Health inspection·July 5, 2023

F 0600 Document behavior and potential causes. Staff to redirect resident when having inappropriate behaviors. Level of Harm - Immediate jeopardy to resident health or safety Record review of statement by LVN A and signed on 6/6/23 documented the following: Tuesday, June 6 @ 0635 This nurse was walking toward the 500 hall nurses stations looking for the O2 key. {Resident #2} was sitting at 500 hall nurses station window. As I approached the 500 hall nurses station window, {Resident #2} grabbed my right breast and squeezed it twice. I reacted by pushing his hand away and then slapping his left arm saying with a firm voice, 'Don't do that!' Residents Affected - Some Record review of resident #2's clinical record to include progress notes and nurse's notes on the date of the incident 6/6/23 did not reveal that the resident was assessed for physical or psychosocial injuries/harm after the incident. Record review of witness statement completed and signed by RN D on 6/6/23 documented the following: 6/6/23 At approximately 0635,{LVN A} was walking in front of the 500 unit nursing station, { Resident #2} was sitting in his wheelchair. This RN D heard {LVN A} state loudly, 'you don't do that.' This RN D looked up and saw {LVN A} take his left wrist away from her body and then smacked him on his upper left arm. This RN D called out to her and told her we couldn't do that. She stated to this RN D, 'he grabbed my breast.' This RN D reminded her we can't react to the behavior and then escorted him from the area to the TV area and reminded him he can't touch staff, can't flirt with staff, etc. he stated, 'Yes, Ma'am.' During an Interview on 6/13/23 at 08:30 AM, administrator was asked if LVN A hit Resident #2. Administrator stated LVN A did push his shoulder and was immediately suspended while facility conducted an investigation. Administrator stated Resident #2 has behaviors and he yells out sexual invitations to female staff, as well as grab breasts and bottoms of female staff. During an interview with LVN B on 6/13/23 at 09:16 AM, LVN B stated she observed LVN A being grabbed by Resident #2 on the breast and she slapped him three times across chest and back. LVN B stated LVN A was suspended for a couple of hours but feels LVN A should have been suspended longer. LVN B stated I know Resident #2 is a handful, but you don't hit them. LVN B stated the incident happened at 06:30 AM and LVN A was back to work by noon the same day. LVN B stated RN D on the floor witnessed the event. During an interview with LVN A on 6/13/23 at 09:59 AM LVN A stated Resident #2 has been inappropriate with her physically. LVN A stated her slapping Resident #2 was not retaliatory. LVN A states the first time Resident #2 physically touched her on her butt and she had a firm tone with him. LVN A stated this second incident he grabbed her breast and she smacked him on his left arm. LVN A stated she did not mean to hit Resident #2. LVN A stated she only slapped him once. LVN A stated she was suspended while the facility did their investigation. LVN A states there were several witnesses to this incident. LVN A stated witnesses for the incident were LVN B, RN D, LVN C and MA. LVN A states she was suspended for ½ a day and returned to the facility to finish her shift by approximately 1:00 PM. LVN A stated she does not know the details of the administration investigation; however she was cleared to return work. During an interview on 6/14/23 at 10:28 AM, RN D stated she heard LVN A yell stop don't do that and saw her swat Resident #2 on the left arm. RN D stated, I heard 'Don't do that' and interjected when I saw LVN A's arm swing up and make contact with the resident's arm. When asked if LVN A struck Resident #2 more than once, RN D stated LVN A did not hit Resident #2 more than one time. RN D stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 2 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some LVN A was suspended but does not know length of time. RN D stated that she began the internal investigation. RN D stated she does not believe LVN A returned to work that day but honestly did not know when LVN A returned to work. During an Interview with LVN C on 6/13/23 at 11:54 AM, LVN C stated I wasn't a witness, I just heard the commotion. LVN C stated I heard what RN D told LVN A. LVN C stated RN D told LVN A You cannot hit Resident #2 like that. LVN A responded to RN D by stating well he grabbed my breast. LVN C stated RN D responded back to LVN A It doesn't matter. LVN C stated LVN A stated I'm sorry. It was a reaction. LVN C stated LVN A was crying. LVN C left interview, however came back in approximately 2 minutes later crying and stated, I just don't understand how they 'suspended' the nurse for just 2 hours. LVN C stated It's not all of Resident #2's fault. LVN C stated How can you let a nurse go for 2 hours and let her come back to the same side that Resident #2 resides on? It's not all of Resident #2's fault. Resident #2 cannot communicate well. During an interview with MA on 6/13/23 at 11:56 AM, MA stated I was on duty. I was getting started. I was cleaning off the medication cart. I heard LVN A on 6/6/23 at approximately 6:35 AM yell 'stop'. MA stated she heard all the commotion but did not actually see what happened. MA stated, I did not see Resident #2 touch her. MA stated that she saw a few nurses run towards LVN A because she was crying inconsolably. MA stated that by the time she started asking questions with LVN A, RN D had come to LVN A and was telling LVN A she needed to speak with her and console her. MA states Resident #2 is 'pretty vulgar' and requires a lot of redirecting and teaching of what is appropriate and what is not appropriate. MA states she did not see LVN A hit Resident #2. MA states the only reaction she saw from LVN A was her crying uncontrollably. MA states it wasn't surprising from what Resident #2 did. During an Interview with Resident #2 on 6/13/23 at 1:11 PM, Resident #2 stated staff treat him real good. When asked who he would go to if he had any problems, Resident #2 stated, the first person I saw. Resident #2 state, I don't have any problems. Resident #2 stated, as far as I know I'm safe here. I haven't had any incidents with anybody that I am aware of. During an interview with Admin on 6/13/23 at 1:25 PM, Admin was asked what steps the facility implements to ensure this type of incident did not occur again. Admin stated, We in serviced staff on appropriate approaches and responses and when staff have those negative behaviors. Admin stated the facility had QAPI'd the incident. During an interview with DON on 6/13/23 at 1:48 PM DON stated QAPI meeting is not scheduled until 6/22/23. DON handed what would be in the QAPI meeting titled What is a Behavior and Helping MANAGE BEHAVIORS Appropriately undated. DON states I will get every resource in here to protect Resident #2, especially when his behaviors effect his quality of life. I want Resident #2 to have the best quality of life. During the interview, a record review of Resident #2's care plan was reviewed with DON, RN D changed Resident #2's care plan to include: The resident has a behavior problem TOUCHING STAFF INAPPROPROIATELY date initiated 6/6/23 revised 6/13/23. DON stated LVN A has been moved to the memory care unit or the 800 hall to give her and Resident #2 a break from each other. DON stated she failed to obtain LVN A's signature on sign in sheet for in service as they did a 1:1 education in her office dated 6/6/23. DON states that Admin and DON counselled LVN A while educating her as they felt LVN A had no intent of harming resident and LVN A needed assistance with dealing and developing coping skills. DON states You're my patient regardless of your past and I put a blanket of protection over all of them. That also goes to my nurses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 3 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review on 6/13/23 of the facility's internal investigation revealed the incident occurred on 6/5/23 with corrective action notice and written counseling held with LVN A for 'failure to demonstrate a respectful, and cooperative demeanor in all interactions with patients.' The corrective action notice was signed by LVN A, DON and Admin on 6/5/23. Record review on 6/13/23 of internal investigation reveals letter written by Admin dated 6/7/23, documented the following: This administrator met with Resident #2 today in his room to discuss his continued inappropriate behavior with staff. Upon approach Resident #2 was alert and oriented. Informed Resident #2 why and what I was there to discuss. Resident #2 stated again. Informed Resident #2 that any form of sexual behavior such as making sexual comments, touching or grabbing is unacceptable and that it will not be tolerated. Informed Resident #2 that his increase in this sexual behavior had been discussed with his daughter in the special care plan last week and consideration for other placement had been discussed if the behavior did not cease. Resident #2 stated I'll behave. Asked Resident #2 if he was aware of his behavior as being inappropriate. He reported that that he just likes to have fun. Allowed Resident #2 to repeat his understanding of the importance of this conversation and the immediate need for this behavior to cease. He verbally acknowledged he understood. Will continue to follow up with staff in regard to Resident #2 behavior. Interview with LVN A on 6/14/23 at 1:26 PM to clarify what date incident occurred. Corrective Action Notice (written counseling) was signed and dated 6/5/23. Witness statements from LVN A and RN D both indicate incident occurred on 6/6/23. LVN A pulled up her timesheet while on phone with surveyor and stated she worked a full day on 6/5/23 and this incident occurred on 6/6/23. Based on this information the Corrective Action Notice (Written counseling) was signed and dated incorrectly with incorrect date on 6/5/23 and should have been dated 6/6/23. Record review of internal investigation reveals a facility copy of Resident Abuse Policy dated 2020, documented the following: Policy Statement: It is the responsibility of our facility employees/associates, consultants, attendings physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriate of resident property to facility management. POLICY INTERPRETATION AND IMPLEMENTATION 1. Our facility will not condone resident abuse by anyone, including associates (associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. The Facility will not employ persons who have been found guilty of abuse, neglect or mistreatment or have had a finding entered into a state registry or licensing authority concerning such behaviors. 4. When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 4 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety source, or abuse is reported, the Facility Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident, if appropriate: a) The State licensing/certification agency responsible for surveying/licensing the Facility. b) The Resident's Representative (Sponsor) of Record. Residents Affected - Some c) Law Enforcement Officials d) The Resident's Attending Physician, and e) The Facility Medical Director 6.Definitions of abuse . a) Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This it includes verbal abuse, sexual abuse, mental/psychological, or physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Including corporal punishment, involuntary seclusion or any other actions within this definition. ABUSE INVESTIGATIONS POLICY STATEMENT All reports of resident abuse, neglect and injuries which have an unknown source (defined per state regulations) shall be promptly and thoroughly investigated by the Facility management. POLICY INTERPRETATION AND IMPLEMENTATION 6. Associates/Employees of this facility who have an allegation against them of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator/designee. On 6/13/23 at 5:00 PM, The Administrator was notified that an Immediate Jeopardy had been identified, IJ template provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted 6/14/23 at 3:45 PM. The Facility's Plan of Removal F600 - 6/13/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 5 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Facility failed to protect the veteran from physical abuse. Resident grabbed LVN breast. In response the LVN physically removed his hand, then slapped the resident on the shoulder/upper arm. 1. Administrator/ DON/Designee to give Abuse and Neglect education/in-service to all staff on 6/6/2023. Residents Affected - Some 2. Administrator/DON/ Designee Abuse and Neglect education/in-service to be provided to staff again beginning on 6/13/2023 and ongoing until all current staff are obtained. To include who is the abuse coordinator, what constitutes abuse, and to always report when in doubt. 3. DON/ Designee Education and Training to all staff provided on difficult/inappropriate behaviors and redirection interventions beginning 6/13/2023 and ongoing on how to deal with redirection/difficult and inappropriate behaviors. 4. DON/ Administrator to perform weekly random Q&A validation audits during rounds to include who is the abuse coordinator, how to deal with difficult behaviors, examples of abuse and neglect. 5. Director of Resident Care Services and Education (regional) provided education to Facility Management team on Regulatory Reporting on 06/13/2023. Facility staff member slapped a resident which has the potential to cause physical or psychosocial harm. 1. Staff member was suspended pending investigation. Prior to return to work on 6/6 employee received a write up to include how to respond to respond when a resident exhibits an inappropriate behavior. Staff member was not put on schedule to work and provide care to this resident. 2. Dir of Resident Care & Services (regional) to follow-up with staff member to validate understanding of how to respond appropriately to inappropriate behaviors (6/14/2023) 3. Administrator/DON/Social Worker to immediately assess and document all investigations of abuse. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 6 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some DON/ADON/Designee to educate/in-service Nursing staff to assess and document in the veterans/residents record a head to toe skin assessment and in a progress note document veterans/residents' psychosocial wellbeing. 5. Psych Services to be notified and ask to visit veteran/resident if currently being seen or SW to ask resident/RR if would agree to psych consult visit request if necessary. 6. Resident Care Plan updated 6/6 and 6/13/2023 and again 6/14/2023 to include interventions to assist staff in helping resident with his inappropriate behavior. Updated C.N.A. POC [NAME] with helpful interventions for staff when interacting with resident. Facility had the responsibility to protect residents from abuse that could cause serious injury or harm. 1. If an abuse allegation is made the Administrator/DON/SW will address the allegation immediately by: a. Protecting the resident(s) immediately involved in the allegation and protecting other residents from the alleged perpetrator(s) b. Immediately reporting all allegations of A/N/E to the State per current regulatory requirements, c. Initiate a thorough investigation as to the allegation(s), including but not limited to assessing the resident(s) involved, obtaining statements of those allegedly involved, interviews with witnesses, suspending staff, re-enactments if needed. d. Follow the facility A/N/E policy. 2. If abuse involves an employee, an employee will be suspended based upon pending investigation. 3. Based upon results of investigation, the employee may be terminated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 7 of 19 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 07/05/2023 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 0600 4. Level of Harm - Immediate jeopardy to resident health or safety If unfounded, facility will determine need for alternative staffing assignment. Residents Affected - Some DON/Administrator/Designee to provide 1:1 education/in-service how to respond/ Appropriate interventions and received a write up prior to returning to a floor assignment. 5. 6. Will report and review Failure to protect to QAPI monthly for compliance for 6 months, plan to be modified as needed based upon audit results. Monitoring of the Plan of Removal included: During an interview on 6/14/23 at 4:29 PM with ADM would obtain copies of all education/in-services listed on Plan of Removal for surveyor. ADM stated facility had Q&A cards with questions about abuse, neglect and behavior interventions and each manager would ask random residents and staff weekly, log it and report this information to the ADM and DON. ADM clarified Corrective Action Notice date was incorrect. ADM stated the Corrective Action Notice (written counseling) date was in error and would be corrected. Copy of crossed-out date of 6/5/23 with corrected date of 6/6/23 and initials from admin was written on Corrective Action Notice. ADM stated once abuse had been reported, there would be a protocol for ADM, social worker and DON to know our part to take action. During interviews on 6/14/23 from 5:11 PM to 5:42 PM with staff members (listed below) regarding receiving in-service training on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Out of 10 CNA's interviewed, 7 stated they had received and signed in-service training on 6/14/23. One CNA stated she was agency, did not sign the in-service training, but did receive the training. One CNA stated she was 'too busy' working and had not received it. One CNA, who was working, stated she had received verbal information about the incident but not about the in-service training. Four LVN's, all stated signed and received the in-service training. Two RN's, all stated signed and received the in-service training. Five office staff, all stated signed and received the in-service training. One Maintenance Director stated he had signed and received the in-service training. During an observation on 6/14/23 at 5:12 PM one RN was educating night supervisor RN regarding in-service training of Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Record review of the facility provided in-service sign in sheet revealed staff were trained on Validation of Education Managing Inappropriate Behaviors on 6/14/23, Abuse and Neglect Inservice Education dated 6/13/23, Regulatory Reports dated 6/14/23, Nursing Skin assessment, Nursing Notes to include psychosocial wellbeing dated 6/14/23, ANE (Resident #2. Incident) dated 6/6/23, How to Re-direct and Deal with Difficult Behaviors - Resident #2 dated 6/7/23, Q&A index Cards - Abuse, Neglect and Behavior Interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 8 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator at 6/13/23 at 5:00 PM. While the immediate jeopardy was lifted on 6/14/23 at 8:00 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The Immediate Jeopardy was re-opened on 7/5/23 at 10:00 AM due to the facility failed to follow their Plan of Removal. Based on the Plan of Removal, if abuse involves an employee, an employee will be suspended based upon pending investigation. LVN A was allowed to continue to work with residents. Interview on 7/5/23 at 10:56 AM with Administrator and DON, administrator stated she and the DON felt that LVN A was capable of working with dementia residents and was very familiar with their behaviors and confused state of minds. Administrator and DON were notified that Immediate Jeopardy was re-opened until further investigation evidence was determined. Administrator stated that LVN A's personnel file had not been updated since 6/14/23, as their had not been any issues or concerns. Admin stated all personnel that worked in the vicinity of the incident had been interviewed and 2 witness statements (LVN A and RN D) were the only statements that had been in the investigation file. Interview on 7/5/23 at 11:20 AM DON stated LVN A had been suspended until investigation was thoroughly completed. Interview on 7/5/23 at 2:00 PM, DON stated the list of employees that completed in-service trainings on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment were color coded and all staff had been trained. The one CNA that had reported to surveyor that she was too busy working had signed the in-service trainings, but no longer works at the facility. DON stated that LVN A has been removed from the schedule effective 7/6/23 through 7/15/23 as proactive measures since facility does not know what is going to happen with this investigation. DON stated schedule has not been posted and this was just for staffing coordinator and DON at this time. Interview on 7/5/23 at 2:15, LVN B stated that administrator or any upper management interviewed her about the incident. LVN B stated that her immediate supervisor (care coordinator previous ADON) was standing directly beside her and saw the entire incident occur. LVN B stated immediate supervisor told LVN B that she would take care of everything. LVN B stated she was told she did not have to document the incident. LVN B stated she was told to call the family and LVN B asked if she was supposed to tell the family that Resident #2 had been slapped she was told no. LVN B stated she yelled at LVN A You can't do that. LVN A stated RN D also yelled You can't do that upon seeing LVN A strike Resident #2. Interview on 7/5/23 at 2:32 PM, RN D stated no on was standing beside her. RN D believes LVN B was standing behind her at her medication cart and that there was someone at the computer but does not recall who this person was. RN D stated she was the only person that yelled You can't do that when she saw LVN A strike Resident #2. RN D stated she took LVN A to her office and had LVN A write up her statement and then sent her home. RN D stated later that day she told LVN B to complete a skin assessment on Resident #2, which was not completed. RN D stated she told LVN B to call Resident #2's family to notify them of the incident. RN D stated LVN B asked what she was supposed to tell the family and RN D stated to LVN B to follow the incident report questions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 9 of 19 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 07/05/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 7/5/23 at 3:22 PM, DON stated social worker completed safety rounds with all residents asking resident if they felt safe. DON stated psychiatrist saw Resident #2 on 6/6/23 and on 6/16/23. DON stated resident was placed in a behavioral facility for 2 weeks due to another incident. DON stated she was unaware of LVN B witnessing incident. DON stated she does not know where LVN B was at the time of the incident and that LVN B did not report to her or administrator that she was a witness to the incident. Interview on 7/5/23 at 3:43 PM, Administrator stated she did not interview LVN B and was unaware that LVN B was a witness to the incident. Administrator stated she had just started working on her investigation when she called corporate and was told this was not a reportable offense and did not need to be investigated. Administrator states the investigation file she has only has the two witnesses (LVN A and RN D) as witnessing the incident. Interview on 7/5/23 at 4:25 PM, Admin interviewed regarding plan of removal to protect all residents from abuse, neglect and exploitation. Plan of Removal reviewed for assurances that employee will be suspended until investigation is completely resolved of deficiencies, plan of care and board of nursing action. Record review of the facility provided in-service sign in sheets revealed all staff were trained on How to Re-direct and Deal with Difficult Behaviors - Resident #2, Abuse and Neglect, Nursing Skin Assessment Nursing Notes to include psychosocial wellbeing, Regulatory Reporting. Record review of the facility provided in-service sign in sheets revealed all residents were interviewed for safety rounds. Record review of the facility Provider Investigation Report dated 6/15/23 with no intake number. Record review of the facility schedule for LVN A for June 2023 and July 2023. LVN A worked 10 days after IJ was lifted and was removed from the facility on 7/5/23 at 11:15 AM. LVN A worked on the following dates: 6/14/23, 6/16/23, 6/19/23, 6/2023, 6/23/23, 6/24/23, 6/25/23, 7/1/23, 7/2/23 and 7/5/23. The Immediate Jeopardy (IJ) that was lifted on 6/14/23 at 8:00 PM was re-opened on 7/5/23 at 10:00 AM due to the facility failing to follow their plan of removal. While the immediate jeopardy was lifted on 7/5/23 at 5:30 PM, the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 10 of 19 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 07/05/2023 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 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 interview and record review it was determined the facility failed to implement its' written policies and procedures that prohibit and prevent abuse for 1 of 8 residents (Resident #2) reviewed for abuse. Residents Affected - Few -the facility was made aware of an allegation that Resident #2 was struck by a staff person but failed to report the allegation to State in a timely manner. The facility's failure to ensure suspicions of abuse/neglect were investigated and report to State could place all residents at risk for poor self-esteem, poor self-worth, neglect, abuse, misappropriation of property and continued contact with the perpetrator of the abuse. The evidence is as follows: Record review of internal investigation for the incident involving Resident #2 revealed an allegation of Resident Abuse occurring on 6/6/23. A written statement dated 6/6/23, by LVN A and RN documented that on 6/6/23 Resident #2 grabbed LVN A's breast. LVN A pushed Resident #2's hand away and slapped his left arm saying in a firm voice Don't do that!. During an interview on 6/13/23 at 8:30 AM, the Administrator stated she was aware of the incident related to Resident #2 and was told by her corporate office that she did not need to report it to the State office as it was not a reportable offense. The Administrator stated the facility suspended LVN A while they did an internal investigation and LVN A returned to the facility that afternoon to finish her shift upon the facility findings of their investigation. Record review reveals a facility copy of Resident Abuse Policy dated 2020, documented the following: Policy Statement: It is the responsibility of our facility employees/associates, consultants, attendings physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriate of resident property to facility management. POLICY INTERPRETATION AND IMPLEMENTATION 4. When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown source, or abuse is reported, the Facility Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident, if appropriate: a) The State licensing/certification agency responsible for surveying/licensing the Facility. b) The Resident's Representative (Sponsor) of Record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 11 of 19 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 07/05/2023 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 0607 c) Law Enforcement Officials Level of Harm - Minimal harm or potential for actual harm d) The Resident's Attending Physician, and e) The Facility Medical Director Residents Affected - Few 12. The Administrator/designee will provide written report HHSC Provider Investigation Report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency within five days of the reported incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 12 of 19 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 07/05/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, it was determined the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriate of resident property were reported immediately, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) after the allegation was made in accordance with State law for 1 of 8 residents (Resident #2) reviewed for abuse/neglect. The facility failed to report an allegation of abuse involving Resident #2 to the State Survey Agency that occurred when LVN A struck Resident #2 in the upper arm after Resident #2 grabbed LVN A's breast. This failure could affect residents by placing them at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and State Survey Agency. Findings included: Record review of Resident #2's clinical record revealed an admission date of 11/5/19, was [AGE] years of age with the following diagnoses: dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, combined systolic (congestive) and diastolic heart failure, type 2 Diabetes mellitus with Diabetic Nephropathy, Osteoarthritis, hypertension, Nonrheumatic aortic valve stenosis, nonrheumatic mitral valve disorder, Dementia in other diseases with other behavioral disturbance, spinal muscular atrophy, Alzheimer's disease with late onset, muscle weakness, muscle wasting and atrophy, malaise, major depressive disorder, intermittent explosive disorder, allergic rhinitis, heart-valve replacement, presence of automatic implantable cardiac defibrillator, atherosclerotic heart disease of native coronary artery, gout, personality and behavioral disorders due to known physiological condition. -A quarterly MDS resident assessment dated [DATE], documented Resident #2 had a BIMS score of 08 out of 15 indicating moderately cognitively impairment. Resident's functionality requires extensive assistance with 2 person assistance with all ADL's. - Resident's care plan indicates resident has a behavior problem related to being inappropriate with female resident initiated 11/23/22. Interventions to include observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Staff to redirect resident when having inappropriate behaviors. Record review of statement by LVN A and signed on 6/6/23 documented the following: Tuesday, June 6 @ 0635 This nurse was walking toward the 500 hall nurses stations looking for the O2 key. {Resident #2} was sitting at 500 hall nurses station window. As I approached the 500 hall nurses station window, {Resident #2} grabbed my right breast and squeezed it twice. I reacted by pushing his hand away and then slapping his left arm saying with a firm voice, 'Don't do that!' Record review of resident's clinical record to include progress notes and nurse's notes did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 13 of 19 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 07/05/2023 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 0609 reveal that the resident was assessed for physical or psychosocial injuries/harm after the incident. Level of Harm - Minimal harm or potential for actual harm Record review of witness statement completed and signed by RN D on 6/6/23 documented the following: 6/6/23 At approximately 0635,{LVN A} was walking in front of the 500 unit nursing station, { Resident #2} was sitting in his wheelchair. This RN D heard {LVN A} state loudly, 'you don't do that.' This RN D looked up and saw {LVN A} take his left wrist away from her body and then smacked him on his upper left arm. This RN D called out to her and told her we couldn't do that. She stated to this RN D, 'he grabbed my breast.' This RN D reminder her we can't react to the behavior and then escorted him from the area to the TV area and reminded him he can't touch staff, can't flirt with staff, etc. he stated, 'Yes, Ma'am.' Residents Affected - Few During an Interview on 6/13/23 at 08:30 AM, administrator was asked if LVN A hit Resident #2. Administrator stated LVN A did push his shoulder and was immediately suspended while facility conducted an investigation. Administrator stated Resident #2 has behaviors and he yells out sexual invitations to female staff, as well as grab breasts and bottoms of female staff. During an interview with LVN B on 6/13/23 at 09:16 AM, LVN B stated LVN A was grabbed by Resident #2 on the breast and she slapped him three times across chest and back. LVN B stated LVN A was suspended for a couple of hours but feels LVN A should have been suspended longer. LVN B stated I know Resident #2 is a handful, but you don't hit them. LVN B stated the incident happened at 06:30 AM and LVN A was back to work by noon the same day. LVN B stated RN D on the floor witnessed the event. During an interview with LVN A on 6/13/23 at 09:59 AM LVN A stated Resident #2 has been appropriate with her physically. LVN A stated her slapping Resident #2 was not retaliatory. LVN A states the first time Resident #2 physically touched her on her butt and she had a firm tone with him. LVN A stated this second incident he grabbed her breast and she smacked him on his left arm. LVN A stated she did not mean to hit Resident #2. LVN A stated she only slapped him once. LVN A stated she was suspended while the facility did their investigation. LVN A states there were several witnesses to this incident. LVn A states she was suspended for ½ a day and returned to the facility to finish her shift by approximately 1:00 PM. LVN A states she does not know the details of the administration investigation; however she was cleared to return work. LVN A stated witnesses for the incident were LVN B, RN D, LVN C and MA. During an interview on 6/14/23 at 10:28am, RN D stated she heard LVN A yell stop don't do that and saw her swat Resident #2 on the left arm. RN D stated, I heard 'Don't do that' and interjected when I saw LVN A's arm swing up and make contact with the resident's arm. When asked if LVN A struck Resident #2 more than once, RN D stated LVN A did not hit Resident #2 more than one time. RN D stated LVN A was suspended but does not know length of time. RN D stated that she began the internal investigation. RN D stated she does not believe LVN A returned to work that day but honestly does not know when LVN A returned to work. During an Interview with LVN C on 6/13/23 at 11:54 AM, LVN C stated I wasn't a witness, I just heard the commotion. LVN C stated I heard what RN D told LVN A. LVN C stated RN D told LVN A You cannot hit Resident #2 like that. LVN A responded to RN D by stating well he grabbed my breast. LVN C stated RN D responded back to LVN A It doesn't matter. LVN C stated LVN A stated I'm sorry. It was a reaction. LVN C stated LVN A was crying. LVN C left interview, however came back in approximately 2 minutes later crying and stated, I just don't understand how they 'suspended' the nurse for just 2 hours. LVN C stated It's not all of Resident #2's fault. LVN C stated How can you let a nurse go for 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 14 of 19 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 07/05/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hours and let her come back to the same side that Resident #2 resides on? It's not all of Resident #2's fault. Resident #2 cannot communicate well. LVN C states the staff joke around with him example given, one staff member had a baby and they joke the baby's name is Resident #2's first name and Jr. During an interview with MA on 6/13/23 at 11:56 AM, MA stated I was on duty. I was getting started. I was cleaning off the medication cart. I heard LVN A yell 'stop'. MA stated she heard all the commotion but did not actually see what happened. MA stated, I did not see Resident #2 touch her. MA stated that she saw a few nurses run towards LVN A because she was crying inconsolably. MA stated that by the time she started asking questions with LVN A, RN D had come to LVN A and was telling LVN A she needed to speak with her and console her. MA states Resident #2 is 'pretty vulgar' and requires a lot of redirecting and teaching of what is appropriate and what is not appropriate. MA states she did not see LVN A hit Resident #2. MA states the only reaction she saw from LVN A was her crying uncontrollably. MA states it wasn't surprising from what Resident #2 did. During an Interview with Resident #2 at 1:11 PM, Resident #2 stated staff treat him real good. When asked who he would go to if he had any problems, Resident #2 stated, the first person I saw. Resident #2 state, I don't have any problems. Resident #2 stated, as far as I know I'm safe here. I haven't had any incidents with anybody that I am aware of. During an interview with Admin on 6/13/23 at 1:25 PM, Admin was asked what steps the facility implements to ensure this type of incident did not occur again. Admin stated, We in serviced staff on appropriate approaches and responses and when staff have those negative behaviors. Admin stated the facility had QAPI'd the incident. During an interview with DON on 6/13/23 at 1:48 PM DON stated QAPI meeting is not scheduled until 6/22/23. DON handed what would be in the QAPI meeting titled What is a Behavior and Helping MANAGE BEHAVIORS Appropriately undated. DON states I will get every resource in here to protect Resident #2, especially when his behaviors effect his quality of life. I want Resident #2 to have the best quality of life. During the interview DON looked at Resident #2's care plan with the DON, RN D changed Resident #2's care plan to include: The resident has a behavior problem TOUCHING STAFF INAPPROPROIATELY date initiated 6/6/23 revised 6/13/23. DON stated LVN A has been moved to the memory care unit or the 800 hall to give her and Resident #2 a break from each other. DON states she failed to obtain LVN A's signature on sign in sheet for in service as they did a 1:1 education in her office dated 6/6/23. DON states that Admin and DON counselled LVN A while educating her as they felt LVN A had no intent of harming resident and LVN A needed assistance with dealing and developing coping skills. DON states You're my patient regardless of your past and I put a blanket of protection over all of them. That also goes to my nurses. Record review of internal investigation reveals a facility copy of Resident Abuse Policy dated 2020, documented the following: Policy Statement: It is the responsibility of our facility employees/associates, consultants, attendings physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriate of resident property to facility management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 15 of 19 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 07/05/2023 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 0609 POLICY INTERPRETATION AND IMPLEMENTATION Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Few When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown source, or abuse is reported, the Facility Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident, if appropriate: a) The State licensing/certification agency responsible for surveying/licensing the Facility. 12. The Administrator/designee will provide written report HHSC Provider Investigation Report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency within five days of the reported incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 16 of 19 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 07/05/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to review and revise the comprehensive care plan after each assessment for 8 of 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) residents reviewed for care plan timing. The facility failed to update to comprehensive person-centered care plans to address resident's needs after MDS assessments. The deficient practice could affect residents by delaying treatment, care and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #1's face sheet dated 6/14/23, revealed a [AGE] year old male admitted to the facility on [DATE] with diagnosis that included, but were not limited to, congestive heart failure, dementia, hypertension, atherosclerotic heart disease, obstructive sleep apnea, schizoaffective disorder bipolar type, cardiomyopathy, atrial fibrillation. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of a 7 out of 15 indicating resident has a moderate cognitive impairment. Record review of Resident #1's EHR care plan tab revealed Resident #1's most recent care plan was completed on 10/25/22, with next review date on 5/23/23. Record review of Resident #1's care plan, initiated 7/20/22, new review date 5/23/23, revealed 29 goals. 27 goals were initiated in 2022, 18 goals were revised on 2/1/23 and had a target date of 5/23/23. Nine goals were revised on 5/22/23 with a target date of 8/30/23. Two goals were initiated in 2023, were revised on 2/1/23 and had a target date of 5/23/23. Record review of Resident #2's face sheet dated 6/14/23, revealed a [AGE] year old male admitted to the facility on [DATE] with a diagnosis that included, but were not limited to, dementia, congestive heart failure, type 2 diabetes mellitus with diabetic nephropathy, osteoarthritis, hypertension. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 08 out of 15 which indicated moderate cognitive impairment. Record review of Resident #2's care plan, dated 11/23/22, revealed 24 goals. All goals had a target date of 2/19/23. Record review of Resident #3's face sheet, dated 06/14/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit, anxiety disorder, prostate cancer, heart disease, and depression. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS of 14 out of 15 which indicated mildly impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 17 of 19 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 07/05/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's EHR care plan tab revealed Resident #3's most recent care plan was completed on 05/18/23. Record review of Resident #3's care plan, dated 05/18/23, revealed 8 goals. All 8 goals had a revision date of 05/18/23. Four of the goals had a target date of 08/30/23 and four had a target date of 05/17/23. Residents Affected - Some Record review of Resident #4's face sheet, dated 6/14/23, revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary hypertension due to lung diseases and hypoxia, type 2 Diabetes Mellitus, Gastro-esophageal Reflux disease, malignant neoplasm of prostate, obstructive sleep apnea. Record review of EHR MDS tab revealed Resident #4's admission MDS, dated [DATE],revealed a BIMS of 15 out of 15. Resident #4 was discharged on 5/13/23 with re-entry to facility on 5/31/23 and a Quarterly MDS in progress dated 6/24/23. Record review of Resident #4's EHR care plan tab revealed Resident #4's most recent care plan was completed on 03/17/23. Record review of Resident #4's care plan, dated 3/17/23, revealed 11 goals. Nine goals were initiated in March 2023 and have a target date of 7/24/23. Two goals were initiated on 6/7/23 and have a target date of 7/24/23. Record review of Resident #5's face sheet, dated 06/14/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart disease, high blood pressure, dementia, chronic kidney disease, and cognitive communication deficit. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS of 5 out of 15 which indicated severely impaired cognition. Record review of Resident #5's EHR care plan tab revealed Resident #5's most recent care plan was completed on 12/05/22. Record review of Resident #5's care plan, dated 12/05/22, revealed 20 goals. All 20 goals had a target date of 12/07/22. 13 of the goals had an initiated date of 11/18/22. Five of the goals had an initiation date of 12/05/22. One of the goals had an initiation date of 11/21/22 and one had an initiation date of 11/22/22. Record review of Resident #6's face sheet, dated 06/14/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's, high cholesterol, congestive heart failure, and obesity. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS of 11 out of 15 which indicated moderate cognitive impairment. Record review of Resident #6's EHR care plan tab revealed Resident #6's most recent care plan was completed on 01/06/23. Record review of Resident #6's care plan, dated 01/06/23, revealed 23 goals. All 23 goals had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 18 of 19 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 07/05/2023 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 0657 target date of 01/05/23. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #7's face sheet, dated 06/14/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, dementia, psychotic disorder with delusions, major depressive disorder, high cholesterol, and high blood pressure. Residents Affected - Some Record review of Resident #7's Quarterly MDS, dated [DATE], revealed no BIMS as the resident is rarely/never understood. Record review of Resident #7's EHR care plan tab revealed Resident #7's most recent care plan was completed on 03/10/23. Record review of Resident #7's care plan, dated 03/10/23, revealed 24 goals. 20 of the 24 goals were initiated in 2022, revised on 03/10/23, and had a target date of 05/18/23. Three of the goals were initiated in 2020, revised on 03/10/23, and had a target date of 05/18/23. One of the goals was initiated on 03/10/23 with a target date of 01/15/23. Record review of Resident #8's face sheet, dated 06/14/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, dementia, anxiety disorder, and psychotic disorder with delusions. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed a BIMS of 5 out of 15 which indicated severe cognitive impairment. Record review of Resident #8's EHR care plan tab revealed Resident #8's most recent care plan was completed on 04/18/23. Record review of Resident #8's care plan, dated 04/18/23, revealed 18 goals. The care plan revealed the last revision date for 17 of the 18 goals was 04/07/23. The other goal was revised on 01/04/23. All 18 goals had a target date of 04/03/23. During an interview on 6/14/23 at 6:44 PM with RN E via phone stated facility utilizes the RAI and state regulations as a policy for care plans and MDS timing. RN E states she is mostly responsible with another corporate RN assisting. RN E states RN D assists with updating care plans as needed in the facility. RN E states there is not a time coordination between MDS and care plans. RN E stated a baseline care plan is due within 48 hours. Care plans are to be completed by day 21 or 7 days of initial MDS and quarterly after 92 days unless a significant change has occurred. RN E stated there is not a negative outcome for completing a care plan prior to completing an MDS. RN E stated the facility may do an update at any time. The facility can initiate the care plan before MDS because it is always in progress and things are resolved or active. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 19 of 19