Health inspection·May 30, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 05/28/2025 at 3:18 PM, Resident #63 was observed to be asleep, sitting in w/c in common area by the television in the locked unit. Observation of Resident #63's catheter bag without a privacy bag. During an interview on 05/30/2025 at 9:03 AM, CNA L stated she worked on the locked unit and started at the facility 2 months ago. She stated that residents should always have a privacy bag covering their catheter bags. CNA L stated that it was everyone's responsibility for making sure privacy bags were on resident's catheter bags, but the nurses were supposed to bring privacy bags and she stated she felt they could do a better job at doing this. CNA L stated that it was the facilities policy to have privacy bags on catheter bags and a possible negative outcome for them not having one could be a dignity issue - no one was supposed to see resident's urine. During an interview on 05/30/2025 at 9:07 AM, the ADON (the nurse for Resident #63 this shift) stated that if a resident with a catheter does not have a privacy bag, it was definitely a dignity issue. The ADON stated that it was everyone's responsibility to make sure that privacy bags are on, but mainly the nurses. She stated it was their policy to have a privacy bag on all catheter bags and a negative outcome for not having them on would be a violation of resident's dignity and rights. During an interview on 05/30/2025 at 9:27 AM, the DON stated that it was everyone's responsibility to make sure that privacy bags were on catheter bags. She stated it was the policy of the facility to have privacy bags on all catheter bags and a possible negative outcome for this not happening could be dignity of the resident would be violated and visitors could see it. Record review of facility provided policy titled, Catheter Care, Male dated 06/2024 revealed in part: Purpose: It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care using proper technique while maintaining the resident's privacy and dignity. No pertinent information concerning the use of privacy bags. Record review of facility provided policy titled, Resident Rights dated 10/2022 revealed in part . 1. Resident Rights. The resident has the right to a dignified existence. 5. Respect and Dignity. The resident has a right to be treated with respect and dignity . 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 05/30/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 24 residents (Resident #117) reviewed for environment. -Resident #117 had his evening meal tray left in his room until the next AM. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: Record review of Resident #117's clinical record revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include myocardial infraction (heart attack), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (a chronic condition in which the heart dose not pump blood as well as it should), basal cell carcinoma of the skin (cancer that begins in the lower part of the epidermis (the outer layer of the skin), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #117's clinical record revealed his last MDS was an admission completed 04/24/25 listing him with a BIMS score of 05 indicating he was severely cognitively impaired, and he had a functionality of requiring supervision/touching assistance with most of his activities of daily living. Record review of Resident #117's clinical record revealed a care plan with the admission date of 04/18/25, which revealed the following: Focus: o Resident is at risk for alteration in nutrition r/t dx: COPD. Is on Regular diet/mechanical soft texture/thin liquids. Date Initiated: 04/21/2025. Interventions: o Encourage resident to eat all food served on meal tray. Assist as needed. Date Initiated: 04/21/2025 During an observation and interview on 05/28/25 at 08:45 AM Resident #117 was observed in his room in his bed under his covers. Resident #117 was sleeping well and did not wake to knocking or introduction. On the bedside table was Resident #117's dinner tray with a ticket that documented Dinner 05/27/25. The plate was covered and when uncovered noted grilled chicken, broccoli, noodles, and a roll. Also noted was a cobbler desert still covered, and the tea drink. None of the meal had been eaten. During an observation on 05/28/25 at 09:54 AM Resident #117 was not present in his room but his (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 05/30/2025 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 0584 dinner meal tray from 05/27/25 was still on the bedside table in the same condition. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 05/28/25 at 10:21 AM Resident #117's dinner tray from 05/27/25 was still present in his room. This surveyor asked CNA H (the CNA responsible for Resident #117 this shift) to entered Resident #117's room. Resident #117 was present and awake but did not respond to our presence or when spoken to by this surveyor. CNA H confirmed that Resident #117's meal tray was his dinner tray from the previous evening, that it should not be present, and that it should have been picked up 1 hour after the evening meal was delivered. CNA H stated that the evening meal was at 5:00 PM and the hall trays were delivered between 5:45-6:00 PM. CNA H stated that the tray left in the residents' room could be an issue because he could eat it, become sick, or it could attract bugs, or another resident could eat it. CNA H stated that staff were to make rounds every two hours and that she had just missed the meal tray this shift. Residents Affected - Few During an interview on 05/29/25 at 08:32 AM the DON stated that all meal trays delivered to resident rooms should be picked up within 30-40 minutes after delivery or at minimum 1 hour after they were delivered. The DON stated that all staff should make rounds, especially the CNA's, every 2 hours and check each resident's room. The DON stated that if a meal tray were left in a resident room for 15 hours, that resident could eat it thus making that resident sick, or any resident could eat it making them sick. During an interview on 05/30/25 at 08:38 AM SC I stated that a resident's tray should not be left in their room for more than one hour after the tray had been delivered and that a tray left overnight could result in that resident or another resident eating food that could make them sick or the food could attract bugs. During an interview on 05/30/25 at 08:40 AM RN J (the nurse for Resident #117 this shift) stated that a residents meal tray should not be left in the resident's room overnight, that it should be picked up within one hour after it was delivered. If the tray is left out over time it could result in an infection if it grew bacteria and a resident ate it. Record review of the facility provided policy titled, Serving and Cleaning Up Room Trays in Long-Term Care undated, revealed the following: Purpose: To ensure safe, sanitary, and respectful delivery and removal of meal trays served in resident rooms, in accordance with CMS, infection control . Policy Statement: All room trays will be delivered and picked up by trained staff in a manor that preserved food safety, upholds resident dignity, and prevents the spread of infection. 3. Cleaning Up Room Trays: - Return promptly after meal service (within 1 hour) to collect trays. 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 05/30/2025 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 interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 24 residents reviewed for accuracy of assessments. Residents Affected - Few Resident #1 had an active order for oxygen at 3 lpm via NC to maintain Oxygen sats above 90% dated 03/14/2025 and his MDS with a completion date of 05/08/2025 did not indicate he received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer in the lungs or airways in the lungs where the specific location or type is not specified), panlobular emphysema (rare form of emphysema which are sacs in the lung can't switch oxygen and carbon dioxide leaving a person breathless, panlobular is a type of emphysema characterized by the destruction of the entire acinus (a cluster of air sacs, or alveoli) in the lung), and pulmonary embolism (clot blocking blood flow to lungs). Record review of Resident #1's quarterly MDS completed on 05/03/2025 revealed a BIMS of 06 which indicated severely impaired cognition. Section O of the MDS revealed Resident #1 was not receiving oxygen On Admission or While a Resident. Record review of Resident #1's care plan with a completion date of 05/07/2025 revealed a focus area of The resident has oxygen therapy r/t Ineffective gas exchange. Resident will maintain O2 sats >90% through next review date. This focus area was initiated on 06/22/23 and revised on 02/2/2024. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @3L/Min via NC to maintain O2 sats>90%. This intervention was initiated on 02/20/2024 and revised on 03/17/2025. Interventions for this focus area stated, resident was encouraged to keep his O2 on at all times and be given medications as ordered by physician. Record review of Resident #1's active order report dated 05/28/2025 revealed the following order: Oxygen at 3L/min via NC to maintain 02 sat>90% every shift . This order had a start date of 03/14/2025 and no end date. Record review of Resident #1's MAR dated 05/01/2025-05/30/2025 revealed Resident #1 was receiving O2 @ 3 lpm via NC to maintain O2 sats > 90% every day, with a start date of 3/14/2025. According to the MAR, Resident #1's O2 sats were being checked morning and evening throughout the month of May. Record review of Resident #1's O2 Sats Summary revealed 32 entries for the 14 days prior to completion of Resident #1's most recent MDS. Of those 32 entries, Resident #1 was receiving O2 31 times and was on room air 1 time. (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 05/30/2025 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 During an interview on 05/30/2025 at 9:16 AM, the DON stated she was the interim DON but had been doing the job of MDS director for one year. She stated she followed the RAI as her policy for completing MDS Assessments and it was her responsibility to make sure MDS's are accurate. The DON stated that a possible negative outcome for a resident not having an accurate MDS assessment could be that the care that they need would not be available for the nurses on the floor. She also stated that an incorrect MDS could affect the facilities funding and it could then affect the care a resident receives. During an interview on 05/30/2025 at 9:29 AM, the ADM stated that the facility used the RAI to fill out residents MDS assessments. She stated a possible negative outcome for not having an accurate MDS could result in an inaccurate care plan and resident could miss services as well as affect funding. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days. 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 05/30/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #1) of 24 residents reviewed for respiratory care. Residents Affected - Few Resident #1 had orders for oxygen at 3 liters per minute and was observed to have an empty oxygen tank for an hour while in the dining area. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer in the lungs or airways in the lungs where the specific location or type is not specified), panlobular emphysema (rare form of emphysema which are sacs in the lung can't switch oxygen and carbon dioxide leaving a person breathless, panlobular is a type of emphysema characterized by the destruction of the entire acinus (a cluster of air sacs, or alveoli) in the lung), and pulmonary embolism (clot blocking blood flow to lungs). Record review of Resident #1's quarterly MDS completed on 05/03/2025 revealed a BIMS of 06 which indicated severely impaired cognition. Record review of Resident #1's care plan with a completion date of 05/07/2025 revealed a focus area of The resident has oxygen therapy r/t Ineffective gas exchange. Resident will maintain O2 sats >90% through next review date. This focus area was initiated on 06/22/23 and revised on 02/2/2024. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @3L/Min via NC to maintain O2 sats>90%. This intervention was initiated on 02/20/2024 and revised on 03/17/2025. Interventions for this focus area stated, resident was encouraged to keep his O2 on at all times and be given medications as ordered by physician. Record review of Resident #1's active order report dated 05/28/2025 revealed the following order: Oxygen at 3L/min via NC to maintain 02 sat>90% every shift . This order had a start date of 03/14/2025 and no end date. Record review of Resident #1's MAR dated 05/01/2025-05/30/2025 revealed Resident #1 was receiving O2 @ 3 lpm via NC to maintain O2 sats > 90% every day, with a start date of 3/14/2025. According to the MAR, Resident #1's O2 sats were being checked morning and evening throughout the month of May. Record review of Resident #1's O2 Sats Summary revealed 32 entries for the 14 days prior to (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 05/30/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completion of Resident #1's most recent MDS. Of those 32 entries, Resident #1 was receiving O2, 31 times and was on room air 1 time. During an observation on 05/28/2025 at 10:32 AM, Resident #1 was sitting in his w/c at a table in the common area of the locked unit. Resident #1 had nasal cannula in nose with an oxygen tank on the back of his w/c that registered 3 lpm, tank was empty. During an interview on 05/28/2025 at 11:15 AM, Resident #1's family member stated that he receives continual oxygen. During an observation on 05/28/2025 at 11:32 AM, Resident #1 was sitting at dining room table with nasal cannula in nose, O2 tank was observed as being empty. During an observation on 05/28/2025 at 11:37 AM, nursing staff were observed to change out empty tank for Resident #1. During an interview on 05/30/2025 at 8:53 AM, CNA K stated she had worked in the facility for 3 months on the locked unit and that the nurses were responsible for changing out oxygen tanks for residents. She stated that a possible negative outcome for a resident to be without oxygen for an hour could be delusion or behaviors, worst case could be passing out or death. CNA K stated that when residents have dementia, many already have behaviors, so going without oxygen could make the behaviors and delusions a lot worse. During an interview on 05/30/2025 at 9:08 AM, the ADON (the nurse for Resident #1 this shift) stated that everyone was responsible for keeping eyes on oxygen tanks, but the nurses were responsible for changing them out. She stated a possible negative outcome for a resident running out of oxygen for an hour could be a big change of condition, they could go unconscious or unresponsive which could lead to death. The ADON also stated that behaviors could change, and an hour with no oxygen could result in bad issues happening for the resident. During an interview on 05/30/2025 at 9:24 AM, The DON stated that the nurses were responsible for changing out oxygen tanks. She stated all nursing staff were supposed to check on levels on tanks during their rounds. The DON stated a possible negative outcome for a resident to be off their oxygen for an hour could be mental status and cardiovascular changes that could affect their health. Record review of facility policy titled, Oxygen Administration and dated February 2015 revealed the following in part: Policy: Correct technique and standards of practice will be used with oxygen administration. Procedure: 1. Check the physician's order for the flow rate and the method of administration. 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 05/30/2025 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 observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 6 residents (Residents #97) who was observed for medication administration. -RN D administered medication to Resident #97 via nebulizer and left Resident #97 unattended. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Findings included: During an observation on 05/29/25 at 08:45 AM Resident #97 was lying in his bed with a nebulizer treatment going and no staff was present in room with the resident. Record review of Resident #97's face sheet, dated 05/29/2025, revealed Resident #97 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of heart failure (heart muscle doesn't pump blood as well as it should), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), pulmonary hypertension due to lung diseases and hypoxia (high blood pressure in your pulmonary arteries, which carry oxygen-poor blood from your heart to your lungs), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (a transient episode of neurologic dysfunction due to the focal brain, spinal cord, or retinal ischemia without acute infarction or tissue injury). Record review of Resident #97's MDS assessment, dated 03/14/2025, revealed that Resident 97 had a BIMS score of 09 which indicates that Resident #1 was moderately cognitively impaired. Resident #97's required supervision assistance with bathing; all care areas are supervision or set-up assistance needed only. Record review of Resident #1's care plan, dated 03/25/2025 revealed the following: Focus o Risk for Ineffective Airway Clearance r/t Respiratory Failure Date Initiated: 09/06/2024 Revision on: 09/06/2024 Goal (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 05/30/2025 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 o Resident Will Maintain Airway Level of Harm - Minimal harm or potential for actual harm Patency Date Initiated: 09/06/2024 Residents Affected - Few Target Date: 03/19/2025 Interventions o Administer nebulizer treatment, per order Date Initiated: 09/06/2024 o Educate Resident / Representative on energy conservation techniques Date Initiated: 09/06/2024 o Encourage ambulation Date Initiated: 09/06/2024 o Encourage participation in coughing, deep breathing and forced expiratory techniques, as ordered Date Initiated: 09/06/2024 o Ensure proper position for optimal breathing Date Initiated: 09/06/2024 o Evaluate for cough Date Initiated: 09/06/2024 o Evaluate for shortness of breath Date Initiated: 09/06/2024 o Evaluate hydration status including: skin turgor, mucous membranes and tongue Date Initiated: 09/06/2024 o Evaluate lung sounds Date Initiated: 09/06/2024 o Evaluate pulse oximetry (continued on next page) 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 05/30/2025 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 Date Initiated: 09/06/2024 Level of Harm - Minimal harm or potential for actual harm o Evaluate respiratory rate and effort Date Initiated: 09/06/2024 Residents Affected - Few o Provide oxygen as indicated by Resident condition and / or provider order Date Initiated: 09/06/2024 Record review of Resident #97's electronic medication record, dated, 05/29/2025, revealed Resident #97 received Ipratropium-Albuterol Inhalation solution 0.5-2.5 (3) MG/3ML (Ipratropium-albuterol) 1 vial inhale orally three times a day related to Chronic Obstructive Pulmonary Disease, Unspecified (J44.9)-Start Date-09/01/2024 Record showed that medication was provided to resident at 08:00am. During an interview on 05/29/25 at 08:56 AM Resident #97 was asked about his nebulizer treatment, and Resident #97 was unable to state if the nurses stay with him during his treatment or not. During an interview on 05/29/25 at 08:57 AM Roommate of Resident #97 stated that they just put it (nebulizer mask) on him (Resident #97) and leave. During an interview on 05/29/25 at 10:39 AM LVN D stated I put it on him and then went to go and do something else, but he is always supervised. LVN D stated the negative outcome would be that the resident would not finish the medication or get the whole medication. During an observation on 05/29/25 at 01:39 PM Resident #97 had his nebulizer treatment mask on and receiving a treatment, no nurse or staff present during medication administration. During an interview on 05/30/25 at 08:39 AM DON stated the negative outcome for not staying with a resident during a nebulizer medication administration could be the resident would not receive all of the medication or have an adverse reaction. Record review of facility provided policy titled, Nebulizer Therapy, dated May 2025, revealed no information related to this event. Record review of facility provided policy titled, Medication Administration, dated October 2012, revealed no information related to this event. 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 05/30/2025 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #20) of 24 residents reviewed for medication storage. The facility failed to ensure Resident #20 did not have access to 650 mg acetaminophen capsules. This failure could place residents at risk of injury due to ingesting non-prescribed medications. Findings Included: Record review of Resident #20's admission record dated 05/28/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), unspecified glaucoma (eye condition that damages optic nerve and can lead to vision loss or blindness), major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and unspecified dementia severe with agitation (decline in cognitive function and increase in behavioral disturbances such as restlessness, irritability, or aggression). Record review of Resident #20's quarterly MDS completed on 03/31/25 revealed the following: Section C Cognitive Patterns revealed Resident #20 had a BIMS score of 8 which indicated moderate cognitive impairment. Section GG Functional Abilities revealed Resident #29 needed supervision or touching assistance across all ADLs except for eating and rolling left to right for which he needed only set up or clean up assistance. Record review of Resident #20's care plan completed on 04/14/25 revealed he had impaired cognitive function/dementia or impaired thought processes r/t Dementia. The care plan revealed no mention of Resident #20 being allowed to administer acetaminophen to himself as needed. Record review of Resident #20's active orders as of 05/28/25 revealed no order for self-administering medication and no order for acetaminophen. During an observation and interview on 05/28/25 at 11:03 AM Resident #20 was seated on the edge of his bed. He stated he had pounding headaches often and when he asked staff for an aspirin, they told him he would need doctor orders for any medication. He expressed his disgust with this and reached over to open the bottom drawer of his nightstand. Resident #20 pulled out a bottle of acetaminophen 650 mg capsules, shook it, and stated, I don't have time for that. This is my doctor. He stated he took one pill and it usually helped with his headaches but sometimes he had to take two pills. During an observation on 05/29/25 at 10:20 AM the bottle of acetaminophen was in the bottom drawer (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 05/30/2025 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 of Resident #20's nightstand. It appeared to be ¾ full of capsules. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/30/25 at 08:57 AM RN J stated nurses and CMAs were the only people allowed to administer medications to residents. She stated if it was care planned, a resident was allowed to have over the counter medication at their bedside. She stated if a resident was not care planned to self-administer medication, They could be taking too much. Residents Affected - Few During an interview on 05/30/25 at 09:25 AM MA M stated nurses and medication aides were the only people allowed to administer medications to residents. She stated some residents had orders to self-administer medications and it was in the residents' care plan. She stated a resident could be negatively affected by having medication in their possession without a care plan or an order to do so. During an interview on 05/30/25 at 09:35 AM DON stated a nurses or CMAs were responsible for administering medications to residents. She stated residents were allowed to keep medications in their rooms sometimes. DON stated, They would do a medication administration test with us, tell us what it (the medication) is and how often they take it and how to use it. She stated if a resident was allowed to have medication in their room it would be in their care plan. She stated if a resident had medication in their room and it was not care planned it could result in medication error or overuse. She stated she was not aware Resident #20 had acetaminophen in his room. She stated staff did regular sweeps to keep that kind of thing from happening but residents could purchase their own over the counter medications or family members could bring said medications to the residents. During an interview on 05/30/25 at 10:23 AM ADM stated Resident #20 was very angry when staff attempted to remove his bottle of acetaminophen. She stated she told staff to give him time to cool off. ADM stated, Then we will get with him and see if he can tell us how to use, how much to use, and then care plan him for having the medication. Record review of facility policy titled Medication Storage and dated June 20, 2023, revealed the following: . It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy, medication rooms, and/or medication carts according to the manufacturer's recommendations . For residents who self-administer and maintain possession of their medications refer to the policy for self-administration. a. All drugs and biologicals will be stored in locked compartments . b. Only authorized personnel will have access to the locked compartments. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides are allowed access to medications. Record review of facility policy titled Self-Administration of Medications and dated March 2021 revealed the following: . A resident may only self-administer medications after the interdisciplinary team has determined which medications may be safely self-administered. 4. Lockable drawers are required to store medications in the resident's room. 6. The resident's care plan will reflect their desire and ability to self-administer medications. 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 05/30/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure [NAME] F and [NAME] G 's hands were washed and gloves were changed during preparation of food. 2. The facility failed to ensure [NAME] E wore beard covers while in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an interview and observation on 5/28/25 at 11:30 am, [NAME] F was observed in the kitchen prep area using the blender to chop meat for the mechanical soft diets. [NAME] F picked up meat patties with her gloved hands and tore meat apart with her gloved hands. [NAME] F put the meat into the blender, then touched the blender buttons, blender lid and kitchen utensils. [NAME] F picked up a container and moved it to the blender. [NAME] F picked up the blender container. [NAME] F removed the lid and used a spatula to scrape meat into the prepared pan. [NAME] F then picked up more meat patties with her gloved hands. [NAME] F tore the meat patties up with her gloved hands and put the meat into the blender. [NAME] F did not change gloves or wash hands during this activity. [NAME] F stated she used her hands because it was easier to break up the food with hands rather than stop and cut it up. She stated I should have used tongs to pick up the meat. I should have changed my gloves. The DM was present and stated the staff should use tongs for everything. She stated she should have also changed gloves between tasks. In an interview and observation on 5/28/25 at 11:36 am, [NAME] E was observed walking into the kitchen with no beard cover on his face. [NAME] E went to the back of the kitchen. [NAME] E stated he was supposed to wear a beard cover while in the kitchen. He stated the consequences of no beard cover would be food borne illnesses. In an observation on 5/28/25 at 11:50 am, [NAME] G was observed in the kitchen prep area with gloved hands. [NAME] G took temperatures of food then opened the steamer oven and took out a pan of zucchini. [NAME] G poured the pan of zucchini into a different serving pan and used his gloved hand to scoop out the remainder of zucchini into the serving pan. [NAME] G put the pan down and walked to the freezer, opened the freezer door, picked up a box of frozen meat patties, carried the box to the prep counter and opened the box. [NAME] G picked up a handful of meat patties from the box. [NAME] G walked to the fryer and put the meat patties into the fryer using his gloved hand. [NAME] G picked up a second handful of meat patties with his gloved hand and put them into the fryer. [NAME] G did not change his gloves or wash his hands. In an observation on 5/28/25 at 12:00 pm, [NAME] G went to the freezer, opened the freezer door, got hamburger patties, and put the patties on a plate with his gloved hands. [NAME] G opened the hamburger bun package and took out the hamburger buns, picked up the butter spatula and put butter on the buns. [NAME] G placed the buttered buns on the griddle with his gloved hand, then put his gloved (continued on next page) 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 05/30/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hand inside the bread wrapper and pulled out bread. [NAME] G picked up the butter spatula and buttered the bread, then put the bread on the griddle. [NAME] G went to the walk-in cooler, opened the door and brought out a package of cheese. [NAME] G unwrapped the cheese and placed cheese slices on the bread on the griddle, picked up a spatula, turned meat patties, took out more cheese from the package, put the cheese slices on the meat, touched the meat, took out ham from a package and put the ham on the grill with his gloved hands. [NAME] G did not change his gloves or wash his hands during this time. In an observation on 5/28/25 at 12:05 pm, [NAME] G picked up a clean pan, walked to the griddle picked up a spatula, slid the spatula under a sandwich, used his gloved hand to slide the sandwich off the spatula, picked up another pan and used his gloved hands to pick up the sandwiches and put the grilled sandwiches into a serving pan. [NAME] G did not change his gloves or wash his hands. In an observation on 5/28/25 at 12:10 pm [NAME] G looked at pages in a menu book, touched pans and kitchen surfaces, adjusted the knobs on the stove, opened the doors of the steamer oven, opened the freezer door, brought out a box of frozen meat, opened the box of meat, then took out the frozen meat patties with his gloved hands and put the meat patties into the fryer. [NAME] G did not change his gloves or wash his hands. In an interview on 5/29/25 at 10:00 am [NAME] G stated he should have changed his gloves and washed his hands when changing tasks and touching food during the lunch meal on 5/28/25. He stated he was busy and just forgot. He stated the consequences for residents would be food borne illness. In an interview on 5/30/25 at 10:10 am, the DM stated she had trained the staff on the use of hair restraints and hand washing. She stated she expected all staff to have all hair and beard covers on at all times and she expected staff to wash hands and change gloves between tasks. She stated the consequences of not having a beard cover or changing gloves and washing hands between tasks would be food borne illnesses and could make residents sick. Record Review of the policy dated October 2018 titled Employee Sanitation documented: Hairnets, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Employees must wash hands and exposed portions of their arms before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapping single service and single use foods . when switching between working with raw food and working with ready to eat foods, during food preparation including working with exposed food, clean equipment, and utensils. Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves. Use single use gloves for one task. Change gloves between each food preparation task, after touching items, utensils or equipment not related to task, when leaving the food prep area for any reason, when damaged soiled or when interrupted, every hour for all tasks taking longer than one hour. Do not store gloves in pockets or apron. Record Review of the policy dated October 2018 titled Handwashing documented: Hands should be washed after the following occurrences: handling raw food, touching un-sanitized equipment, work surfaces, changing tasks. 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 05/30/2025 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 9 of 32 residents (Resident #22, #35, #11, #70, #51, #25, #58, #107, and Resident #9) reviewed for infection control. Residents Affected - Some -CNA A failed to use proper hand hygiene techniques in between assisting Resident #22, #35, #11, #70, and Resident #51 with cutting up their food. -CNA B failed to use proper hand hygiene techniques when assisting Resident #107 to eat after assisting Resident #9 with the cutting up of his meal. -CNA C failed to use proper hand hygiene techniques when assisting Resident #25 to eat after assisting Resident #9 to sit up in his wheelchair. This failure could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/28/25 at 12:25 PM CNA A was cutting up Resident # 22 chicken fried steak, CNA A then went to Resident # 35 to assist her with cutting up her steak, No HH was performed between these 2 residents. CNA A went to Resident # 11 to cut up his steak and then went to Resident # 70, no HH was performed between these 2 residents. CNA A proceeded to touch her hair and then went to assist Resident # 51 to cut up his steak, no HH was performed before touching Resident #51's eating utensils after touching her hair. During an observation on 05/28/25 at 12:44 PM CNA C was assisting Resident # 25 with eating her lunch and then got up to assist another Resident # 58 with cutting up his steak and then returned to feeding Resident #25, no HH was performed before or after assisting Resident #25 or Resident #58. During an observation on 05/28/25 at 12:46 PM CNA B was assisting Resident # 107 with eating, CNA B went to help another staff member move Resident # 9 to sit up more in his Geri-chair, then went back to assist Resident #107 with eating. No HH was performed before or after performing these tasks with either resident. During an interview on 05/28/25 at 02:34 PM CNA B was asked why HH was not performed when assisting a resident to eat, she stated, I didn't think about it, there could have been anything on his w/c. CNA B stated the negative outcome would be infection control. During an interview on 05/28/25 at 03:11 PM CNA A was asked why HH was not performed when assisting residents with the cutting up of their meals, CNA A stated, I wasn't thinking, I just wanted to get it done. CNA A was asked what a negative outcome would be she stated, There isn't one. During an interview on 05/28/25 at 03:14 PM CNA C was asked why HH was not performed, CNA C stated, it flew my mind. CNA C stated a negative outcome was there could be an infection control issue. (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 05/30/2025 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 During an interview on 05/30/25 at 08:39 AM DON stated a negative outcome for not performing HH could lead to an increased risk of infection for the residents. Level of Harm - Minimal harm or potential for actual harm Record review of facility provided policy titled, Handwashing, dated 2013, revealed the following: Residents Affected - Some .After handling soiled equipment or utensils. During good preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. .After in engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 17 of 17