Inspection·August 31, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without asking. He did not know who she had given his medical records to, but he did not appreciate it one bit. She apologized only after she got caught. He said the incident made him mad and he had problems with his anger due to having PTSD. He said it also made him paranoid because he could not figure out who she gave his information to or why. During an interview on 8/28/23 at 5:04 p.m. the DON said Resident #1 gave her paperwork that the hospital had given him for his discharge. The DON said on that paperwork was an access code for Resident #1's MyChart (electronic record.) She said he did not ask him if she could use the access code information. She just set up the account and got copies of his records. The DON said the only thing the hospital sent was his discharge papers and nothing else. She said they had attempted to contact hospital 3 times for additional records, and they did not send anything. The DON said Resident #1 returned with an access code and that is what she used. She said Resident #1 knew that she had used the code only after she had used it. The DON said she had assisted Resident #1 with getting his passcode changed and set up his account so he could access it himself. During an interview on 8/28/23 at 5:30 p.m. the Administrator said she was aware of the issue with Resident #1's records. She had gone with the DON as a witness that he was informed his access code was used and the DON apologized for using his information without permission. During an interview on 8/29/23 at 2:00 p.m. the SW said Resident #1 had received his discharge paperwork from the hospital on 8/24/23. He was upset that the DON was able to access his online hospital records. She said Resident #1 was trying to get into his chart but could not because the account had already been activated. The SW said she knew the DON and Administrator had apologized to him. Record review of the facility Resident Rights Policy dated October 2022 indicated the resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communications. The resident has the right to secure confidential personal and medical records. The resident has the right to refuse the release of personal and medical records Record review of a Privacy Acknowledgment and Non-Disclosure Agreement indicted the facility is committed to protecting the privacy of all its Residents and protecting the confidentiality of their health care information. While with Residents at the facility, I realize that I may have access to or become aware of confidential resident medical information, whether or not I am directly involved in providing care to the resident. I understand that I must keep this information in the strictest of confidence. As a condition of my employment at that facility, I agree that i: will not examine, use or disclose confidential resident medical information except as needed to perform the duties of my job. Signed by the DON on 5/3/23 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 2 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure allegations of abuse, and neglect were reported within 24 hours to the state agency for 1 of 6 residents reviewed for abuse (Resident #2.) Resident #2 attempted to commit suicide on 7/24/23 with a contributing factor of the facility failing to ensure he received counseling. The facility did not report the incident of possible serious bodily harm with the risk of death to the state agency. This failure caused the allegation to go unreported and could result in other instances of abuse or neglect not being reported. Findings included. Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. Record review of Resident #2's care plan dated 9/8/22 indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of difficulty in psychosocial adjustments related to admission to the facility. One of the interventions weas to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall 7/24/23 indicated sent to the ER for psychiatric evaluation. A fall 8/22/23 therapy to screen and treat if indicated. A fall 8/25/23 anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on 7/25/23 indicated the resident has a history of suicide attempts. referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on 8/28/23 were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 3 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's computerized physician orders indicated an order dated 9/16/22 for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated 6/7/23 indicated refer to counseling services for evaluation and treatment related to depression. An order dated 8/15/23for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and modalities. Residents Affected - Few Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made known to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Record review of Resident #2's nurses note dated 07/24/23 at 10:29 a.m. indicated staff was called to Resident # 2 room and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell. He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated 7/24/23 at 11:00 a.m. indicated: The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the writer tried to remove the cord from his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck and put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on 7/25/23 the form indicated the DON was notified on 7/24/23 at 11:00 a.m. The NP and responsible party were notified on 7/25/23 at 11:00 a.m. completed by LVN A. Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday 7/24/23. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1(one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on 7/24/23 to 11:00 a.m. on 7/25/23. The monitoring tool was not located in the computer file. They were provided on 8/29/23 at 1:30 p.m. by SW Record review of Resident #2's nursing note dated 7/25/23 at 4:19 p.m. entitled late entry for a note dated 7/24/23 at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 4 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, then her grabbed my hand, trying to prevent me from removing the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified. Signed by LVN A. Record review of social services note dated 7/25/23 at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 stated that he did try to kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to hospitalization. The SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by SW Record review of Resident #2's nursing note dated 7/25/23 at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations and attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Written by RN D During an interview and record review on 8/28/23 at 5:04 p.m. the DON said Resident #2 tried to commit suicide on 7/24/23 someone had informed her, but she did not recall what had occurred after that. The DON said she had looked at Reportable incident triage form that was dated 2017 and it had attempted suicide listed as one of the things to report. The Administrator was out at that time, and she had not reported the incident. During an interview on 8/28/23 at 5:30 p.m. the Administrator the facility Abuse Coordinator said she was at a conference the week of 7/24/23 and was not aware of the incident until she returned the following week. She had not reported the incident to the state agency she did not think it was reportable. During an interview on 8/28/23 at. 6:30 p.m. DON and Administrator were informed of concerns with Resident #2. The Administrator said she was confused about the whole issue. The DON said she understood, Resident #2 had tried to commit suicide and they had basically done nothing. During an interview on 8/29/23 at 1:07 p.m. the SW said Resident #2 had an appointment on 6/29/23 for counseling but he did not attend the appointment apparently there was a problem with his payer source. She said he did not have Medicaid part B and his payer source would not pay for the counseling. She thought he was being seen by counseling weekly, but he was not. She said she was not made aware of the payer source issue until yesterday. Record review of the facility policy on abuse dated October 2022 indicated each resident had the right to be free from abuse. One of the categories of abuse was Deprivation of goods and services that are necessary to attain or maintain physical, mental, or psychosocial wellbeing. Staff has the knowledge and ability to provide care and services, but choose not to do so, or acknowledge the request (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 5 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for assistance from a resident which result in care deficits to a resident. Another category of abuse was Serious bodily injury is an injury involving substantial risk of death, involving protracted loss or impairment of the duction of the body requiring medical intervention such as hospitalization, or physical rehabilitation. The policy indicated any allegation of abuse will be immediately reported to the facility Administrator. The facility will designate an Abuse Prevention Coordinator responsible for reporting allegations of abuse to the state agency. Event ID: Facility ID: 676311 If continuation sheet Page 6 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident environment remained free of accident hazards as possible and the resident received adequate supervision to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #2) The facility failed to put interventions in place to prevent accidents regarding Resident #2 that had a history of self-injurious behaviors. Resident #2 tried to harm himself by placing a call light cord around his neck twice on [DATE]. The resident also had a history of throwing himself out of his wheelchair in attempts to himself. The facility failed to ensure: Resident #2's room was free of all harmful items including the call light cord. Resident #2 was provided observation and other interventions to ensure he did not harm himself. Resident #2 was provided with appropriate interventions to prevent or improve his behaviors. The facility failed to ensure care plan interventions were implemented. They failed to notify the physician when the resident exhibited self-injurious behavior. They failed to follow their policy on suicide precautions protocol. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 6:30 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure placed residents at risk for hazards due to lack of adequate supervision with the potential for serious injury and death. Findings included: Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. Record review of Resident #2's care plan dated [DATE] indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 7 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some difficulty in psychosocial adjustments related to admission to the facility. One of the interventions was to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall [DATE] indicated sent to the ER for psychiatric evaluation. A fall [DATE] therapy to screen and treat if indicated. A fall [DATE] anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on [DATE] indicated the resident has a history of suicide attempts. Referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on [DATE] were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. During an interview on [DATE] at 12:15p.m. the DON said saw the safety assessment mentioned on the care plan for Resident #2. She said that was not something that nurses did; it may be something the SW completed. She also said she reviewed the care plan for Resident #2 and saw the 15 minutes checks. She said they should still be going on because there was no assessment that said otherwise. However, the Resident #2 was not being monitored. The DON said the SW had monitoring sheets of 15-minute checks done on [DATE] and [DATE]. She said she could not remember what she had done on [DATE] to ensure Resident #2 was safe. She said because at that time she was the only one here and she was over my head. The DON said the Administrator was at conference, ADON, nurse supervisor, and staff development nurse all out with Covid. She said the NP was not notified until the next day and she was not aware of any other residents exhibited suicidal behaviors. She said she did not remember saying anything about making Resident #2 a DNR. The DON said she was not aware of the recommendations made on [DATE] from the psychologist for Resident #2 and they were not done. During an interview on [DATE] at 11:22 a.m. the MDS Coordinator said she put a different care plan intervention in place every time Resident #2 had a fall. He had 4 falls since [DATE]. She said when he came back from the hospital, he had some medical changes and now is not as independent as he once was. She said he was noted to be throwing himself on the floor on [DATE]. She said on [DATE] he said he did not know how he got on the floor. She said the resident is on Paxil and aspirin and they do weekly skin assessments to ensure he had no bruising. She said she had put one of interventions for the suicide was to complete a safety assessment. She said that was nursing 101. She said all they had to do was make sure the room was safe, remove any objects that could cause harm. She said she was just made aware today that the call light cord was still in the room. She said the 15-minute checks intervention was to be removed after the resident and his environment were deemed safe. She said she had no idea that was not completed. Record review of Resident #2's computerized physician orders indicated an order dated [DATE] for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated [DATE] indicated refer to counseling services for evaluation and treatment related to depression. An order dated [DATE] for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 8 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 modalities. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with a diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made know to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Completed by Psychologist contracted by the facility. Residents Affected - Some Record review of Resident #2's nurses note dated [DATE] at 10:29 a.m. indicated was called to Resident # 2 and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell. He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated [DATE] at 11:00 a.m. indicated. The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the write tried to remove the cord form his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck nd put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on [DATE] the form indicated the DON was notified on [DATE] at 11:00 a.m. The NP and responsible party were notified on [DATE] at 11:00 a.m. Completed by LVN A Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday [DATE]. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1 (one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on [DATE] to 11:00 a.m. on [DATE]. The monitoring tool was not located in the computer file. They were provided on [DATE] at 1:30 p.m. by the SW Record review of social services note dated [DATE] at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 to stated that he did try to kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 9 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hospitalization. SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by the SW. Record review of Resident #2's nursing note dated [DATE] at 4:19 p.m. entitled late entry for a note dated [DATE] at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, there is a grabbed my hand, trying not to let me remove the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified signed by LVN A. Record review of Resident #2's nursing note dated [DATE] at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations in attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Record review of Resident #2's hospital psychiatric consult dated [DATE] at 10:36 p.m. indicated Resident #2 presented to the ER with a history of depression, schizophrenia presenting following a suicide attempt he has extensive medical history with severe debility and neurocognitive deficits. It is difficult to perform a complete psychiatric eval, given his memory impairments and aphasia. He did report depressive symptoms along with his suicide attempt yesterday in the contacts of recent family stressors. It seemed many of the symptoms had been ongoing for some time. His chart showed he was only taking Zoloft 50 mg and he denied taking any other psychiatric medications recently. Finding placement for him will likely take some time since he is completely dependent upon staff for ADLs. We will continue to monitor him and monitor his progress daily disposition given intimate risk outside of a secure environment. Recommended inpatient psychiatric admission on ce medically cleared. It was reported the resident was transferred from the nursing home after attempting suicide by wrapping a cord around his neck and falling from his wheelchair. The patient does not deny that he was did that thing. He said he was a suicidal but stated he is no longer having suicidal ideations now. He reported that he wanted to hurt himself because he was tired of sitting around and doing nothing all day. He stated that he had these thoughts recently for recurrently for several years, but he could not say exactly how long. The resident said he had no previous suicide attempts and stated he would not try. If he returned home, and he reported auditory hallucinations. He reported that these hallucinations revolve around light at the end of the tunnel, but they did not tell him to harm his himself. He has had recent stressors of his family member taking his money. The resident reported occasional hopelessness, and he reported auditory hallucinations 2 to 3 times a month regarding going down a tunnel but is unable to elaborate. He also reported visual hallucinations of his deceased mom for the past 10 years he denied these hallucinations as being distressful and stated they are not related to his attempt. He said he was diagnosed with schizophrenia three years ago and said the voices started after he had a heart attack. The resident had three suicide attempts. His suicidal screen indicated that he was a high risk for suicide. His judgment was poor. He is unable to perform self-care and ADLs without assistance. His insight was in poor condition, his coping skills and reasoning reasons for continuing living comments. The patient is cooperative on exam but can become irritable when discussing his life at the nursing home. Given the patient age and some inconsistencies in his history and personal information between the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 10 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some patient in the nursing home, raising suspicion of the contributory factors from possible dementia there is a high suspicion of depressive origins due to the patient's history of major depressive disorder, decreased concentration, suicidal ideation/attempts, hallucinations, raise, concerns of depression, with psychotic features. The resident was placed on suicide precautions. Record review of Resident #2's history and physical dated [DATE] at 2:53 p.m. indicated that a psychiatric consult was performed on the patient while he was in the emergency room on 7/25 /23 with repeat visits by the inpatient psychiatric team on [DATE] and [DATE]. It was recommended inpatient psychiatric admission for the patient when medically cleared. He was admitted today into inpatient due to mental status and for emerging atrial fibrillation. Geriatric psychiatric unit here at the hospital is unable to take the patient due to his condition. Record review of a nursing note dated [DATE] at 1:27 PM. Indicated Resident #2 remained in the ER at the local hospital at this time. The staff at the hospital currently trying to find placement for him due to active hallucinations and suicidal ideations, as well as multiple attempted suicides. The ER staff have not been able to place this resident due to physical/medical limitations of mobility. The medical records from the ER stay were obtained as well as his current face sheet, medication list, and previous records have been provided to the VA land board representative to assist with placement for the resident as well. Per the ER staff the resident is calm and compliant at this time and he admitted , his attempts, and he continued to want help with the issues and will sign a voluntary for inpatient psychiatric treatment. Signed by RN D Record review of Resident #2's nursing note dated [DATE] at 10:00 a.m. indicated the RN called a local hospital and spoke with a nurse who reported on yesterday they were still waiting on psychiatric placement for Resident #2 however, had medical episode, and then he was admitted medically at the hospital the admitting MD included suicidal ideations in his diagnosis and he will be seen by psychiatric services during his admission. At this time, it is expected to be a 3-to-5-day admission due to the onset of arrhythmia( improper beating of the heart). Signed by RN D Record review of Resident #2 's nurses note dated [DATE] at 10:02 a.m. indicated a report received from the doctor at the local hospital physician said that the psychiatrist has signed off on the residence discharge and it will take a few days to weeks for the resident to return to baseline. They feel medical status was related to dementia and delirium, causing suicidal ideations. The resident has been on one-to-one observation the doctor recommended returning to the home facility for removal of potential harmful items no access to linens, at risk items, and frequent checks every 2-to-3-hour checks. The resident continued Zoloft, Abilify discontinued, potassium and magnesium a little low so supplement, recommend it with repeat lab in one week. The DON was notified and approved the return of the Resident with Resident up a wheelchair without one-to-one supervision, the hospital to arrange transport. Signed by RN H Record review of Resident #2 's nurses note dated [DATE] at 1:10 p.m. indicated the resident retuned to the facility from the hospital. Signed by LVN A Record review of Resident #2 's nurses note dated [DATE] indicated the resident was found unresponsive and sent to the hospital. Signed by LVN Z Record review of Resident #2 's nurses note dated [DATE] at 9:46 p.m. indicated the resident retuned to the facility due to a diagnosis of acute encephalopathy(functional alteration of mental status due to systemic factors). At 11:37 p.m. the resident was placed on suicide protocol of every 15 min (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 11 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 checks. Signed by RN Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2 's nurses note dated [DATE] at 3:38 p.m. indicated frequent visual checks done and monitor for suicidal thoughts and behaviors. (last mention of suicidal monitoring) signed LVN A Residents Affected - Some Record review of Resident #2's 15-minute monitoring sheets from [DATE] starting at 9:45 p.m. to [DATE] at 8:00 p.m. Record review of Resident #2's incident report dated [DATE] at 4:00 p.m. indicated the DON was called by the charge nurse to report Resident #2 had fallen. The resident was lying on the floor in his room with his head towards the floor and the feet toward the bed. On the floor was the resident's remote control and a water bottle. The resident stated that he lost his balance and fell out of the wheelchair attempting to pick up his tv remote off the floor. A head-to-toe assessment was conducted with no injuries noted, the resident was assisted off the floor into bed, initiated neuro checks, and notified responsible party of fall with no injuries. Record review of Resident #2's incident report dated [DATE] at 3:00 p.m. indicated the was called to the room with Resident #2 lying on the floor next to the bed. Ensure they initiated the facility policy of suicide precautions, the resident said he was getting up. The resident was assessed, and neuros and vital signs taken. Record review of Resident #2's a Fall Risk Screen dated [DATE] at 1:46 p.m. indicated the resident had falls on [DATE] and [DATE] and was identified as high risk for falls. The comments were Resident #2 did not know his limitations Record review of Resident #2's Post Fall Assessment form with a lock date of [DATE] at 4:10 p.m. Record review of Resident#2's fall on [DATE] at 1:00 p.m. The resident said he didn't know how it happened. He was getting up from the wheelchair, he received a skin tear to the left elbow and the nurse practitioner was notified and the responsible party. The care plan review indicated it was an intentional fall due to being mad at family interventions and recommendations. Post fall was one hour observation checks initiated on [DATE] into monitor for signs and symptoms of hallucinations and flashbacks initiate Q1 hour observation sheet the potential interventions were assistive, mobile device, wheelchair, positioning/seating device, elevation, evaluation of footwear, elevation of hide the bed, change in footwear, nightlight, bed in lowest position, recline chair, mechanical lift for transfer, toileting, schedule, therapy , safety cues, reinforce reminders, assistive devices within reach, signage, stop sign, evaluate timing of medication's, occupational therapy, daily nap, restorative program, psychiatric evaluation, medical evaluation, anti-tippers, pain assessment, body pillows for positioning, wider mattress, drop seat in wheelchair, anti-roll back brakes, wheelchair, break, extensions with tops, painted orange for additional visual cues, medication review, and evaluate activity program and encourage participation. The care plan had been updated and addendum indicated. Risk factors included multiple recent and previous falls, current flashbacks/hallucinations, previous intentional falls due to suicidal ideations, and anger towards family. During the IDT review, it was determined that the root cause of the fall was due to flashbacks/intentional falling to the anger with the family member. Resident number two admitted throwing himself on the floor due to anger and admitted to having current flashbacks to war/hallucinations, intervention/care plans, updated and documented above. Record review of Resident #2 's nurses note dated [DATE] at 10:34 a.m. indicated it was reported to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 12 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some this RN the resident fall on [DATE] was most likely purposeful due to anger and another attempt to harm himself. This resident spoke with his family member just prior to his fall. The family member said they were not coming to visit that day. The resident was very angry and upset. This resident has also stated in the past that he throws himself from his wheelchair on purpose to inflict harm on himself. The fall occurred immediately after he spoke to the family member. It was his third fall within this past week. The resident told the SW he was not trying to hurt himself. However, her had a smirk on his face and laughed during the evaluation. A cowbell was placed in the resident's room for use as a call light system. Th maintenance was contacted to assist staff in making the room safe and safely removed the old call light. Signed by RN D. Record review of Resident #2's social service note created on [DATE] at 11:07 a.m. titles late entry for [DATE] at 10:03 a.m. indicated the SW spoke with Resident #2 to inquire on whether his recent falls were an attempt for self-harm or [NAME] as the resident has historically caused falls as an attempt to self-harm. Resident #2 stated he did not try to hurt himself. He denied having any suicidal indication. The resident stated, I am in a better mindset. SW encouraged the resident to let staff know if his mental health starts to decline. The SW will continue to monitor the resident for behaviors. Signed by the SW Record review of Resident #2's social services note dated [DATE] at 11:21 a.m. indicated Resident to be evaluate for counseling though the VA on [DATE] at 9:00 a.m. During an interview on [DATE] at 2:00 p.m. the SW said on [DATE] she was told by multiple staff that on Monday, [DATE] Resident #2 wrapped a cord around his neck and said he wanted to die. The SW said she was off on [DATE] but when she returned to work on [DATE] the only thing that was said about Resident #2 in the morning meeting was the DON said to look at making him a DNR. The SW said an ECA reported to RN D that Resident #2 had tried to kill himself the day before, and they got sent him out to the hospital. She said there were issues with care dynamic with his family member a few months ago, he got really depressed. She said she did a referral for psychological services at that time. The SW said she asked Resident #2 today if he was suicidal and he was very sarcastic, but said no. He went to the hospital but was not admitted to the Behavioral health due to physical and medical issues. She said he received weekly counseling, but she did not know how that was going. During an interview on [DATE] at 2:35 p.m. with RN D said Resident #2 had two suicide attempts on Monday, [DATE]. They were not informed about the suicide. The only thing that was brought up in the Morning meeting regarding Resident #2 was the DON wanted to make him a DNR. She said the DON was aware of the attempted suicide and did not put any interventions into place. She said LVN A was the nurse that was on duty on [DATE]. RN D said LVN A did not complete a nursing note or incident report until instructed to do so on [DATE]. RN D said LVN A said Resident #2 wrapped the call light cord around his neck, and she told the DON. She said LVN A said she was not given any instruction of what to do or how to procced with Resident #2. RN D said she called the SW on [DATE], and she came and did a suicide screen. She said the SW contacted the Behavior Health Hospital and Resident #2 was sent to the local hospital for a medical clearance to be admitted to the Behavior Health unit. RN D said on today [DATE] they removed all sharps from his room. She said they gave Resident #2 a call bell and moved the call light out of his reach. She said she had requested help from Maintenance to remove Resident #2's call light cord from the room, they had tried to remove the call light but was unable to without it continuously beeping. She said maintenance told her to push the reset button and did not come and remove the call light cord. She said she had told him his directions did not work. RN D said Resident#2 was agitated today because were trying to remove things from his room. She said he had been depressed for a while. She said he is often depressed around Christmas because he lost several (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 13 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some family members around Christmas. RN D said she had gotten reports that Resident #2 was depressed, and they got counseling for him. She said she did not know exactly what lead to the attempt on [DATE]. RN D said Resident #2 often gets upset with the family member and acted out. She said Resident # 2 had put himself on the floor on yesterday per staff reports after having an issue with the family member. RN D said they asked him today if he wanted to hurt himself, he said no but was sarcastic with his remark. During an interview on [DATE] at 2:50 a.m. LVN E said he had worked at the facility for 1 year. He said Resident #2 had moments that he appeared depressed. He said he had not voiced any suicidal thoughts to him. He said he thought part of his problems with his falls was he did not know his limitations. During an interview and observation on [DATE] at 2:55 p.m. observation of Resident #2 showed him in bed and the bed was at waist height, there was a mat on the floor. Resident #2 said he did not want to die. He said that he wrapped the cord around his neck to prove to them that he could do it. He could not explain what he meant by them. He answered questions with appropriate answers and facial expressions. Observation of the room showed the call light was present. It was behind the bed; however, Resident #2 had a grabber on his table that would assist him to reach it. There was also a long cord connected to the electric lift over the bed the cord was between 6 to 9 feet long plugged into the wall by his bed. He said he was not throwing his self on the floor to hurt his self. Resident #2 said he just fell, and he did not know why. Said he was not feeling well, he was eating okay, and sleeping okay. He said he did not like to attend activities he was a loner and mostly liked to stay to himself. He said had his tv and his computer. He said he was depressed sometimes and would like to have someone to talk to about his issues. The resident said he had not talked to a counselor but would like to. During an interview on [DATE] at 3:10 p.m. ECA F said she was not here when Resident #2 put the cord around his neck. She said Resident #2 had put himself on the floor a few times. He would get mad with his family member either they would not come to visit, not answer the phone or something that would make him mad. She said on yesterday the family member would not answer the phone, or said something he did not like, and he wound up on the floor. She said he had just gone into his room. He was barley in the door, and he was on the floor. ECA F said Resident #2 had temper tantrums when did not get his way. She said Resident #2 did say he did not want to be here on occasion. She said he cannot stand up and he is a Hoyer lift transfer. She said Resident #2 puts his bed up high even when we tell him to keep it low. ECA F said Resident #2 had a fall mat on the floor, in July he told me he would not be here long. She said they moved all his sharps and things in the bathroom, and Resident #2 cannot get them without assistance. She said they gave him a call bell if he needs anything, but the call light is still in the room. During an interview on [DATE] at 3:20 p.m. ESA L said Resident #2 had not told her he wanted to die. She said sometimes he said he want to go, get out of here, and he talked of going home to Arkansas or Oklahoma. She said the normal behavior for Resident #2 was agitated. he will throw cups and tables. ECA L said for last two months he had been a little nicer, spend most time in the room. She said they told her he had a cord around his neck, but did not see it. During an interview on [DATE]at 3:24 p.m. ECA R said she worked here one year and said that Resident #2 was lonely. She said his family member used come a lot but does not anymore. She said he got mad at the family member and would be depressed. She said when he is depressed, he just looks sad and disconnected from everything. ECA R said Resident #2 did not interact much with the others, but he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 14 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some did show some difference in his moods. She said she was told in July Resident # 2 wrapped the cord around his neck, but he said nothing to her about wanting to die. ECA R said Resident #2 did throw temper tantrums and would throw his self out of chair at times. ECA R said she did not know if he was just angry or trying to hurt himself for attention. She said when asked how did you fall or why did you fall Resident #2 would say thing like I just fell. During an interview on [DATE] at 4:05 p.m. the Maintenance Director said he was informed this morning that they wanted to remove the call light in Resident #2's room. He told whoever called him what to do to remove it. He said they called him about it still ringing when the cord was removed. He told them to just press reset button. He had not gone to check it out and he had not sent any of his guys to look at the issue. He said he did not know if the call light was still there or not. During an interview and record review on [DATE] at 5:04 p.m. the DON said Resident #2 tried to commit suicide on 7/2[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 15 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents reviewed for behavioral services. (Resident #2) The facility failed to: Ensure psychological services were provided as ordered by the physician Intervene and provide safety measures on [DATE] when Resident #2 tried to kill himself. He wrapped a call light cord around his neck twice and threw himself from the wheelchair. Ensure they initiated the facility policy on Suicide Precautions. Have a interventions and a system in place to monitor Resident #2's behaviors when he began to exhibit harmful behaviors of throwing his self on the floor. Ensure Resident #2's care plan interventions were followed such as continued 15-minute morning, a safety assessment. Ensure the physician was aware of his self-injurious behaviors. Ensure the call light cord was removed and out of his reach after the resident used it twice by wrapping it around his neck. It was removed on [DATE] after surveyor intervention. Facility failed to put interventions in place after the resident returned from the hospital to address his behavioral health needs. An Immediate Jeopardy (IJ) situation was identified on [DATE] p.m. While the IJ was removed on [DATE] at 6:30 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for lack of behavioral health services with the potential for serious injury and death. Findings included: Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 16 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #2's care plan dated [DATE] indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of difficulty in psychosocial adjustments related to admission to the facility. One of the interventions was to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall [DATE] indicated sent to the ER for psychiatric evaluation. A fall [DATE] therapy to screen and treat if indicated. A fall [DATE] anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on [DATE] indicated the resident has a history of suicide attempts. Referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on [DATE] were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. During an interview on [DATE] at 12:15p.m. the DON said saw the safety assessment mentioned on the care plan for Resident #2. She said that was not something that nurses did; it may be something the SW completed. She also said she reviewed the care plan for Resident #2 and saw the 15 minutes checks. She said they should still be going on because there was no assessment that said otherwise. However, the Resident #2 was not being monitored. The DON said the SW had monitoring sheets of 15-minute checks done on [DATE] and [DATE]. She said she could not remember what she had done on [DATE] to ensure Resident #2 was safe. She said because at that time she was the only one here and she was over my head. The DON said the Administrator was at conference, ADON, nurse supervisor, and staff development nurse all out with Covid. She said the NP was not notified until the next day and she was not aware of any other residents exhibited suicidal behaviors. She said she did not remember saying anything about making Resident #2 a DNR. The DON said she was not aware of the recommendations made on [DATE] from the psychologist for Resident #2 and they were not done. During an interview on [DATE] at 11:22 a.m. the MDS Coordinator said she put a different care plan intervention in place every time Resident #2 had a fall. He had 4 falls since [DATE]. She said when he came back from the hospital, he had some medical changes and now is not as independent as he once was. She said he was noted to be throwing himself on the floor on [DATE]. She said on [DATE] he said he did not know how he got on the floor. She said the resident is on Paxil and aspirin and they do weekly skin assessments to ensure he had no bruising. She said she had put one of interventions for the suicide was to complete a safety assessment. She said that was nursing 101. She said all they had to do was make sure the room was safe, remove any objects that could cause harm. She said she was just made aware today that the call light cord was still in the room. She said the 15-minute checks intervention was to be removed after the resident and his environment were deemed safe. She said she had no idea that was not completed. Record review of Resident #2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 17 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some computerized physician orders indicated an order dated [DATE] for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated [DATE] indicated refer to counseling services for evaluation and treatment related to depression. An order dated [DATE] for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and modalities. Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with a diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made know to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Completed by Psychologist contracted by the facility. Record review of Resident #2's nurses note dated [DATE] at 10:29 a.m. indicated was called to Resident # 2 and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell. He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated [DATE] at 11:00 a.m. indicated. The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the write tried to remove the cord form his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck nd put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on [DATE] the form indicated the DON was notified on [DATE] at 11:00 a.m. The NP and responsible party were notified on [DATE] at 11:00 a.m. Completed by LVN A Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday [DATE]. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1 (one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on [DATE] to 11:00 a.m. on [DATE]. The monitoring tool was not located in the computer file. They were provided on [DATE] at 1:30 p.m. by the SW Record review of social services note dated [DATE] at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 to stated that he did try to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 18 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to hospitalization. SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by the SW. Residents Affected - Some Record review of Resident #2's nursing note dated [DATE] at 4:19 p.m. entitled late entry for a note dated [DATE] at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, there is a grabbed my hand, trying not to let me remove the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified signed by LVN A. Record review of Resident #2's nursing note dated [DATE] at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations in attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Record review of Resident #2's hospital psychiatric consult dated [DATE] at 10:36 p.m. indicated Resident #2 presented to the ER with a history of depression, schizophrenia presenting following a suicide attempt he has extensive medical history with severe debility and neurocognitive deficits. It is difficult to perform a complete psychiatric eval, given his memory impairments and aphasia. He did report depressive symptoms along with his suicide attempt yesterday in the contacts of recent family stressors. It seemed many of the symptoms had been ongoing for some time. His chart showed he was only taking Zoloft 50 mg and he denied taking any other psychiatric medications recently. Finding placement for him will likely take some time since he is completely dependent upon staff for ADLs. We will continue to monitor him and monitor his progress daily disposition given intimate risk outside of a secure environment. Recommended inpatient psychiatric admission on ce medically cleared. It was reported the resident was transferred from the nursing home after attempting suicide by wrapping a cord around his neck and falling from his wheelchair. The patient does not deny that he was did that thing. He said he was a suicidal but stated he is no longer having suicidal ideations now. He reported that he wanted to hurt himself because he was tired of sitting around and doing nothing all day. He stated that he had these thoughts recently for recurrently for several years, but he could not say exactly how long. The resident said he had no previous suicide attempts and stated he would not try. If he returned home, and he reported auditory hallucinations. He reported that these hallucinations revolve around light at the end of the tunnel, but they did not tell him to harm his himself. He has had recent stressors of his family member taking his money. The resident reported occasional hopelessness, and he reported auditory hallucinations 2 to 3 times a month regarding going down a tunnel but is unable to elaborate. He also reported visual hallucinations of his deceased mom for the past 10 years he denied these hallucinations as being distressful and stated they are not related to his attempt. He said he was diagnosed with schizophrenia three years ago and said the voices started after he had a heart attack. The resident had three suicide attempts. His suicidal screen indicated that he was a high risk for suicide. His judgment was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 19 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some poor. He is unable to perform self-care and ADLs without assistance. His insight was in poor condition, his coping skills and reasoning reasons for continuing living comments. The patient is cooperative on exam but can become irritable when discussing his life at the nursing home. Given the patient age and some inconsistencies in his history and personal information between the patient in the nursing home, raising suspicion of the contributory factors from possible dementia there is a high suspicion of depressive origins due to the patient's history of major depressive disorder, decreased concentration, suicidal ideation/attempts, hallucinations, raise, concerns of depression, with psychotic features. The resident was placed on suicide precautions. Record review of Resident #2's history and physical dated [DATE] at 2:53 p.m. indicated that a psychiatric consult was performed on the patient while he was in the emergency room on 7/25 /23 with repeat visits by the inpatient psychiatric team on [DATE] and [DATE]. It was recommended inpatient psychiatric admission for the patient when medically cleared. He was admitted today into inpatient due to mental status and for emerging atrial fibrillation. Geriatric psychiatric unit here at the hospital is unable to take the patient due to his condition. Record review of a nursing note dated [DATE] at 1:27 PM. Indicated Resident #2 remained in the ER at the local hospital at this time. The staff at the hospital currently trying to find placement for him due to active hallucinations and suicidal ideations, as well as multiple attempted suicides. The ER staff have not been able to place this resident due to physical/medical limitations of mobility. The medical records from the ER stay were obtained as well as his current face sheet, medication list, and previous records have been provided to the VA land board representative to assist with placement for the resident as well. Per the ER staff the resident is calm and compliant at this time and he admitted , his attempts, and he continued to want help with the issues and will sign a voluntary for inpatient psychiatric treatment. Signed by RN D Record review of Resident #2's nursing note dated [DATE] at 10:00 a.m. indicated the RN called a local hospital and spoke with a nurse who reported on yesterday they were still waiting on psychiatric placement for Resident #2 however, had medical episode, and then he was admitted medically at the hospital the admitting MD included suicidal ideations in his diagnosis and he will be seen by psychiatric services during his admission. At this time, it is expected to be a 3-to-5-day admission due to the onset of arrhythmia( improper beating of the heart). Signed by RN D Record review of Resident #2 's nurses note dated [DATE] at 10:02 a.m. indicated a report received from the doctor at the local hospital physician said that the psychiatrist has signed off on the residence discharge and it will take a few days to weeks for the resident to return to baseline. They feel medical status was related to dementia and delirium, causing suicidal ideations. The resident has been on one-to-one observation the doctor recommended returning to the home facility for removal of potential harmful items no access to linens, at risk items, and frequent checks every 2-to-3-hour checks. The resident continued Zoloft, Abilify discontinued, potassium and magnesium a little low so supplement, recommend it with repeat lab in one week. The DON was notified and approved the return of the Resident with Resident up a wheelchair without one-to-one supervision, the hospital to arrange transport. Signed by RN H Record review of Resident #2 's nurses note dated [DATE] at 1:10 p.m. indicated the resident retuned to the facility from the hospital. Signed by LVN A Record review of Resident #2 's nurses note dated [DATE] indicated the resident was found unresponsive and sent to the hospital. Signed by LVN Z (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 20 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2 's nurses note dated [DATE] at 9:46 p.m. indicated the resident retuned to the facility due to a diagnosis of acute encephalopathy(functional alteration of mental status due to systemic factors). At 11:37 p.m. the resident was placed on suicide protocol of every 15 min checks. Signed by RN Record review of Resident #2 's nurses note dated [DATE] at 3:38 p.m. indicated frequent visual checks done and monitor for suicidal thoughts and behaviors. (last mention of suicidal monitoring) signed LVN A Residents Affected - Some Record review of Resident #2's 15-minute monitoring sheets from [DATE] starting at 9:45 p.m. to [DATE] at 8:00 p.m. Record review of Resident #2's incident report dated [DATE] at 4:00 p.m. indicated the DON was called by the charge nurse to report Resident #2 had fallen. The resident was lying on the floor in his room with his head towards the floor and the feet toward the bed. On the floor was the resident's remote control and a water bottle. The resident stated that he lost his balance and fell out of the wheelchair attempting to pick up his tv remote off the floor. A head-to-toe assessment was conducted with no injuries noted, the resident was assisted off the floor into bed, initiated neuro checks, and notified responsible party of fall with no injuries. Record review of Resident #2's incident report dated [DATE] at 3:00 p.m. indicated the was called to the room with Resident #2 lying on the floor next to the bed. Ensure they initiated the facility policy of suicide precautions, the resident said he was getting up. The resident was assessed, and neuros and vital signs taken. Record review of Resident #2's a Fall Risk Screen dated [DATE] at 1:46 p.m. indicated the resident had falls on [DATE] and [DATE] and was identified as high risk for falls. The comments were Resident #2 did not know his limitations Record review of Resident #2's Post Fall Assessment form with a lock date of [DATE] at 4:10 p.m. Record review of Resident#2's fall on [DATE] at 1:00 p.m. The resident said he didn't know how it happened. He was getting up from the wheelchair, he received a skin tear to the left elbow and the nurse practitioner was notified and the responsible party. The care plan review indicated it was an intentional fall due to being mad at family interventions and recommendations. Post fall was one hour observation checks initiated on [DATE] into monitor for signs and symptoms of hallucinations and flashbacks initiate Q1 hour observation sheet the potential interventions were assistive, mobile device, wheelchair, positioning/seating device, elevation, evaluation of footwear, elevation of hide the bed, change in footwear, nightlight, bed in lowest position, recline chair, mechanical lift for transfer, toileting, schedule, therapy , safety cues, reinforce reminders, assistive devices within reach, signage, stop sign, evaluate timing of medication's, occupational therapy, daily nap, restorative program, psychiatric evaluation, medical evaluation, anti-tippers, pain assessment, body pillows for positioning, wider mattress, drop seat in wheelchair, anti-roll back brakes, wheelchair, break, extensions with tops, painted orange for additional visual cues, medication review, and evaluate activity program and encourage participation. The care plan had been updated and addendum indicated. Risk factors included multiple recent and previous falls, current flashbacks/hallucinations, previous intentional falls due to suicidal ideations, and anger towards family. During the IDT review, it was determined that the root cause of the fall was due to flashbacks/intentional falling to the anger with the family member. Resident number two admitted throwing himself on the floor due to anger and admitted to having current flashbacks to war/hallucinations, intervention/care plans, updated and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 21 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 documented above. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2 's nurses note dated [DATE] at 10:34 a.m. indicated it was reported to this RN the resident fall on [DATE] was most likely purposeful due to anger and another attempt to harm himself. This resident spoke with his family member just prior to his fall. The family member said they were not coming to visit that day. The resident was very angry and upset. This resident has also stated in the past that he throws himself from his wheelchair on purpose to inflict harm on himself. The fall occurred immediately after he spoke to the family member. It was his third fall within this past week. The resident told the SW he was not trying to hurt himself. However, her had a smirk on his face and laughed during the evaluation. A cowbell was placed in the resident's room for use as a call light system. Th maintenance was contacted to assist staff in making the room safe and safely removed the old call light. Signed by RN D. Residents Affected - Some Record review of Resident #2's social service note created on [DATE] at 11:07 a.m. titles late entry for [DATE] at 10:03 a.m. indicated the SW spoke with Resident #2 to inquire on whether his recent falls were an attempt for self-harm or [NAME] as the resident has historically caused falls as an attempt to self-harm. Resident #2 stated he did not try to hurt himself. He denied having any suicidal indication. The resident stated, I am in a better mindset. SW encouraged the resident to let staff know if his mental health starts to decline. The SW will continue to monitor the resident for behaviors. Signed by the SW Record review of Resident #2's social services note dated [DATE] at 11:21 a.m. indicated Resident to be evaluate for counseling though the VA on [DATE] at 9:00 a.m. During an interview on [DATE] at 2:00 p.m. the SW said on [DATE] she was told by multiple staff that on Monday, [DATE] Resident #2 wrapped a cord around his neck and said he wanted to die. The SW said she was off on [DATE] but when she returned to work on [DATE] the only thing that was said about Resident #2 in the morning meeting was the DON said to look at making him a DNR. The SW said an ECA reported to RN D that Resident #2 had tried to kill himself the day before, and they got sent him out to the hospital. She said there were issues with care dynamic with his family member a few months ago, he got really depressed. She said she did a referral for psychological services at that time. The SW said she asked Resident #2 today if he was suicidal and he was very sarcastic, but said no. He went to the hospital but was not admitted to the Behavioral health due to physical and medical issues. She said he received weekly counseling, but she did not know how that was going. During an interview on [DATE] at 2:35 p.m. with RN D said Resident #2 had two suicide attempts on Monday, [DATE]. They were not informed about the suicide. The only thing that was brought up in the Morning meeting regarding Resident #2 was the DON wanted to make him a DNR. She said the DON was aware of the attempted suicide and did not put any interventions into place. She said LVN A was the nurse that was on duty on [DATE]. RN D said LVN A did not complete a nursing note or incident report until instructed to do so on [DATE]. RN D said LVN A said Resident #2 wrapped the call light cord around his neck, and she told the DON. She said LVN A said she was not given any instruction of what to do or how to procced with Resident #2. RN D said she called the SW on [DATE], and she came and did a suicide screen. She said the SW contacted the Behavior Health Hospital and Resident #2 was sent to the local hospital for a medical clearance to be admitted to the Behavior Health unit. RN D said on today [DATE] they removed all sharps from his room. She said they gave Resident #2 a call bell and moved the call light out of his reach. She said she had requested help from Maintenance to remove Resident #2's call light cord from the room, they had tried to remove the call light but was unable to without it continuously beeping. She said maintenance told her to push the reset button and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 22 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some come and remove the call light cord. She said she had told him his directions did not work. RN D said Resident#2 was agitated today because were trying to remove things from his room. She said he had been depressed for a while. She said he is often depressed around Christmas because he lost several family members around Christmas. RN D said she had gotten reports that Resident #2 was depressed, and they got counseling for him. She said she did not know exactly what lead to the attempt on [DATE]. RN D said Resident #2 often gets upset with the family member and acted out. She said Resident # 2 had put himself on the floor on yesterday per staff reports after having an issue with the family member. RN D said they asked him today if he wanted to hurt himself, he said no but was sarcastic with his remark. During an interview on [DATE] at 2:50 a.m. LVN E said he had worked at the facility for 1 year. He said Resident #2 had moments that he appeared depressed. He said he had not voiced any suicidal thoughts to him. He said he thought part of his problems with his falls was he did not know his limitations. During an interview and observation on [DATE] at 2:55 p.m. observation of Resident #2 showed him in bed and the bed was at waist height, there was a mat on the floor. Resident #2 said he did not want to die. He said that he wrapped the cord around his neck to prove to them that he could do it. He could not explain what he meant by them. He answered questions with appropriate answers and facial expressions. Observation of the room showed the call light was present. It was behind the bed; however, Resident #2 had a grabber on his table that would assist him to reach it. There was also a long cord connected to the electric lift over the bed the cord was between 6 to 9 feet long plugged into the wall by his bed. He said he was not throwing his self on the floor to hurt his self. Resident #2 said he just fell, and he did not know why. Said he was not feeling well, he was eating okay, and sleeping okay. He said he did not like to attend activities he was a loner and mostly liked to stay to himself. He said had his tv and his computer. He said he was depressed sometimes and would like to have someone to talk to about his issues. The resident said he had not talked to a counselor but would like to. During an interview on [DATE] at 3:10 p.m. ECA F said she was not here when Resident #2 put the cord around his neck. She said Resident #2 had put himself on the floor a few times. He would get mad with his family member either they would not come to visit, not answer the phone or something that would make him mad. She said on yesterday the family member would not answer the phone, or said something he did not like, and he wound up on the floor. She said he had just gone into his room. He was barley in the door, and he was on the floor. ECA F said Resident #2 had temper tantrums when did not get his way. She said Resident #2 did say he did not want to be here on occasion. She said he cannot stand up and he is a Hoyer lift transfer. She said Resident #2 puts his bed up high even when we tell him to keep it low. ECA F said Resident #2 had a fall mat on the floor, in July he told me he would not be here long. She said they moved all his sharps and things in the bathroom, and Resident #2 cannot get them without assistance. She said they gave him a call bell if he needs anything, but the call light is still in the room. During an interview on [DATE] at 3:20 p.m. ESA L said Resident #2 had not told her he wanted to die. She said sometimes he said he want to go, get out of here, and he talked of going home to Arkansas or Oklahoma. She said the normal behavior for Resident #2 was agitated. he will throw cups and tables. ECA L said for last two months he had been a little nicer, spend most time in the room. During an interview on [DATE]at 3:24 p.m. ECA R said she worked here one year and said that Resident #2 was lonely. She said his family member used come a lot but does not anymore. She said he got (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 23 of 24 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 676311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some mad at the family member and would be depressed. She said when he is depressed, he just looks sad and disconnected from everything. ECA R said Resident #2 did not interact much with the others, but he did show some difference in his moods. She said she was told in July Resident # 2 wrapped the cord around his neck, but he said nothing to her about wanting to die. ECA R said Resident #2 did throw temper tantrums and would throw his self out of chair at times. ECA R said she did not know if he was just angry or trying to hurt himself for attention. She said when asked how did you fall or why did you fall Resident #2 would say thing like I just fell. During an interview on [DATE] at 4:05 p.m. the Maintenance Director said he was informed this morning that they wanted to remove the call light in Resident #2's room. He told whoever called him what to do to remove it. He said they called him about it still ringing when the cord was removed. He told them to just press reset button. He had not gone to check it out and he had not sent any of his guys to look at the issue. He said he did not know if the call light was still there or not. During an interview and record review on [DATE] at 5:04 p.m.[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676311 If continuation sheet Page 24 of 24