Health inspection·February 8, 2023

F 0636 Problems: The resident has the potential for shortness of breath r/t Obstructive Sleep Apnea-Date initiated 8-30-2022 Level of Harm - Minimal harm or potential for actual harm Interventions: Resident has a CPAP but does not use it every night-Date initiated 8-30-2022 Residents Affected - Few Record review of the Resident #9's progress notes revealed the following: Effective 6-23-2022 at 6:55 PM-Resident admitted to the facility at 2:00 PM . Resident has his own CPAP machine . Per observation completed on 02-06-2023 at 09:42 AM, Resident #9 was in his room laying in his recliner sleeping with noted snoring. Resident #9 was noted to have a CPAP on his bedside dresser on the opposite side of the resident's current position and he was not wearing the CPAP. During an interview on 02-06-2023 at 11:24 AM Resident #9 reported that he was admitted last May, and he has had his CPAP since he was in his 50's, and that he cannot sleep without the CPAP. Resident #9 reported that staff will help him with his CPAP if needed. During an interview on 02-08-2023 at 10:09 AM MDS A reviewed Resident #9's admission MDS dated [DATE], verified that Resident #9 was not marked/addressed for the use of CPAP, verified that Resident #9 did not have documentation in his chart for the use of his CPAP other that his admission note. MDS A reported that if Resident #9 had CPAP in his room, then it should be addressed on his MDS. MDS A reported that it only affects facility reimbursement if Resident #9's CPAP was not addressed in his MDS and the facility could lose money, that it does not affect resident care. During an interview on 2-8-2023 at 10:09 AM the MDS A reported that the facility policy is to use the RAI manual to complete all MDS assessments. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section O0100 Special Treatment, Procedures, and Programso O0100G, Non-invasive Mechanical Ventilator (BiPAP/CPAP) Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support his or her own spontaneous respiration by providing enough pressure when the individual inhales to keep his or her airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes his/her own BiPAP/CPAP mask/device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 2 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 21 residents (Resident #49) whose records were reviewed for assessments. Residents Affected - Few Resident #49 was assessed in his quarterly MDS dated [DATE] for having a catheter when he was not receiving catheter care. These failures to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings include: Record review of Resident #49's face sheet dated 2-8-2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), cognitive communication deficit (difficulty with language and how someone uses language), muscle wasting (the decrease in size of muscle tissue), disorder of the kidney and ureter (a blockage in one or both of the tubes that care urine from the kidneys), malnutrition (lack of nutrition) and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #49's quarterly MDS dated [DATE] listed him with a BIMS of 14 indicating he was cognitively intact, and he had a functionality of requiring one to two-person assistance with all his activities. Record review of Resident #49's quarterly MDS dated [DATE] revealed the following: Section H Bladder and Bowel -H0100 Appliances A. Indwelling Catheter-Resident #49 is marked as having a catheter Record review of Resident #49's Order Summary Report with active orders as of 11-1-2022 revealed the resident had no orders for a catheter for the month of November Record review of Resident #49's care plans with admission date of 5-6-2021 with last update of 12-23-2021 revealed no care plans for a catheter. Record review of Resident #49's treatment administration record and progress notes for the month of November revealed no documentation for the use of a catheter. During an observation on 2-06-2023 at 02:24 PM Resident #49 observed in his room with no catheter. During an interview on 02-08-2023 at 09:54 AM, MDS A reviewed Resident #49's clinical record, determined that Resident #49 was marked on his 11-27-2022 quarterly MDS as having a catheter, had no documentation in his clinical record during the month of November 2022 for a catheter, had no care plans (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 3 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for a catheter, and had no progress notes documenting the use of catheter. MDS A verified that the 11-27-2022 quarterly MDS was marked incorrectly. During an interview on 02-08-2023 at 10:07 AM the DON reported that she was aware that Resident #49 was marked incorrectly for having a catheter on his MDS and that she had already asked for the MDS to be corrected. The DON reported that the facility was aware that this was a problem and that on January 1, 2023 she had started a review of every resident's care plans to hopefully address any issues that might have been missed on MDS especially since their MDS Coordinator is new. The DON also reported that she felt resident care was not affected as the residents continued to receive all required care and that only facility reimbursement was affected if the MDS was incorrect. During an interview on 2-8-2023 at 10:09 AM the MDS A reported that the facility policy is to use the RAI manual to complete all MDS assessments. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section H Bladder and Bowel H0100 Appliances - Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliance's A-D were used in the past 7 days. o H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 4 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 of 21 residents (Residents #67 and #79) reviewed for PASRR compliance. Residents Affected - Few The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #67 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #79 prior to admission to the facility. These failures could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings Include: Record review of Resident #67's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), dementia, type 2 diabetes, anxiety disorder, paranoid schizophrenia, and encephalopathy (a brain disease that alters brain function or structure). Record review of Resident #67's MDS, dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. The MDS indicated Resident #67 needed limited assistance or supervision by one staff member across all ADLs. Record review of Resident #67's care plan, dated 10/26/22, revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #67's EHR titled PASRR Level 1 Screening indicated that the assessment was completed on 04/04/22, 4 days after he was admitted to the facility. Record review of Resident #79's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, high blood pressure, cognitive communication deficit, dementia, history of falling, and muscle weakness. Record review of Resident #79's MDS, dated [DATE], revealed a BIMS score of 01 out of 15 which indicated severe cognitive impairment. The MDS indicated Resident #79 needed extensive assistance by one or two staff members across all ADLs except eating where she required supervision and set up help only. Record review of Resident #79's care plan, dated 11/18/22 revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #79's EHR titled PASRR Level 1 Screening indicated that the assessment was completed on 01/17/22, 3 days after she was admitted to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 5 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0645 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/08/23 at 10:32 AM MDS A stated she has only been working for the facility for three weeks and she was just learning about PASRR. She said she was the person responsible for ensuring PASRRs are completed prior to admission as required. When asked why the PASRRs for Residents #79 and #67 were not performed prior to their admission to the facility she replied, I wasn't here, or I could tell you. Residents Affected - Few During an interview on 02/08/23 at 11:22 AM the DON said a possible negative outcome of not having a PASRR completed prior to admission was, You're not gonna know what you need to be treating or care planning. She stated the resident might have a mental illness that is not recognized upon admission and that could cause a problem because it is a disease process we need to be addressing. During an interview on 02/08/23 at 11:38 AM the ADM said she could not think of a negative outcome of not having a PASRR completed prior to admission. She stated, I mean, no, it's not gonna affect the resident initially. The facility did not have a policy regarding PASRR. Instead, the DON provided a Texas Health and Human Services document, titled, Detailed Item by Item Guide for Referring Entities to Complete the PASRR Level 1 Screening Form dated 07/2021. Record review of the Texas Health and Human Services document titled, Detailed Item by Item Guide for Referring Entities to Complete the PASRR Level 1 Screening Form dated 07/2021 revealed no information on the requirement for PASRR Level 1 to be completed prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 6 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services that include the accurate dispensing and administering of all dugs and biologicals to meet the need of each resident for 1 of 4 (Resident #31) residents reviewed for medication administration. The facility administered insulin to Resident #31 after it was expired. This deficient practice can affect residents that receive medications resulting in deterioration in their health, exacerbation of their disease process, and/or hospitalization. Finding include: Record review of Resident #31's face sheet dated 2-7-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include diabetes (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, hypertension (a condition in which the force of the blood against the artery walls is too high), pain, anxiety (intense, excessive, and persistent worry), agoraphobia (fear of places and situations that might cause panic), and post-traumatic stress disorder (a disorder win which a person has difficulty recovering after experiencing or witness a terrifying event). Record review of Resident #31's annual MDS dated [DATE] lindicated her BIMS score was 10 of 14, indicating she was moderately cognitively impaired, she had a functionality of requiring set-up assistance with her activities, and Section I2900 she was positive for Diabetes Mellites. Record review of Resident #31s care plan with admission dated of 2-8-2017 revealed the following: Problem: I have diabetes-Date initiated 7-13-2022 Intervention: Administer my medications as recommended by my doctor .-Date initiated 8-25-2020 Record review of Resident #31's physician active orders as of 2-7-2023 revealed the following: Novolog Solution 100 Units/Ml (inulin/Aspart) inject per sliding scale-If 200-250=2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units, 401-450=10 units. Start date of 10-16-2020 Record Review for Resident #39's February-2023 medication administration record revealed the following: 1-29-2023-Resident 39 received 1 dose of Novolog 1-30-2023-Resident 39 received 2 doses of Novolog 1-31-2023-Resident 39 received 2 doses of Novolog 2-1-2023-Resident 39 received 4 doses of Novolog (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 7 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 0755 2-2-2023-Resident 39 received 2 doses of Novolog Level of Harm - Minimal harm or potential for actual harm 2-3-2023-Resident 39 received 1 dose of Novolog 2-4-2023-Resident 39 received 1 dose of Novolog Residents Affected - Few 2-5-2023-Resident 39 received no doses of Novolog 2-6-2023 Resident 39 received 2 doses of Novolog Resident #39 received 15 doses of Novolog insulin after the insulin was opened/accessed and expired. During an observation on 02-07-2023 at 09:39 AM with RN B of the 600 Hall medication cart Resident #31's NovoLog insulin was noted with an open date of 12-31-2022 and an expiation date that was illegible. This was verified by RN B. RN B reported that if the insulin was not marked correctly then you will not know when it expires which can result in giving a resident medication that was ineffective. She reported she has been on night shifts at this facility, and it was the night shift supervisor's responsibility to complete an audit of the medication cart to ensure that the cart was clean and ready for the day shift. During an interview on 02-07-2023 at 10:29 AM RN B reported Resident #31's Novolog insulin had to be discarded within 28 days of being opened. Resident #31's insulin was expired and was discarded per facility policy. RN B reported that she had not given Resident #31's insulin today but it was given yesterday and was expired at that time. She verified Resident #31 does not appear to have any ill effects from the expired insulin at this at this time according to her assessment of Resident #31 today. During an interview on 02-07-2023 at 11:24 AM RN B reported that if medications are not labeled in the medication carts correctly then residents could receive doses that could affect their condition and/or place them at risk of endangering their condition. It could affect their treatment. During an interview on 2-7-2023 at 3:32 PM the DON reported that administering an expired medication can be ineffective and a resident could receive medication that would not treat their condition. With the expired insulin it could affect the resident's diabetes. The DON reported that they had started an Inservice with nursing staff to address monitoring medications especially multidose such as insulin and ensuring that they are not expired. Record review of the facility provided policy titled Storage and Expiration Dating of Medication, Biologicals dated revised 7-21-2022, revealed the following: 5.3-If a multi-dose vial of injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 8 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (400 Hall, 500 Hall and 600 Hall) reviewed. The facility failed to ensure medication carts on the 400 Hall, 500 Hall and 600 Hall did not contain loose pills. This failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional missed doses or administration of medications to the wrong resident. Findings include: During an observation on 02-07-2023 at 08:42 AM of the 400 Hall medication cart, 6 loose pills were found under blister packs. The following loose pills removed from the cart included: *2 tabs Carbidopa-Levadopa for Parkinson's, *1 cap Lubiprostone 24 mcg for constipation, *1 tab Wellbutrin for depression, *1 tab Finasteride 5 mg for benign prostatic hyperplasia, and *½ tab unknown medication. During an interview on 02-7-2023 at 08:46 AM, LVN I stated the medications could fall on the floor and a resident ambulating by could pick them up and put them in their mouth. LVN I also stated, nurses just being lazy and the nurse either popped another out of the blister pack or the medication was not given. During an observation on 02-07-2023 at 09:53 AM of the 500 Hall medication cart the following 2 loose pills removed from the cart were: 1 tab Eliquis 5 mg and 1 tab Eliquis 2.5mg for blood thinners. During an observation on 02-07-2023 at 09:39 AM of the 600 Hall medication cart the following 5 loose pills removed from the cart were: *½ tab of 40mg Lasix for excess fluid, *½ tab 25/100mg Carbidopa-Levadopa for Parkinson's, *1 tab Namenda 5mg for dementia, *1 tab Metoprolol 25mg for high blood pressure, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 9 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 *½ tab 25 mg Metoprolol for high blood pressure. Level of Harm - Minimal harm or potential for actual harm During an interview with RN B during this observation, she reported she has been on night shifts at this facility, and it was the night shift supervisor's responsibility to complete an audit of the medication cart to ensure that the cart was clean and ready for the day shift. Residents Affected - Some During an interview on 02-07-23 at 09:58 AM, LVN H stated the nurse may have thought it popped out and missed it. LVN H stated the nurse could have popped another out of the pack which causes the count to be off. She stated, the nurse was being lazy if they just popped it out. She stated the residents may not have gotten their medications or the nurses popped out new ones and are wasting medications. During an interview on 02/07/23 11:24 AM, RN B reported if the pills are misplaced or not labeled in the medications carts they can fall out on the floor and a resident could pick them up and take them especially on the memory care unit which the 600 Hall medication cart was for. She reported that residents could miss doses that could affect their condition and/or place them at risk of endangering their condition. It could affect their treatment. Record review of the facility provided policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, dated 7/21/22, revealed: Applicability This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications biologicals, . Procedure .Facility should ensure that medication and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding . .Facility should ensure that the medication and biologicals for each resident are stored in the containers in which they were originally received .Facility personnel should inspect nursing station storage areas for proper storage compliance on all regularly scheduled basis . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 10 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized for four out of 21 residents (Residents #17, #45, #50 and #94) reviewed for complete and accurate medical records. Residents #17, #45, #50, and #94 had Out-Of-Hospital DNR forms that were not accurately completed. This failure could place residents with advance directives at risk for not having their end-of-life wishes followed. Findings include: 1. Record review of Resident #17's face sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (a stroke during which the brain does not get the blood flow it needs), venous insufficiency (veins in legs and occasionally arms have trouble moving blood back to the heart, results in swelling and often pain), type 2 diabetes, high blood pressure, major depressive disorder, and cognitive deficits following cerebral infarction. The face sheet also indicated under the section titled, Advance Directive that Resident #17 had a DNR. Record review of Resident #17's significant change MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Section G of the MDS revealed Resident #17 required extensive assistance by one or two staff members across all ADLs. Record review of Resident #17's care plan, dated [DATE], revealed, in part, I/Family/RP has completed documentation for DNR status. I wish to be designated DNR. Community will follow DNR status request through review date. Review code status quarterly and as needed. Record review of Resident #17's physician's orders revealed, in part, .DNR . Advance Directive Status: Current and Verified . dated [DATE] Record review of a document in Resident #17's chart titled Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated [DATE], revealed a date, printed name, and a signature by Resident #17 in Section A labeled Declaration of the adult person which reflected, I am competent and at least [AGE] years of age. I direct that no resuscitation measures be initiated or continued for me. The section titled Two Witnesses contained the printed names of two witnesses with corresponding dates the form was signed and signatures. The section titled Physician's Statement reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. This section contained the physician's name, license number, and signature but no date the form was completed by the physician. 2. Record review of Resident #45's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to, Alzheimer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 11 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm disease, cognitive communication deficit, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), high blood pressure, and psychotic disorder with delusions. The face sheet also indicated under the section titled, Advance Directive that Resident #45 had a DNR. Residents Affected - Few Record review of Resident #45's quarterly MDS, dated [DATE], revealed a BIMS score of 8 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #45 required extensive assistance or supervision by one or two staff members across all ADLs. Record review of Resident #45's care plan, dated [DATE], revealed, in part, I/Family/RP has completed documentation for DNR status. I wish to be designated DNR. Community will follow DNR status request through review date. A physician's order for DNR is to be placed in my clinical record .Keep a copy of the OOHDNR form in my clinical record .Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility . Record review of Resident #45's physician orders revealed, in part, .DNR . Advance Directive Status: Current and Verified . dated [DATE]. Record review of a document in Resident #45's chart titled Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated [DATE], revealed a date, printed name, and a signature by Resident #45's family member in Section B labeled Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication: I am the agent in a Medical Power of Attorney. The section titled Two Witnesses contained the printed names of two witnesses with corresponding dates the form was signed and signatures. The section titled Physician's Statement reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. This section contained the physician's name, license number, and signature but no date the form was completed by the physician. 3. Record review of Resident #94's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses, post-traumatic stress disorder, displaced intertrochanteric fracture of left femur (break of the large bone in the top of the left leg), and high blood pressure. The face sheet also indicated under the section titled, Advance Directive that Resident #94 had a DNR. The face sheet also indicated Resident #94 had been receiving hospice care since [DATE]. Record review of Resident #94's admission MDS, dated [DATE], revealed a BIMS score of 10 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #94 required extensive assistance or supervision by one or two staff members across all ADL's. Record review of Resident #94's care plan, dated [DATE], revealed, in part, I/Family/RP has completed documentation for DNR status. I wish to be designated DNR .Community will follow DNR status request through review date .A physician's order for DNR is to be placed in my clinical record .Keep a copy of the OOHDNR form in my clinical record .Review code status quarterly and as needed .Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility . Record review of Resident #94's physician orders revealed, in part, .DNR . Advance Directive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 12 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Status: Current and Verified . dated [DATE]. Level of Harm - Minimal harm or potential for actual harm Record review of a document in Resident #94's chart titled Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated [DATE], revealed a date, printed name, and a signature by Resident #94's family member in Section C labeled Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above noted person's adult child. The section titled Two Witnesses contained the printed names of two witnesses with corresponding dates the form was signed and signatures. The section titled Physician's Statement reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. This section contained the physician's name, license number, and signature but on the line for the date the form was completed by the physician there was only a numeral 1. Residents Affected - Few 4. Record review of Resident #50's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), benign prostatic hyperplasia (the flow of urine is blocked due to the enlargement of prostate the gland; symptoms include increased frequency of urination at night and difficulty in urinating), muscle wasting and atrophy, violent behavior, major depressive disorder, migraine, kidney disease, post-traumatic stress disorder, and umbilical hernia. The face sheet also indicated under the section titled, Advance Directive that Resident #50 had a DNR. Record review of Resident #50's quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Section G of the MDS revealed Resident #50 requires supervision and set up help only across all ADL's. Record review of Resident #50's care plan, dated [DATE], revealed, in part, I have completed documentation for DNR status. I wish to be designated DNR .Community will follow DNR status request through review date .A physician's order for DNR is to be placed in my clinical record .Keep a copy of the OOHDNR form in my clinical record .Review code status quarterly and as needed .Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility . Record review of Resident #50's physician orders revealed, in part, .DNR . Advance Directive Status: Current and Verified . dated [DATE]. Record review of a document in Resident #50's chart titled Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated [DATE], revealed a printed name and the signature of Resident #50 but no date in the requisite blank in section A labeled Declaration of the adult person which reflected, I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. The section titled Two Witnesses contained the printed names of two witnesses with corresponding dates the form was signed and signatures. The section titled Physician's Statement reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. This section (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 13 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 contained the physician's name, license number, signature, and the date the form was signed. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on [DATE] at 08:27 AM the power of attorney for Resident #45 stated Resident #45's desire to be DNR. Residents Affected - Few During an interview on [DATE] at 08:46 AM RN B looked at the DNR for Resident #45 and said she believed it was valid. When the lack of a date by the physician was shown to her, RN B gasped and shook her head. When asked for a possible negative outcome for a resident if a DNR is not valid she answered, Somebody gets coded when family didn't want it. During an interview on [DATE] at 09:32 AM LVN C looked at the DNR for Resident #94 and was unable to identify the missing physician date. When asked for the date the DNR was activated she looked at the date the witnesses wrote on the form. When shown the missing physician date she looked surprised. When asked for a possible negative outcome of an invalid DNR for a resident she said, They would not have their wishes followed. During an interview on [DATE] at 09:37 AM Resident #94 nodded emphatically when asked if he wanted to be DNR. He stopped nodding and said, Yes. During an interview on [DATE] at 10:18 AM the DON said SW oversees getting DNR forms filled out and scanned into the EHR. She said a DNR form that was not dated by the physician was invalid. When asked for a possible negative outcome for a resident if their DNR was invalid she replied, Initiating a code and not following their wishes. That (DNR form) is a two-parter, they (physicians) have to sign it and date it or it is not valid. During an interview on [DATE] at 11:06 AM SW said a DNR that is not signed by the physician shouldn't be valid. She continued, That is where I usually come in to make sure they are dated. When asked why there appeared to be a few that were not dated in the facility's EHRs she said it was probably before she was hired. When asked what a possible negative outcome could be for a resident if their DNR was not valid she did not respond. During an interview on [DATE] at 08:28 AM Resident #50 confirmed he wanted to be DNR. He said, I want to die. During an interview on [DATE] at 08:31 AM Resident #17 confirmed his desire to be DNR. Record review of instructions accompanying Residents #94, and #45's DNRs titled, INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER, dated as revised on [DATE], revealed, in part, .The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Record review of the facility's policy titled Do Not Resuscitate Order and dated 04/2017, did not indicate how a DNR should be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 14 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 of 5 staff (CNA E and CNA F) observed for hand hygiene. Residents Affected - Few -CNA E and CNA F failed to use proper hand hygiene techniques when providing incontinent care to Resident #54. This failure had the potential to affect all residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation of incontinent care on 02/07/23 at 10:25 am for Resident #54, CNA E and CNA F entered room and introduced self to Resident #54. Door to resident #54 was closed, and privacy curtain was closed. All supplies were assembled before procedure. CNA F explained to Resident #54 they were going to change his brief. Resident #54 approved. Both CNA E and CNA F washed their hands with soap and water prior to starting care. Both CNA E and SNA F placed gloves on and completed the incontinent care. Resident #54 was rolled over and his anal region was cleaned. Linens were removed due to being soiled. During entire process, CNA E and CNA F removed their gloves and changed them often, however they did not wash their hands or utilize ABHR between glove changes. Upon leaving Resident #54 in a clean and safe position with call light in place, both CNA E and CNA F removed their gloves and washed their hands with soap and water. Observed ABHR dispenser in room outside restroom. During an interview on 02/07/23 at 10:42 am with CNA E, she was asked about changing her gloves multiple times but not washing her hands or using ABHR between glove changes. CNA E responded, I forgot. During an interview on 02/07/23 at 10:44 am with CNA F, she was asked about changing her gloves multiple times but not washing her hands or using ABHR between glove changes. CNA F responded, I didn't have any on hand. I thought about it and questioned it but didn't really know if I needed to do it or not. During an interview on 02/08/23 at 3:11 pm with the DON, she stated she handed out ABHR 'like Oprah'. I have a bottle for you, I have one for you and one for you The DON stated all staff should have ABHR on hand and utilizing it when caring for the residents. Record review of facility's provided competency titled, Handwashing/Hand Hygiene revised date August 2019, revealed the following: Policy Statement This community considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 15 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Level of Harm - Minimal harm or potential for actual harm .Before and after direct contact with residents Residents Affected - Few .Before moving from a contaminated body site to a clean body site during resident care . .After contact with a resident's intact skin . .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 infection . Record review of facility's provided policy titled, Standard Precautions revised October 2018, revealed the following: Policy Statement Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation Standard precautions include the following practices: .Hand hygiene .Hand hygiene is performed with ABHR or soap and water: .before and after contact with the resident . .Hands are washed with soap and water whenever: .after direct or indirect contact with dirt, blood or body fluids .after removing gloves . .Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one) . .Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident . Record review of facility's provided policy titled, ML Healthcare Standard Precautions revised July 5, 2021, revealed the following: Handwashing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 16 of 17 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 All associates are required to wash their hands after each direct veteran/resident contact for which handwashing is indicated by accepted professional practice. As stated earlier, handwashing facilities are available and accessible to all associates. Handwashing techniques are posted at each handwashing station. The CDC guidelines regarding handwashing are to be followed by associates after each veteran/resident contact. Residents Affected - Few Record review of facility provided bulletin titled, Your 5 Moments for Hand Hygiene not dated, revealed the following: 1) Before touching a patient 2) Before clean/aseptic procedure 3) After body fluid exposure risk 4) After touching a patient 5) After touching patient surroundings FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 17 of 17