Health inspection·November 30, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #28's physician order summary, dated 10/10/22, revealed an order Do Not Resuscitate - DNR dated 10/10/22. Record review of Resident #28's care plan, dated 06/09/22, revealed care plan for Advance Care Plan: No CPR, Hospice Care. Residents Affected - Some Record review of Resident #28's Out of Hospital Do Not Resuscitate form dated 08/04/20 revealed under Physician's Statement revealed no information. Under F. Directive by two physicians, the attending physician's signature is filled out and the date, but no printed name or license number is provided, nor is a second physician's information provided. Record review of Resident #34's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (memory loss) , bilateral cataract (clouding of eye lens in both eyes), difficulty walking, anxiety, major depressive disorder, and hypertension (high blood pressure). Record review of Resident #34's physician order summary, dated 10/06/22, revealed an order Do Not Resuscitate - DNR dated 10/23/19. Record review of Resident #34's care plan, dated 11/11/21, revealed care plan for Advance Care Plan: No CPR. Record review of Resident #34's Out of Hospital Do Not Resuscitate form dated 10/23/19 revealed under Physician's Statement revealed no license number, date or printed name. Furthermore, the date of birth for the resident was marked 11/04/19218. Record review of Resident #39's (dated 11/28/22) face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, insomnia( problems falling and staying asleep), depression and obesity. Record review of Resident 39's physician order summary dated for November 2022 revealed an order ADC: Do Not Resuscitate - DNR dated 11/03/22. Record review of Resident #39's care plan, dated 02/06/22, revealed care plan for DNR started 2/16/22. Record review of Resident #39's Out of Hospital Do Not Resuscitate form dated (undated) revealed under Physician's Statement revealed no date. Record review of another copy provided of Resident #39's Out of Hospital Do Not Resuscitate form dated (undated) revealed under Physician's Statement revealed no date, license #, printed name or signature. Under directive by two physicians there is one signature (not the same physician signature from the first document). There was no notary or witness signatures. Record review of Resident #41's face sheet revealed an [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include achalasia cardia (rare disorder that causes food to collect in the mouth and causes difficulty in swallowing) and Parkinson's ( central nervous system disease). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 2 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #41's physician order summary dated for the month of November 2022 revealed an order ADC: Full Code dated 10/13/22. Record review of Resident #41's care plan, dated 10/26/22, revealed a care plan for DNR that started 10/25/22. Residents Affected - Some Record review of Resident #41's Out of Hospital Do Not Resuscitate form dated 10/12/21 revealed the form was completed correctly. During an interview on 11/30/22 at 10:00 AM, the Administrator said a DNR is a do not resuscitate order, and the business office manager was responsible for initiating the process upon admission. She said the business office manager would get the signatures from the Resident, family, and witness and send the document to the physician. She said that she was taught that once the physician signs it, then the document is valid. She said with the physician's signature and the presence of the second page, it was safe to place it in the resident's chart. She said she expected the DNR to be placed in the chart once it is complete in its entirety. She said that the DON and the Administrator are ultimately responsible for ensuring that the DNRs are complete. When asked what makes a DNR valid, she said that the out-of-hospital DNR order is effective with signatures. When asked for clarification, she said that the form must be completed in its entirety. When asked about the physician's order, she said the actual paper copy is an order. When asked why some of the residents have a separate order vs. some do not, she said that it is her expectation for the facility to be consistent and that all residents have both but that the staff should be looking at the paper copy, not the physician order. When told that both nurses interviewed reported that they checked the order first, she said she was now aware of an issue with the system. She said she was not aware that there were incomplete DNRs. When asked about multiple versions being in different areas of the facility (electronic medical record, green binder in ADON office, and the physical chart at the nurses' station), she said that this results in the incompletion of the DNR process. She said there was no specific reason why the DNRs were not complete. When asked what would be a negative outcome for an incomplete DNR, she initially said none, but when asked for clarification, she said she did not believe that there would be a negative outcome because her staff would still do CPR if they knew that this was the wishes of the resident. During an interview on 11/30/22 at 10:08 AM, the DON stated DNR means do not resuscitate. She said that she and the Administrator were ultimately responsible for completing the resident DNRs. She stated that the process for a DNR is usually initiated upon admission. She said the business office manager starts the process and obtains the signature from the resident and the notary. She said the document was sent to the physician for a signature. Once the physician signs it, it is scanned and physically placed in the chart. She said the following made a DNR valid in their facility: Signature, physician signature, and date, witness signatures and dates or notary. She said the DNR should be located in the residents' medical record. She said there are 27 residents that wish to have an active directive of do not resuscitate. She said she was unaware there were residents whose DNR paperwork was incomplete. When asked why there were multiple versions of the incomplete DNRs in the facility and how this may affect the resident, she said that this result is incompletion. When asked what she meant by this, she said that the system for DNRs in the facility is incomplete and that there were multiple versions because the DNRs were not being updated. She said there was no specific reason why the DNR was not completed correctly. She initially said there was no adverse outcome to the resident DNR not being completed in its entirety but then said that the resident may not get their wishes for end a life carried out. She said her expectation is for the DNR form to be completed correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 3 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/30/22 at 10:10 AM, the ADON said a DNR was a piece of paper that tells others that you do not want to be resuscitated. She said that the BOM initiates the DNR process upon admission. She said that she is responsible for DNRs at the facility but that the Medical Doctor (MD) is responsible for ensuring the form is completed correctly according to Health and Human Services. She said that the MD signature is what makes the DNR valid. She responded yes when asked if there was no separate order for the DNR and whether the paper copy was valid. She said the medical staff uses the DNR. She clarified that only the nurses do CPR at the facility. She said the DNR could be found in either the electronic medical record or the paper chart of the green binder in her office. When asked what the outcome of having multiple versions in multiple places in the facility is, she said that she believed that having multiple versions was necessary and that them not being all correct and updated was her failure. When asked if there was a particular reason why the DNRs were not updated and completed correctly, she said that she did not review them or ask anyone else to review them before filing them in the residents' chart. She said generally, the Administrator would review the DNR before she would process it. She said recently, when the DNR was given to her; she would not check for anything but the MD signature. When asked about the negative outcome of not having the form completed correctly, her response was that if medical staff see a DNR on a resident's chart, they will not perform CPR regardless of whether the date is on there. During an interview on 11/30/22 at 10:33 AM, LVN C stated if a resident coded (cardiac arrest) that, her first place of reference was to check the doctor's orders. She said if the resident did not have a physician order for DNR, she would administer CPR as that person would be considered a full code. She said that if they administered the wrong end-of-life wishes, she would be upset if she was brought back, but if it was a resident that was the opposite, the resident would not know, but the family might be upset to learn that CPR was not administered. During an interview on 11/30/22 at 10:45 AM, RN A said that if a resident coded (cardiac arrest), she would check the orders and then proceed to check the chart. She said that she was taught to always look at the orders. She said when checking the chart, she checked to ensure that the appropriate signatures are there. She said if she saw that not all appropriate signatures were there, she would start CPR. She said the DNR is not complete without all appropriate signatures. She said if the right end-of-life wishes are not carried out, this could upset the family. Record review of the facility policy, Do Not Resuscitate (DNR) Order, Revised April 2017, revealed the following documentation: Applicability: this policy sets forth the procedures relating to DNRs Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 4 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 2. Level of Harm - Minimal harm or potential for actual harm A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. Residents Affected - Some 6. The interdisciplinary care planning team will review advance directives with the resident during a quarterly care planning session to determine if the resident wishes to make changes in such directives. Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. This Order does NOT affect the provision of other emergency care, including comfort care. APPLICABILITY: This OOH-DNR Order applies to health care professionals in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C. Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR Order in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D. Section E - If the person is a minor (less than [AGE] years of age), who has been diagnosed by a physician as suffering from a terminal or irreversible condition, then the minor's parents, legal guardian, or managing conservator may execute the OOH-DNR Order by signing and dating it in Section E. Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 5 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in Section F with concurrence of a second physician (signing it in Section F) who is not involved in the treatment of the person or who is not a representative of the ethics or medical committee of the health care facility in which the person is a patient. In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. REVOCATION: An OOH-DNR Order may be revoked at ANY time by the person, person's authorized representative, or physician who executed the order. Revocation can be by verbal communication to responding health care professionals, destruction of the OOH-DNR Order, or removal of all OOH-DNR identification devices from the person. AUTOMATIC REVOCATION: An OOH-DNR Order is automatically revoked for a person known to be pregnant or in the case of unnatural or suspicious circumstances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 6 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 8 of 18 residents (Residents #4, #12, #15,#17, #18,#34, #36, and #39) reviewed for care plans as follows: 1. Resident #4 did not have a care plan for visual function. 2. Resident #12 did not have a care plan for communication pattern. 3. Resident #15 did not have a care plan for urinary incontinence and dental care. 4. Resident #17 did not have a care plan for visual function. 5. Resident #18 did not have a care plan for visual function. 6. Resident #34 did not have a care plan for visual function. 7. Resident #36 did not have a care plan for cognitive loss, visual function and communication. 8. Resident #39 did not have a care plan for visual function, urinary incontinence, and pressure ulcer. These failures could place residents at risk of not receiving the care required to meet their needs. Findings include: 1. Record review of Resident #4's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, dizziness, and psychotic disorder with delusions. Record review of Resident #4's care plan, dated 11/13/22, revealed no care plan for vision impairment. Record review of Resident #4's annual Minimum Data Set assessment, dated 10/26/22, revealed: The Brief Interview for Mental Status score was 0 out of 15, which indicated the resident's cognition was severely impaired. The Care Area Assessment (CAA) Summary triggered for visual function. Resident #4's vision was indicated as impaired. The resident can see large print, but not regular print in newspapers or books. 2. Record review of Resident #12's (11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include gastro-esophageal reflux disease (risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 7 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 stomach acid going back and forth between the mouth and stomach), cirrhosis of the liver( chronic liver damage), and chest pains. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #12's care plan, dated 10/03/22, revealed no care plan for communication. Residents Affected - Some Record review of Resident #12's admission Minimum Data Set assessment, dated 09/26/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 04. Communication Section B Hearing, Speech, Vision B0600 Speech Clarity-Enter Code: 0 - Clear Speech - distinct intelligible words. B0700 Make Self Understood-Enter Code: 0 - Understood B0800 Ability To Understand Others-Enter Code: 0 - Understands - clear comprehension. 3. Record review of Resident #17's undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include fracture of the left femur (thigh bone), edema (swelling), and hypertension (high blood pressure). Record review of Resident #17's care plan, dated 10/18/22, revealed no care plan for vision impairment. Record review of Resident #17's annual Minimum Data Set assessment, dated 07/27/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section B 1200. Corrective Lenses 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 8 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 Yes Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #15's undated face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, schizophrenia, and insomnia. Residents Affected - Some Record review of Resident #15's care plan, dated 07/14/22, revealed no care plan for urinary incontinence and dental care. Record review of Resident #15's annual Minimum Data Set assessment, dated 07/07/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was moderately intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary 15. Dental Care Section H Bladder and Bowel H0300 Urinary Incontinence-Enter Code: 01- Occasionally incontinent - less than seven episodes of incontinence Section L Oral/Dental Status

L0200 Dental The following were checked: Obvious or likely cavity or broken natural teeth Mouth or facial pain, discomfort or difficulty chewing. 5. Record review of Resident #18's undated face sheet revealed an [AGE] year-old-male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease, unsteadiness on feet, heart failure (chronic heart condition), and hypertension (high blood pressure). Record review of Resident #18's annual Minimum Data Set assessment, dated 02/20/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 9 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 03. Visual Function Level of Harm - Minimal harm or potential for actual harm Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Residents Affected - Some Record review of Resident #18's care plan, dated 02/27/22, revealed no care plan for vision. 6. Record review of Resident #34's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, bilateral cataract(clouded eye lens in both eyes), difficulty walking, anxiety, major depressive disorder, and hypertension (high blood pressure). Record review of Resident #34's annual Minimum Data Set assessment, dated 11/03/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severe cognitively impairment. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section B 1200. Corrective Lenses Yes Record review of Resident #34's care plan, dated 11/11/21, revealed no care plan for vision. 7. Record review of Resident #36's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, muscle weakness, and major depressive disorder. Record review of Resident #36's care plan, dated 12/14/21, revealed no care plan for cognitive loss, visual function, and communication. Record review of Resident #36's annual Minimum Data Set assessment, dated 12/07/21, revealed: Section C Brief Interview for Mental Status score revealed a score of 5, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 10 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 02. Cognitive Loss Level of Harm - Minimal harm or potential for actual harm 03. Visual Function 04. Communication Residents Affected - Some Section B Hearing, Speech and Vision B0200 Hearing -Enter Code: 1 - Minimal Difficulty - difficulty in some environments B0700 Make Self Understood -Enter Code: 1 - Usually understood- difficulty communicating some words or finishing thoughts but is able if prompted or given time. B0800 Ability To Understand Others-Enter Code: 1 - Usually Understands - misses some part/intent of message but comprehends most conversations. B1000 Vision -Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. 8. Record review of Resident #39's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, insomnia, depression and obesity. Record review of Resident #39's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 10, which indicated the resident's cognition was moderately intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence 16. Pressure Ulcer Section B Hearing, Speech and Vision B0200 Hearing -Enter Code: 1 - Minimal Difficulty - difficulty in some environments. B0800 Ability to Understand Others -Enter Code: 1 - Usually Understands- missies some part/intent of message but comprehends most conversation. B1000 Vision -Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. B1200 Corrective lenses-Enter Code: 1 - Yes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 11 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 Section H Bladder and Bowel Level of Harm - Minimal harm or potential for actual harm H0300 Urinary Continence -Enter Code: 1 - Occasionally Incontinent- less than 7 episodes of incontinence. Section M Skin Conditions Residents Affected - Some M0150. Risk of Pressure Ulcer/Injuries -Enter Code: 1 - Yes Record review of Resident #39's care plan, dated 02/16/22, revealed no care plan for vision impairment, urinary incontinence, and pressure ulcer. 9. During an interview on 11/30/22 at 09:18 AM, the MDS Coordinator revealed that she had obtained all the information for the MDS assessment from the resident charts, orders, diagnoses, and facility kiosks that nursing staff document in and from her observations. She said that she had been trained to do MDS assessments and that if a resident triggered for a care area in section V, it was accurate to her knowledge. She said if any of the information appears to be incorrect or inconsistent with the resident or the previous assessment, she follows up with further steps, such as asking staff so that her assessments are correct to meet the needs of the Resident. She said all CAAs should be addressed if triggered because if the area is not addressed, the residents' area of concern could become a more significant problem for the Resident, or the care plan will be missed. Regarding the specific care areas for each Resident, she stated the following was pertinent regarding each Resident: Resident #4's vision has declined, and she takes eyedrops throughout the day. She said that sometimes there is a build-up in her eyes that staff needs to clean and monitor. She said the Resident does well after you tell her where her items are that are sat directly in front of her. She said because of her eyesight, she needs verbal prompts. Resident #12, when initially admitted , had difficulty communicating, but since then, she has improved. However, she said although she has improved, staff need to know to slow down when speaking with her and allow her time to say what she needs to say. She said staff should also know that the Resident often will repeat herself. Resident #15 does well with going to the restroom, but sometimes holds her urine and then has accidents. She said this Resident prefers to wear a pull-up, which may be good information for the staff to know so that they stay within her preferences. She said Resident #15 does have dental issues and will rush through brushing her teeth. Staff should know this to encourage dental hygiene and know ahead of time that she might be reluctant. Resident #17 wears glasses, and if she wears her glasses, her vision is not too bad. However, she said staff would need to know that she has glasses and potentially how to care for them. She said Resident #18 vision is good, but regarding activities, staff should know that he needs the large print crossword puzzles. Resident #34 does wear glasses and needs verbal prompts because of her vision. Resident #36 wears glasses. She said the resident would place her glasses on the floor, and staff should know this to look for them and encourage her to wear them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 12 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #39 does have visual issues and uses eye drops. Staff should know to look for redness and swelling. She said Resident #39 wears glasses and sometimes will not use them when utilizing her tablet. She said staff should know that things should be within reach for her visual impairment. She also said Resident #39 sometimes would have small accidents and pee on herself a little. She said this is because the resident moves slowly. She said Resident #39 would sometimes walk backward to the restroom. She said it would be beneficial for staff to know this because staff would be aware and check on frequently as the resident sometimes waits until she has gone to the restroom to pull the call light, and this is after she has made an accident. She said although the resident does not have a pressure ulcer, she is at risk. She sometimes said the resident would not get up if she had frequent incontinence, which could increase the risk of pressure ulcers. She said if the staff did not know, the resident could be at risk for a pressure ulcer. During an interview on 11/30/22 at 10:00 AM, the Administrator said the DON was responsible for care plans. She said the care plan is for nursing staff to provide the plan of care for the resident's individual needs. She said the MDS and section V determine what goes into a care plan. She said she expects the care plan to be individualized and that the triggered areas on the MDS should be care planned for each resident. She said she was unaware there were missing care plans for the identified residents. She said there is a system put in place to monitor care plans as they review them quarterly, annually, and any time there is a change of condition with the resident. When asked what the negative outcome for a resident is if they triggered for visual, communication, urinary, pressure ulcer, cognitive loss, and dental care, she said that the outcome would be the same for all the residents meaning that the resident would not receive the care that they need. She said there was no particular reason why the care plans were incomplete. During an interview on 11/30/22 at 10:08 AM, the DON stated she was responsible for completing care plans for the facility. She stated the care plan was used for taking care of the residents, and the nursing staff utilizes the care plan. She said that she uses the MDS and section V of the MDS to determine what goes in the care plan. She said that her expectation is for the care plan to be individualized and for the triggered areas from the MDS to care planned. She said she was unaware that the residents were missing care plans and did not know until the surveyor's intervention. She said that she has been trained on how to do care plans and did not have a particular reason why the care plans were not completed, except that it was just an error on her part. She said she reviews care plans on a quarterly and annual basis. When asked what the specific negative outcome would be for the residents missing visual, communication, urinary, pressure ulcer, cognitive loss, and dental care, she said that the outcome would be the same, meaning that the residents could potentially not receive the care that they need. Record review of the facility policy Care Plans, Comprehensive Person-Centered, Revised November 2019, revealed the following documentation: Applicability: this policy sets forth the procedures relating to developing a comprehensive, person-centered care plan. Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial and functional needs is developed and implemented for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 13 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 0656 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm #8. The comprehensive, person-centered care plan will: (a.) Residents Affected - Some Include measurable objectives and time frames; (b.) Describe the services that are to be furnished to attain or maintain the Residents highest practicable physical, mental, and psychosocial well-being. (c.) Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. (k.) Reflect treatment goal, timetables and objectives in measurable outcomes; #10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the Resident, are the endpoint of an interdisciplinary process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 14 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for three of three residents (Residents #30, #35, and #37) reviewed for wound care/infection control. Residents Affected - Some LVN A failed to perform hand hygiene while performing wound care for Residents #30 and #37. LVN B failed to perform hand hygiene while performing wound care for Resident #35. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #37 Record review of admission record for Resident #37 dated 11/29//22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include displaced fracture of left femur (broken leg bone), type 2 diabetes mellitus (blood sugar), anxiety, and depression. Record review of active physician orders for Resident #37 for November 2022 revealed the following order: Start date: 11/29/22 - Cleanse coccyx with skin integrity. Mix collagen with sodium chloride to a paste. Pack mixture into wound and apply dressing. Record review of Comprehensive Assessment for Resident #37 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, M0210 Unhealed Pressure ulcers/injuries: 1. Yes Record review of care plan for Resident #37 dated 04/11/22 revealed Focus: Skin Integrity, Goal: Pressure area will have no signs of deterioration and will show signs of healing in the next 90 days. Intervention: Cleanse pressure injury to coccyx with wound cleanser; mix collagen with sodium chloride to form a paste and apply to wound and cover with a dressing for Nursing staff. During an observation of wound care on 11/29/22 at 9:40 AM, LVN B provided wound care for Resident #37. LVN B did not change gloves or perform hand hygiene after removing the dirty dressing. LVN B then cleansed the wound and applied the new dressing to the wound bed. LVN B took the bottle of skin integrity from Treatment cart into Resident #37's room with no barrier used. LVN B then returned the skin integrity to the Treatment cart after wound care was provided to Resident #37. The bottle of skin integrity was not cleaned. During an interview with LVN B on 11/29/22 at 1:01 PM, LVN B stated she had not received specific training regarding wound care and hand hygiene at the facility. LVN B stated she should have cleaned the bottle of skin integrity before returning to the cart. LVN B stated she didn't think about the risks of infection to the residents due to improper glove changes and hand hygiene. LVN B stated the ADON checked up on the nurses, but she did not remember the last time she had been in-serviced regarding wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 15 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 Resident # 30 Level of Harm - Minimal harm or potential for actual harm Record review of admission record for Resident #30 dated 11/29/22 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include dementia (cognitive loss), repeated falls, congestive heart failure (fluid around heart), and fracture of left humerus (broken arm). Residents Affected - Some Record review of active physician orders for Resident #30 for November 2022 revealed the following order: Start date: 11/14/22 - Cleanse right heel with skin integrity. Mix collagen with sodium chloride to a paste. Pack mixture into wound and apply dressing. Record review of Comprehensive Assessment for Resident #30 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, M0210 Unhealed Pressure ulcers/injuries: 1. Yes. Record review of Resident #30's care plan dated 07/06/22 revealed Focus: Skin Integrity, Goal: I will maintain good skin integrity evidenced by no new red or broken areas to my skin in the next 90 days. Intervention: Cleanse pressure injury to right heel with wound cleanser, mix collagen with sodium chloride into a paste and apply to wound and cover with a dressing every day and PRN. During an observation of wound care on 11/29/22 at 9:52 AM, LVN B provided wound care for Resident #30. LVN B did not change gloves or perform hand hygiene after removing the dirty dressing. LVN B then cleansed the wound and applied the new dressing to the wound bed. LVN B took the bottle of skin integrity from Treatment cart into Resident #30's room with no barrier used. LVN B then returned the skin integrity to the Treatment cart after wound care was provided to Resident #30. The bottle of skin integrity was not cleaned. During an interview with LVN B on 11/29/22 at 1:05 PM, LVN B stated she had not received specific training regarding wound care and hand hygiene at the facility. LVN B stated she didn't think about the risks of infection to the residents due to improper glove changes and hand hygiene. LVN B stated the ADON checked up on the nurses, but she does not remember the last time she had been in-serviced regarding wound care. Resident #35 Record review of admission record for Resident #35 dated 11/29/22 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include dehydration, peripheral vascular disease (poor blood circulation), hypertension (high blood pressure), and dementia (cognitive loss). Record review of active physician orders for Resident #35 for November 2022 revealed the following order: Start date: 11/26/22 - Cleanse [NAME] x 2 to coccyx with skin integrity. Apply Anasept and collagen and cover with dressing every day and PRN. Record review of Comprehensive Assessment for Resident #35 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: B. Formal assessment instrument/tool, M0150 Risk of Pressure ulcers/injuries: 1. Yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 16 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #35's care plan dated 07/06/22 revealed Focus: Skin Integrity, Goal: I will maintain good skin integrity evidenced by no new red or broken areas to my skin in the next 90 days. Intervention: Cleanse pressure injury x3 to coccyx with wound cleanser, apply Anasept and collagen and cover with a dressing every day and PRN. During an observation of wound care on 11/29/22 at 11:45 AM, LVN A provided wound care for Resident #35. LVN A did not change gloves or perform hand hygiene after removing the dirty dressing. LVN A then cleansed the wound and applied the new dressing to the wound bed. LVN A took the bottle of skin integrity from Treatment cart into Resident #35's. The bottle of skin integrity was grabbed with dirty gloves to spray directly onto wound bed. LVN A then returned the skin integrity to the Treatment cart after wound care was provided to Resident #35. The bottle of skin integrity was not cleaned. During an interview with LVN A on 11/29/22 at 2:15 PM, LVN B was asked about glove changes and hand hygiene during wound care for Resident #35. LVN A stated she was taught to change gloves only when going from one sore to another sore on the same resident. LVN A stated she had not been trained to change gloves after removing the dirty dressing and before applying the clean one. LVN A stated the residents were at risk of spreading infections and germs due to improper glove changes and hand hygiene. LVN A stated the ADON monitors the staff once a year on competencies and she cannot remember the last time hers was done, but she knows it was done in the year of 2022. During an interview on 11/29/22 at 2:30 PM, the ADON stated she expected the nurses to change gloves after removing the dirty dressing. The ADON stated she expected the skin integrity bottle to be dedicated to the residents' room or used at the treatment cart and not taken into the resident's room. The ADON stated the nurses made the mistake out of habit and the residents were at risk of cross-contamination. The ADON stated she did skills competencies once a year with staff and monitored them frequently on the floors. During an interview on 11/30/22 at 9:21 AM, the DON stated she expected the nursing staff to use a barrier when providing wound care to the residents. The DON stated she expected a barrier to be used if the skin integrity bottles were going into resident rooms from the treatment cart or for the skin integrity bottle to stay at the treatment cart. The DON stated she expected the nursing staff to change gloves and perform hand hygiene after removing the dirty dressing. The DON stated the residents were at risk of infections spreading or unhealing wounds. The DON stated the nurses were probable nervous and forgot. The DON stated the ADON monitored the nurses for infection control but does not know how often it is done. Interview on 11/29/22 at 3:15 PM, the ADON stated the facility did not have a policy specific to glove changes. Record review of Competency review for LVN B performed on 04/08/22 revealed: On 04/08/22, LVN B was observed performing proper handwashing based on facility policy and procedure. Yes. On 04/08/22, LVN B was observed performing a treatment based on facility policy and procedure. Yes. Record review of Competency review for LVN A performed on 04/08/22 revealed: On 04/08/22, LVN A was observed performing proper handwashing based on facility policy and procedure. Yes. On 04/08/22, LVN A was observed performing a treatment based on facility policy and procedure. Yes. Record review of facility's policy titled Wound Care; revision October 2010 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 17 of 18 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 676225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mitchell County Nursing and Rehabilitation Center 971 W I 20 Colorado City, TX 79512 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 Steps in Procedure: Level of Harm - Minimal harm or potential for actual harm 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. .4. Put on exam gloves. Loosen tape and remove dressing. Residents Affected - Some 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves Record review of the facility's policy titled Infection Prevention and Control revised October 2010 revealed: Purpose: To establish and maintain an effective Infection Prevention and control program designed to minimize and help prevent infections. FACILITY Medication Administration FACILITY Infection Control FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676225 If continuation sheet Page 18 of 18