Inspection·July 28, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some year-old female admitted to the facility on [DATE] with the diagnoses of: type 2 diabetes mellitus, Hypertension, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), bipolar disorder. Review of Resident #27's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 4 indicating severe cognitive impairment. Review of Resident #27's Care Plan dated 05/23/2023 reflected focus: (Resident #27) has an ADL self-care performance deficit r/t Bi-polar disorder: .: Personal hyg, limited Goal: Resident #27 will maintain current level of function through the review dates. Intervention: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation on 07/26/23 11:17 am reveled Resident#27 sleeping in bed covered with blanket with visible long dirty fingernails. Resident#27 fingernails on both hands were approximately 0.4 centimeter in length extending from the tip of her fingers. A record review of Resident #39 face sheet dated 07/27/2023 revealed: Resident#39 was [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of: type 2 diabetes mellitus, hypertension, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), depression. Review of Resident #39's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 4 indicating severe cognitive impairment. Review of Resident #39's Care Plan dated 07/19/2023 reflected focus: (Resident #39) has an ADL self-care performance: ., Personal hygiene, ext assist x 1 Goal: Resident #39 will maintain current level of function through the review dates. Intervention: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation on 07/26/2023 at 11:26 a.m., Resident #39 was sitting up in the wheelchair, Resident #39 fingernails visibly long and dirty. Interview/observation on 07/28/23 09:32 a.m., CNA B stated Resident #22's fingernails looked dirty, and needed to be clipped, and this was the first time that she noticed that the resident fingernails were dirty and needed clipping. CNA B further stated that Resident #22 ate with her fingers all the time. CNA B asked Resident #22 Can I trim your fingernails, Resident #22 replied yes will holding her hands up. CNA B stated CNAs were responsible to clean, and to clip resident's fingernails, and nurses are responsible to clip resident's fingernails if residents were diabetic or using blood thinner. CNA B further stated most of the time she performed cleaning and clipping resident's fingernail during the shower, and Resident #22's showers were done by the evening staff. CNA B stated the risk to resident were a lot of things including the development of an infection. CNA B proceeded to clip Resident #22's fingernails. Interview and observation on 07/28/2023 at 09:51 a.m., CNA B stated Resident #27 fingernails should be cleaned, and trimmed, they were long and dirty. CNA B stated the risk to resident was the development of an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 2 of 6 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview and observation on 07/28/23 09:46 a.m., revealed CNA B stated Resident #39's fingernails needed to be trimmed, they were long. LVN K stated Resident #39's fingernails were long, and Resident #39 liked them long. Resident #39 responded to LVN K and said she would like her fingernails trimmed. LVN K stated the CNAs were responsible for resident's fingernail care, and to report resident's fingernails status to nurses. LVN K further stated that nurses were responsible to check and follow up with CNAs regarding residents' daily care. LVN K stated the risk to residents was the residents could scratch themselves and the development of infections. Interview on 07/28/23 11:48 a.m., the ADO stated the CNAs were responsible for checking, and cleaning residents' fingernails and toes nails ever time during showers or shower days. The ADON stated the charge nurses should be checking the residents' fingernails and toenails, she stated but, she guessed the charge nurses were behind on that. The ADON stated her expectations for the residents' fingernails and toenail care should be done when it should be done, and if the CNAs, and nurses could not do it; ether her or the DON could do it. The ADON further stated risk to residents was the development of infection. Interview on 07/28/23 at 01:05 p.m., the DON stated the residents' fingernail care should be done; during or after shower when the residents' fingernails are soft; by the CNA. The DON stated for the residents that were diabetic it should be done by the nurses or podiatrist. The DON stated the charge nurses, ADON, and DON were responsible of making sure the residents' fingernail care were done. The DON stated the risk to residents were the development of infection. Review of the facility's policy titled, Fingernails/toenails, Care of with revised date February 2018 reflected, . General Guidelines: 1. Nail care includes daily and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trim and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 3 of 6 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 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 three of five (CNAs B, CNA D, and LVN K) staff observed for infection control. Residents Affected - Some CNAs (Certified Nursing Assistance) B, and D failed to change gloves, and perform hand hygiene during incontinence care for Resident #18. LVN (licensed Vocational Nurse) K failed to change gloves, and perform hand hygiene during blood sugar check for Resident #38 These failures could place residents at risk for infection through cross-contamination. Findings included: Review of Resident #18's face sheet, dated 07/28/2023, reflected she was a [AGE] year-old female admitted to facility 08/18/2018. Her diagnoses included Heart failure, diabetes mellitus, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident #18's most recent Quarterly MDS Assessment, dated 04/07/2023, reflected she had a BIMS score of 08 indicating moderate cognition impairment. The review further reflected the resident was always incontinent of bladder and bowel. Review of Resident #18's Care Plan dated 05/23/2023 reflected the following: Focus: [Resident #18] has an ADL self-care performance deficit r/t COPD (Chronic obstructive pulmonary disease) and tremors; incontinent of bladder and bowel. Goal: Resident#18 will maintain current level of functioning through the review date. Intervention . PERSONAL HYGIENE: The resident requires assistance by (1) staff with personal hygiene and oral care. Review of Resident #38's face sheet, dated 07/28/2023, reflected she was a [AGE] year-old female admitted to facility 06/08/2020. Her diagnoses included diabetes mellites, hypertension (elevated blood pressure), urinary tract infection (UTI). Review of Resident #38's most recent Quarterly MDS Assessment, dated 05/17/2023, reflected she had a BIMS score of 14 indicating cognitively intact. Review of Resident #38's Care Plan dated 04/20/2023 reflected the following: Focus: [Resident #38] has Diabetes Mellitus . Accuchecks QID with ss (sliding scale) insulin Observation on 07/27/23 at 10:25 AM, during incontinence care for Resident #18 in resident's room reveled: CNAs came into Resident#18 room with supplies. CNA B, and CNA D washed their hands in the Residents bathroom sink. CNA B draped table with a towel, and got wipes ready over the draped bedside table, CNA B put on gloves. CNA D got Resident #18 clothes from the closet and put on gloves. CNA B uncovered Resident #18, and draped Resident #18 with a towel. Both CNAs unfastened Resident #18's brief. CNA D cleaned Resident #18 front area using one wipe at a time. Both CNAs turned Resident #18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 4 of 6 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 - Some to her right side. CNA D cleaned Resident #18 buttocks area using one wipe at time then tacked the dirty brief inside the reusable under pad and pushed them underneath Resident #18. CNA B got the clean under pad, sling and clean brief and put them on the bed. CNA D without changing glove, or any form of hand hygiene picked the sling, clean under pad, and the clean brief put them underneath Resident #18. Both CNAs turned Resident to her left side CNA B removed the dry under pad and the dirty brief, and put them to side over the bed, she then unrolled out the sling, the clean reusable under pad, and the clean brief without changing glove, and sanitizing hands. Both CNAs rolled resident to her back, finished putting the clean brief, and fastened it. CNA D removed glove put clean glove without hand hygiene got Resident#18 top wear from the drawer and helped Resident #18 got dressed. CNA D put resident oxygen tubing together in a zip lock bag over the nightstand with the same glove. Interview on 07/27/23 at 10:49 AM, CNA D stated she had been working as a CNA with the facility for two months. CNA D stated she supposed to change gloves when going from dirty to clean, and she know that, but she got nervous. CNA D stated that she supposed to perform hands hygiene before putting on gloves and after removing gloves. She acknowledged that she did not perform hand hygiene when changing glove during Resident #18 peri care. CNA D acknowledged that she used the same gloves, she used for Resident #18 care to put away Resident #18 oxygen tubing. CNA D stated she had in service just few months ago with the ADON on hands hygiene. CNA D stated the risk to residents was cross contamination, and the development of an infection. Interview on 07/27/23 at 10:57 AM, CNA B stated she had been working with the facility for six years. CNA B stated during peri care one of CNAs supposed to do dirty task, and one should do the clean task, but sometimes they forgot, and they made mistakes. She acknowledged that she removed the dirty under pad, and the brief put them over the bed and unrolled the clean ones without changing glove, and cleaning hands. CNA B stated that she supposed to do hand hygiene with gloves change. CNA B stated that she received in service on hands hygiene, and residents' peri care couple of months ago, and the in service was done by ADON and ADON. Observation on 07/27/23 at 11:13 AM, revealed LVN K got to Resident #38's to room check her blood sugar. LVN K washed hands, opened the cart, put on glove, got wipe and wax paper. LVN K wiped bedside table, remove glove, put clean glove, and got the glucometer from a zip lock bag in the cart upper drawer, wiped the glucometer, and put it over the bedside table. LVN K removed glove and put on clean glove. LVN K opened the cart top drawer, and got lancet, blood sugar test strip, and alcohol pad. LVN K wiped Resident#38 finger with alcohol pad and got a blood drop. LVN K picked trash and glucometer, put the trash into trash can, and glucometer over the cart and removed glove. LVN K logged the result in the system (PC: Personal computer) over the medication cart. LVN K put glucometer in the cart, put on glove, got the insulin pen. LVN K gave Resident #38 Insulin. LVN K removed glove and put insulin pen in the cart. LVN K logged the injection information in the PC, closed the PC, and put the paper wax package in the medication cart drawer. LVN K went back to another room changed the trash plastic bag. LVN K got her cart close to the nursing station, picked the PC and went back to the nursing station, put the PC over the counter, then went and picked a half empty soda bottle without hands hygiene, and she was going for a break. Interview on 07/27/23 at 11:28 AM, LVN K stated that she worked in the facility on: Thursdays and Fridays since March 2023, and work in another facility part time. LVN K acknowledge that she did not perform hand hygiene since she went to Resident #38 room to check the Residents blood sugar, and she had been only changing gloves, without hands hygiene. LVN K stated she had in-service on hands hygiene not very long ago. She stated the in-service was done by the ADON. LVN K stated not following proper hands hygiene can lead to residents developing infections, and if she had something in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 5 of 6 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 - Some hands the residents could got it, and she could get contaminated from the residents to. She stated there would be the possibilities of cross contamination. She stated hands hygiene supposed to be done before and after putting and removing glove, and before and after any activity with resident. She further stated that she would work on that. Interview at 07/28/23 at 11:37 AM, with ADON/IP-RN revealed: ADON stated she was responsible for the infection control in the facility, since 2019. ADON stated the staff supposed to sanitize hands before going to residents' room, and after leaving the residents' room. ADON stated the staff supposed to change glove between residents, and any time they touched anything dirty. ADON stated staff supposed to sanitize hands before donning glove and after removing them. She stated that she or the charge nurses were responsible to correct the staff regarding hands hygiene and the charge nurses are responsible to report to her. ADON stated the risk to residents were the possibly of residents developing an infection. Interview at 07/28/23 at 11:44 AM, with the ADON revealed: ADON stated any time the CNAs did resident's peri care and if they worked two of them at the same time with the resident, one of them supposed to handle the dirty task and the other one the dirty task to prevent cross contamination. ADON stated CNAs supposed get the clean brief after they change the gloves and sanitize hands. ADON stated the CNAs, and the charge nurse were just done with the in service, and the in service were done monthly. ADON stated the risk to residents were the possibly of residents developing an infection and UTI (urinary tract infection). Interview on 07/28/23 at 01:05 PM, with DON reveled: DON had been with the facility for 14 years. DON stated the staff supposed to use hand gel between every resident, and to wash hands after the third time of using hand gel. DON stated the staff supposed to wash hands before putting on gloves and when taking the glove off. DON stated the DON and ADON were responsible for making sure the staff followed the proper hands hygiene during residents' care, and contacts. DON stated the staff supposed to wash hands and put on glove any time they move from dirty to clean. The DON stated that in service could be done daily, and once monthly by the state requirements. she further stated the risk to residents was the development of an infection. Record review of the facility policy titled Handwashing/Hand Hygiene revised August 2015 reveled: 1. All personnel shall be trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.7. Use an alcohol-based hand rub .a. Before and after coming on duty. Before and after direct contact with residents .h. Before moving from a contaminated body site to a clean body site during resident care .I After contact with object (e.g., medical equipment) in the immediate vicinity of the resident . m. after removing gloves .8. Hand hygiene is the final step after removing and disposing of protective equipment.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 6 of 6