Q was the abuse coordinator and that was who to report to. The NA K named the Administrator-in-Training F as the acting Administrator of the facility. In an interview on 8/17/25 at 3:00pm ADON E stated the Administrator-in-Training F was under the Owner D and the Owner D made all the decisions. In an interview on 8/17/25 at 5:23 pm with Administrator-in-Training F, she stated she had been working this position since January 2025 and had completed her schooling and just needed her hours. Administrator-in-Training F named Administrator Q as son of the Owner D, and he is the day-to-day Administrator. Administrator-in-Training F named Owner D as her supervisor, and she came 3-4 days a week to help with her training. Administrator-in-Training F stated Administrator Q was responsible for reporting to the State Agency and doing the investigations. Administrator-in-Training F stated she took the lead in the investigation with the incident with Resident #3 and Owner D was over her and helped her with that one. Administrator-in-Training F stated she thought she did everything, but she forgot to call the police. Administrator-in-Training F stated she just needed to look at policy and she had started a checklist of what to do. Administrator-in-Training F stated that there is just so much to learn. In an interview on 8/18/25 at 9:34am Administrator Q stated he had been the administrator for one year and one month. Administrator Q stated to monitor staff to make sure they do their job; he did physical observations, verbal report, and documentation. He was physically in the building once a week. Since January 1st, Administrator-in-Training F was in the facility Monday-Friday. Administrator Q stated the owner is in the building maybe 3-5 days a week. Owner D was training and over Administrator-in-Training F. Administrator Q stated he checked staff documentation and the electronic resident record and occasionally employee files. He stated Administrator-in-Training F did run the investigation for the elopement of Resident #2. Owner D and Administrator Q both oversaw this investigation. The incident with Resident #1, the Administrator-in-Training F did the investigation, and Administrator Q stated he also did his own investigation in the background to make sure it was checks and balances. Administrator Q stated his investigation found the incident did not occur therefore the incident would not need to be reported. The incident with Resident #3 was about respect and dignity and the resident wanted it kept quiet that is why the police were not called. Administrator-in-Training F stated she did not state to not call the police. Administrator Q stated they have increased trainings now because they used to be monthly before all these incidents happened. In a follow-up interview on 8/21/25 at 10:38am, Owner D stated she was not aware Administrator-in-Training F did not know that she had to submit an investigation report. She said this did not meet her expectation and the negative outcome was she needed to train and educate staff, and an incident would not be reported adequately. Owner D stated she trained Administrator-in-Training F on it but apparently the training did not sink in. Owner D stated there are days the Administrator-in-Training F is left in the facility unsupervised, but she can call Owner D or Administrator Q whenever she needs anything.Record review of the Administrator Policy dated April 2007 revealed A licensed Administrator is responsible for the day-to-day functions of the facility. The policy further stated that 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for but not limited to: a.d. Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies, and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities;.Record review of Licensed Nursing Home Administrator (LNHA) Job Description dated 1/1/25 revealed Position summary: The Licensed Nursing Home Administrator is responsible for the overall management, leadership, and operation of the Facility in accordance with federal, state, and local 676053 Page 18 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many regulations. The LNHA ensures the delivery of high-quality resident care, compliance with applicable laws, financial integrity, and the effective supervision of staff. The description stated essential duties and responsibilities: Leadership & Oversight Provides executive leadership to ensure the Facility operates in compliance with all CMS, state, and local regulatory requirements. Implements policies and procedures approved by the Governing Body. Promotes a positive organizational culture, emphasizing resident-centered care. This description also revealed Regulatory Compliance.serves as the primary contact for state and federal surveyors.Coordinates survey preparation and directs corrective action plans. Resident & Family Relations.Investigates and resolves complaints or grievances promptly. Working Conditions: Full-Time, exempt position. Regular business hours with availability for emergencies, evenings, weekends, and holidays, as needed. 676053 Page 19 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility. The facility failed in conducting the facility assessment to ensure involvement from nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.Findings included: In an interview on 8/15/25 at 1:29 pm, Administrator-in-Training F did not know what a facility assessment was, and Owner D stated she could not locate it. The Administrator-in-Training F stated she began working for the facility in January 2025. In an interview on 8/15/25 at 6:50 pm, Administrator-in-Training F stated what she provided at that time was the Facility assessment dated [DATE], reviewed by QAPI on 8/15/25, and created after being requested the facility assessment. Prior to this date, there was no facility assessment. Record review of the Facility assessment dated [DATE] revealed the date assessment reviewed with QAPI is 8/15/25. Facility Assessment revealed the Person involved in completing the assessment were the Administrator-in-Training F and DON C. The facility Assessment for medical supplies read DON reviews census and acuity to ensure appropriate equipment is ordered and available. Record review of the Facility Assessment Policy dated October 2018, revealed 1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. 2. The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. The Administrator; b. A representative of the governing body; c. the medical director; d. the director of nursing; e. the infection preventionist; f. the director (or designee) from the following departments: 1. Environmental services; 2. Physical operations; 3. Dietary services; 4. Social services; 5. Activity services; and 6. Rehabilitative services. The Facility Assessment Policy further revealed 4. The Facility Assessment also includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes.b. Equipment and Supplies (medical and non-medical);. 676053 Page 20 of 21 676053 08/22/2025 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0844 Level of Harm - Potential for minimal harm Residents Affected - Many Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Based on interview, and record review the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility.The facility failed to notify the State Agency of a change in AdministrationThis failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility.Findings included:Review of the Texas Unified Licensure Information Portal (TULIP) accessed on 08/15/2025 at TULIP HOME | Salesforce revealed the administrator of the facility was Owner D.In an interview on 8/15/25 at 1:24pm Administrator Q introduced himself as the administrator to the facility.In an interview on 8/15/25 at 3:33pm, Owner D stated she was the owner, and her family member was the Administrator, and family member B was the Administrator-in-Training. The owner stated she had not yet changed the Administrators name yet from herself to family member in TULIP and was not sure if she should do that yet.In an interview on 8/17/25 at 5:23 pm Administrator-in-Training F stated she was the Administrator-in-Training, and Owner D was training her. The Administrator-in-Training F named Administrator Q as a family member and stated he was the day-to-day Administrator.In an interview on 8/18/25 at 9:34 am Administrator Q stated he had been the Administrator for one year and one month. He stated Owner D as the owner and not the Administrator.Record review of the facility posting at the nurse's station revealed Administrator Q as the Abuse Coordinator. The facility had no evidence of a policy on notifying State Agency with changes in Administrator/ 676053 Page 21 of 21