Health inspection·September 29, 2023

F 0761 -CHRONIC RESPIRATORY FAILURE WITH HYPOXIA Level of Harm - Minimal harm or potential for actual harm -PSORIASIS VULGARIS Medication orders are as follows: Residents Affected - Some Start date of 06/30/2022 Trelegy Ellipta Aerosol Powder Breath Activated 10062.5-25 MCG/INH (Fluticasone-Umeclidin-Vilant) 1 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION; CHRONIC RESPIRATORY FAILURE WITH HYPOXIA Start date of 05/08/2023 Triamcinolone Acetonide Cream 0.1 % Apply to legs topically every 12 hours as needed for psoriasis Attempted interview with LVN A on 09/27/23 06:06 AM, She stated that her shift ended at 6am, and she walked off without answering any further questions. Interview on 09/27/23 06:18 AM with LVN D, stated the carts should be locked at all times, LVN D stated that there was a resident that does wander around facility and does try to open the medication carts. LVN D stated that the resident could take a medication and it could lead to a negative outcome, it could even be very bad, such as an adverse reaction to the medication, allergic reaction and even death, depending on the med. Interview on 09/27/23 6:51 AM with MA E, stated that medication carts should be always locked. MA E stated that it is not supposed to happen no matter what. Nurses and med aids were to wait until medication is consumed and then leave the room, under no circumstances do you leave a medication with a resident. Interview on 09/27/23 9:26 AM with ADON stated that carts need to be always locked. No matter the circumstances. Medications should not be left in resident's room, and under no circumstances were medications to be left on bedside tables. ADON stated that she would in-service her staff regarding this concern. Interview on 09/27/23 9:34 AM with DON stated that carts need to be always locked, no matter what. Medications should not be left in resident's room, and under no circumstances were medications to be left on bedside tables. DON was asked what a negative outcome could be, she stated an adverse reaction for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676347 If continuation sheet Page 2 of 5 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 676347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/28/23 12:37 PM of Resident #20's bedside table revealed his Triamcinolone cream was left out on bedside table. Resident was asked if the medication was his, Resident #20 confirmed the cream was his for his skin. Interview on 09/29/23 11:00 AM with RN F stated that the policies that were provided were the policy that she has regarding medication being left out and not being locked up. Policy on locking the medication cart was provided, along with medication administration. No other policy provided by facility. Record review of policy provided by facility named Medication Carts, dated 2003 states but not limited to the following: 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use of under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building. 4. Carts must be secured. 5. Carts should be clean. 6. Should said equipment be found unsuitable for use or in need of general maintenance. This equipment includes medication carts, administration records, notebooks, and Emergency Kits facility or designee will repair/replace. Record review of policy provided by facility named Medication Administration Procedures, dated 2003 does not have any recommendations for medications being left at bedside of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676347 If continuation sheet Page 3 of 5 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 676347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 (Resident #7) of 17 Residents in that: Residents Affected - Few 1. LVN A did not perform hand hygiene during medication pass. 2. Observation during incontinent care for Resident #7 hand hygiene was not performed by NA B. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Observation and interview on 09/27/23 5:05 AM revealed LVN A, did not perform hand hygiene in between medication administration. LVN A stated that she performs hand washing after every 3rd resident. Observation on 09/27/23 05:24 AM revealed incontinent care performed by NA B and NA C, on Resident #7. Hand Hygiene was not performed by NA B and NA C before care started. NA B and NA C donned clean gloves, NA B removed dirty brief was removed, used wipes to clean residents genitals. Resident #7 was turned to the right side with assistance from NA C. NA B obtained a new brief, it was placed under resident, with gloves that were used to perform perineal care. Gloves were removed after the placement of the clean brief under Resident #7. NA removed gloves and discarded them in the trash, by and hygiene was not performed by NA B. New gloves were donned, Resident #7 was rolled back to his back, and the clean brief was then placed over the front of the resident and secured in place. Gloves were used to move dirty linens and then used to dress resident for the day. Interview on 09/27/23 05:54 AM with NA B stated that there was no hand sanitizer to use. NA B asked what a negative outcome would be NA stated infection. Interview was attempted interview with LVN A 09/27/23 06:06 AM, She stated that her shift ended at 6am, and she walked off without answering any further questions. Interview on 09/27/23 9:26 AM with ADON revealed that hand hygiene should be performed between each resident during med pass, when you enter the resident's room, before you administer meds, and after you leave the room, either with ABHS or with soap and water. Hand hygiene should be performed between the dirty and clean areas incontinent care for a resident. ADON was asked what a negative outcome could be from a lack of HH, ADON stated increased risk for infection. Interview on 09/27/23 9:34 AM with DON revealed that HH should be performed between each resident during med pass, when you enter the residents room, before you administer meds, and after you leave the room. Either with ABHS or with soap and water. Hand hygiene should be performed between the dirty and clean areas of incontinent care for a resident, and this could lead to increased risk for infection. DON stated that ADON will in-service staff and make the Nurse Educator aware of hand hygiene education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676347 If continuation sheet Page 4 of 5 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 676347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of policy titled Infection Control Policy & Procedure Manual 2019, Updated 03/2023 reveals the following but not limited to: 1. Hand Hygiene Hand hygiene continues to the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: . When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); . Record review of policy titled Perineal Care, dated 05/11/2022, reveals the following but not limited to: Procedure Content . 10.) Perform hand hygiene . .24.) Doff gloves and PPE 25.) Perform hand hygiene Conclude .30.) Tie off the disposable plastic bag of trash and/or linen 31.) Perform hand hygiene . Important Points Doffing and discarding of gloves are required if visibly soiled Always perform hand hygiene before and after glove use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676347 If continuation sheet Page 5 of 5