Health inspection·April 6, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record Review of Resident # 58's face sheet, dated 04/05/2023, reflected a [AGE] year-old female admitted the facility on 02/09/2022 with diagnoses which included age-related osteoporosis without current pathological fracture ( a disorder characterized by loss of bone mass and strength due to nutritional, metabolic, or other factors, usually resulting in deformity or fracture), need assistance with personal care ( actually performing a personal care task for a person), post-traumatic osteoarthritis , right shoulder (inflammation in your joints that forms after you've experienced a trauma), muscle weakness ( a lack of strength in muscles) and, muscle wasting and atrophy, multiple sites ( wasting/thinning or loss of muscle tissue). Record review of Resident # 58's Comprehensive Care plan, dated 02/28/2023, reflected Resident was at risk for falls related to gait/balance problems. Intervention: be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Resident #58 needed a safe environment such as a working and reachable call light. Discharge from the facility was not possible as shown by poor safety awareness and poor decision-making skills. Resident had osteoporosis and arthritis. Record review of Resident #58's Annual MDS Assessment, dated 02/10/2023, reflected Resident #58 had a BIMS score of 11 which indicated her cognition was mildly impaired. Resident #58 needed supervision with ADLs. Resident #58 had a fall during the assessment period. Observation on 04/04/2023 at 10:33 AM reflected Resident #58 was sitting in a recliner in her room. The call light was found on the floor near Resident #58's bed and approximately 4 feet from the residents' recliner. There was a clip attached to the call light. In an interview on 04/04/2023 at 10:35 AM Resident #58 stated staff will attach the call light near her if she was sitting in her recliner or was in her bed. She stated if she tried to pick up the call light she may fall. She also stated she preferred not to stand up without some help from the nurses. She also stated she had a softer voice. She did not yell very loud for people in the hall to hear her if she needed help with anything. She stated if she had an emergency or needed help, she would probably wait until someone came into her room. She stated staff did come into her room every few hours about every hour half or two hours. She stated the staff left her room few minutes ago after they had made her bed. She did not remember the staff's name. She stated after they had made her bed and left the room this is when she realized the call light was on the floor. She stated the call light was on the bed prior to the staff making her bed. and wouldn't be back in her room for another hour or more. In an interview on 04/06/2023 at 7:55 AM the Administrator stated residents call lights were expected to be placed by the resident when the resident was in their room. He stated the call light was to be attached to the bed, recliner, or the wheelchair anywhere the resident was laying or sitting in their room. He also stated a resident would not have a device to call for help if there was an emergency. He stated it may be difficult for a resident to yell for help or be heard if staff was not near the resident room. He stated it was a possibility a resident would not receive the assistance needed for an extended period. He stated there was a potential a resident attempt to pick up the call light from the floor and fall. He also stated if a resident waited long period of time the resident may attempt to assist themselves from the bed or chair. He stated a resident had a potential for any type of injury. He stated if a resident had an emergency related to some type of physical issue the issue had a potential of becoming more serious if the resident was not capable of calling for help and had to wait a long time such as an hour for assistance. He stated it was all staff's responsibility when the staff enters a room to ensure the call light was placed where resident could have access (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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 0558 to the call light immediately. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/06/2023 at 8:20 AM the Director of Nurses stated if a call light was not in reach when a resident was in their room, there was a possibility if they had an emergency or needed any type of assistance there was no device, they could use to alert staff they needed assistance. She stated some residents was able to yell loud, however, this was not the appropriate protocol for resident to yell for help. She stated a resident had a potential of becoming restless and attempt to assist themselves out of bed, wheelchair or recliner to find the call light or assist themselves to bathroom or whatever they needed from the staff. She also stated if a resident assisted themselves the resident may fall and have an injury from the fall. She stated it was all staff responsibility when the staff enters a resident room to check the call light to ensure it was in reach of the resident. Residents Affected - Few In an interview on 04/06/2023 at 8:35 AM LVN A stated all call lights were expected to be where a resident always had access to the call light when a resident was in the room. She stated if a resident was in wheelchair, recliner or in bed the call light was to be placed beside the resident. She also stated if a resident required assistance from staff for any type of reason and the call light was not in reach there was a potential a resident may need assistance immediately. She stated there was a potential a staff would not be in resident room again for another one - two hours. She stated it depended on the last time the staff made rounds on that resident. She also stated a resident may fall or have an emergency and would not have any device to alert staff they needed immediate care or assistance. In an interview on 04/06/2023 at 8:50 AM CNA F stated all residents call lights were to be placed by the resident no matter where the resident was sitting in their room. She stated if a resident had an emergency, the resident would not have a device to notify staff they needed assistance if the call light was on the floor or not in their reach. She stated there was a possibility anything could happen to a resident and the staff would not know the resident needed immediate nursing care. She stated all staff was expected to check the call lights when they enter a resident's room. In an interview on 04/06/2023 at 1:10 PM the Administrator stated the facility did not have a policy related to call lights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 7 residents (Resident #3 & #37) reviewed for resident assessment and care screening. Residents Affected - Few Facility failed to accurately complete the minimum data set for Resident #3's and Resident #37's oxygen therapy. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings include: Review of Resident #3's face sheet, dated 04/05/23, revealed a [AGE] year-old was admitted to the facility on [DATE] with diagnoses including Essential (Primary) Hypertension (abnormally high blood pressure), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and Shortness of Breath (difficult, painful or short of breath). Review of Resident #3's MDS, dated [DATE]. Revealed Resident #3's BIMS score was 12 (Out of 15) which indicated moderately impaired. Resident 3's MDS did not address the use of oxygen. Review of Resident #3's physician orders, dated 09/09/21, revealed Resident #3 may use oxygen at 2-4 liters per minute via nasal canula every 8 hours or as need. The oxygen order status was active on the physician orders dated 04/06/23. Observation on 04/04/23 10:15 am of Resident #3's room revealed an oxygen machine inside of the room. Observation on 04/05/23 1:15 pm of Resident #3's room revealed an oxygen machine inside of the room. Observation on 04/06/23 9:40 pm of Resident #3's room revealed an oxygen machine inside of the room. Review of Resident #37's face sheet, dated 04/05/23, revealed an [AGE] year-old was admitted to the facility on [DATE] with diagnoses including Respiratory Failure (a serious condition that makes it difficult to breathe on your own), Depression (constant feeling of sadness and loss of interest), and Hyperlipidemia (high cholesterol). Review of Resident #37's Care Plan, dated 03/07/23, did not address the use of oxygen Review of Resident #37's MDS, dated [DATE]. Revealed Resident #37's BIMS score was 5 (Out of 15) which indicated severe impairment. Resident #37's MDS did not address the use of oxygen. Review of Resident #37's physician orders, dated 04/05/23, revealed Resident #37 was admitted to skill services effective 12/02/22 with diagnoses of aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed). The diagnoses of aspiration pneumonia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 status was active on the physician orders, dated 04/05/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #37's oxygen stat summary, dated 04/05/23, revealed Resident #37 received oxygen via nasal cannula on 03/05/23, 01/20/23, and 01/19/23. Residents Affected - Few Observation on 04/04/23 10:45 am of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Observation on 04/05/23 1:45 pm of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Observation on 04/06/23 9:45 pm of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Interview with DON on 04/06/23 at 11:25am. DON stated that if a resident was on oxygen, then it should be reflected on the MDS and Care Plan. DON indicated its the MDS coordinator responsibility to complete the MDS and care plans. DON stated that resident #37 or Resident #3 do not use oxygen often. DON stated that if a resident was receiving oxygen, but it's not noted on the Care Plan then would not be able to provide appropriate care. Interview with MDS Coordinator on 04/06/23 at 11:30am MDS Coordinator stated if there is no documentation on treatment notes then oxygen would not be care planned or indicated on the MDS. MDS stated if the resident doesn't have an order, then there would be no treatment. MDS Coordinator stated she was responsible for entering the MDS and care plan but all IDT team members were included in gathering the information for both the MDS and Care Plan. Interview with CN on 04/06/23 at 11:45am CN stated that resident #37 used his oxygen last week. According to the CN Resident #37 was gotten better with using his nasal canula because at first, he would not also use it. CN stated that Resident #37 does use oxygen but not often. CN stated she has not seen Resident #3 use oxygen but was aware of the oxygen machine in Resident #3's room. Interview with Administrator on 04/06/23 at 1:25pm. The Administrator stated if a resident was using oxygen, then that residents' care plan and MDS should reflect the usage of oxygen. If the Resident's care plan or MDS does not reflect oxygen use, then the resident could possibly receive inadequate care. A record of review of the facility's Resident Assessment dated 2003 stated A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI) The assessment will include at least the following: A. Medically defined conditions and prior medical history B. Medical status measurement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 C. Level of Harm - Minimal harm or potential for actual harm Physical and mental functional status D. Residents Affected - Few Sensory and Physical impairments E. Nutritional status and requirements F. Special treatments or procedures G. Mental and psychosocial status H. Discharge potential I. Dental condition J. Activities potential K. Rehabilitation potential L. Cognitive status M. Drug therapy [NAME] assessments must be conducted within 14 days after the date of admission: promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or within two weeks, whichever is earlier); The facility will examine each resident and review minimum data set expanded core elements (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm specified in RAI no less than once every three (3) months and as appropriate. Results must be recorded to assure continued accuracy of the assessment. The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care. Residents Affected - Few The facility will coordinate assessments with the preadmission screening program in order to avoid duplicating testing and efforts of the resident and staff. Each assessment will be conducted or coordinated with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment. Any individual who willingly and knowingly certifies (or cause another individual to certify) a material and false statement in a resident assessment will be terminated and is subject to civil money penalties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 7 residents (Residents #3 & #37) reviewed for care plans. 1.Resident #3's comprehensive care plan did not address the resident's use of oxygen. 2. Resident #37's comprehensive care plan did not address the resident's use of oxygen. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. The findings included: Review of Resident #3's face sheet, dated 04/05/23, revealed a [AGE] year-old was admitted to the facility on [DATE] with diagnoses including Essential (Primary) Hypertension (abnormally high blood pressure), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and Shortness of Breath (difficult, painful or short of breath). Review of Resident #3's Care Plan, dated 01/12/23, did not address the use of oxygen. Review of Resident #3's MDS, dated [DATE]. Revealed Resident #3's BIMS score was 12 (Out of 15) which indicated moderately impaired. Resident 3's MDS did not address the use of oxygen. Review of Resident #3's physician orders, dated 09/09/21, revealed Resident #3 may use oxygen at 2-4 liters per minute via nasal canula every 8 hours or as need. The oxygen order status was active on the physician orders dated 04/06/23. Observation on 04/04/23 10:15 am of Resident #3's room revealed an oxygen machine inside of the room. Observation on 04/05/23 1:15 pm of Resident #3's room revealed an oxygen machine inside of the room. Observation on 04/06/23 9:40 pm of Resident #3's room revealed an oxygen machine inside of the room. Review of Resident #37's face sheet, dated 04/05/23, revealed an [AGE] year-old was admitted to the facility on [DATE] with diagnoses including Respiratory Failure (a serious condition that makes it difficult to breathe on your own), Depression (constant feeling of sadness and loss of interest), and Hyperlipidemia (high cholesterol). Review of Resident #37's Care Plan, dated 03/07/23, did not address the use of oxygen. Review of Resident #37's MDS, dated [DATE]. Revealed Resident #37's BIMS score was 5 (Out of 15) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 which indicated severe impairment. Resident 37's MDS did not address the use of oxygen. Level of Harm - Minimal harm or potential for actual harm Review of Resident #37's physician orders, dated 04/05/23, revealed Resident #37 was admitted to skill services effective 12/02/22 with diagnoses of aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed). The diagnoses of aspiration pneumonia status was active on the physician orders, dated 04/05/23. Residents Affected - Few Review of Resident #37's oxygen stat summary, dated 04/05/23, revealed Resident #37 received oxygen via nasal cannula on 03/05/23, 01/20/23, and 01/19/23. Observation on 04/04/23 10:45 am of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Observation on 04/05/23 1:45 pm of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Observation on 04/06/23 9:45 pm of Resident #37's room revealed Oxygen In Use signage in doorway and an oxygen machine inside of the room. Interview with DON on 04/06/23 at 11:25am DON stated that if a resident was on oxygen, then it should be reflected on the MDS and Care Plan. DON indicated its the MDS coordinator responsibility to complete the MDS and care plans. DON stated that resident #37 or Resident #3 do not use oxygen often. DON stated that if a resident was receiving oxygen, but it's not noted on the Care Plan then would not be able to provide appropriate care. Interview with MDS Coordinator on 04/06/23 at 11:30am MDS Coordinator stated if there is no documentation on treatment notes then oxygen would not be care planned or indicated on the MDS. MDS stated if the resident doesn't have an order, then there would be no treatment. MDS Coordinator stated she was responsible for entering the MDS and care plan but all IDT team members were included in gathering the information for both the MDS and care plan. Interview with CN on 04/06/23 at 11:45am CN stated that resident #37 used his oxygen last week. According to the CN Resident #37 was gotten better with using his nasal canula because at first, he would not also use it. CN stated that Resident #37 does use oxygen but not often. CN stated she has not seen Resident #3 use oxygen but was aware of the oxygen machine in Resident #3's room. Interview with Administrator on 04/06/23 at 1:25pm the Administrator stated if a resident was using oxygen, then that residents' care plan and MDS should reflect the usage of oxygen. If the Resident's care plan or MDS does not reflect oxygen use, then the resident could possibly receive inadequate care. A record of review of the facility's Comprehensive Care Planning dated 03/2018 stated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the followThe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Each resident will have a person-centered comprehensive care plan developed and implemented to meet the other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of fifteen residents (Resident # 39, Resident # 57 and Resident #10) reviewed for quality of care. Residents Affected - Some The facility failed to ensure Resident # 39's, Resident #57's and Resident #10's nails were trimmed and cleaned. These failures placed residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings include: Record Review of Resident # 39's face sheet, dated 04/05/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy, multiple sites ( decrease in size and wasting of muscle tissue), unspecified abnormalities of gait and mobility ( when a person is unable to walk in the usual way), lack of coordination (prevents people from being able to control the position of their arms and legs or their posture), and assistance with personal care ( actually performing a personal care task for a person). Record review of Resident #39's Annual MDS Assessment, dated 03/23/2023, reflected Resident #39 had a BIMS score of 9 which indicated her cognition was mildly impaired. Resident #39 needed supervision with ADLsS except for bathing and she needed physical help with one person assistance. Resident #39 had a fall during the assessment period. Resident #39 needed one person assistance with bathing. Record review of Resident # 39's Comprehensive Care plan, dated 04/04/2023, reflected Resident was at risk for falls. Intervention: be sure the resident's call light was within reach and encourage the resident o use it for assistance as needed. Resident had an ADL self-care performance deficit. Observation on 04/04/2023 at 9:39 AM, Resident #39 was in bed. Resident #39's fingernails on both hands had brownish/blackish substance underneath each fingernail. There was a blackish/brownish substance on the tip of her middle and ring finger on her right hand. In an interview on 04/04/2023 at 9:42 AM, Resident #39 stated she tried to remove something underneath her bottom, and she accidentally put her fingers in her bowels. She also stated she used her sheet to clean majority of the bowel. She stated she was not capable of removing the bowel mess from underneath her fingernails and on her fingertips. She stated this happed at night and she was not able to use the call light to ask for assistance. She stated the call light had been on the floor most of the night. She stated if you look my call light continues to be on the floor. She stated her nails needed to be clean every day and most nights. Record Review of Resident # 57's face sheet, dated 04/05/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy (progressive death of nerve fibers, which leads to loss of nerves and increased sensitivity. Cells do not respond normally to insulin), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination (prevents people from being able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some control the position of their arms and legs or their posture) and muscle weakness (when full effort does not produce a normal muscle contraction of movement) Record review of Resident #57's Quarterly MDS Assessment, dated 03/05/2023, reflected Resident #57 had a BIMS score of 10 which indicated her cognition was mildly impaired. Resident #57 did not have any behavior symptoms such as rejection of care. She required supervision with ADLs except for bathing. Resident #57 needed one-person assistance with bathing. Record review of Resident #57's Comprehensive Care Plan, dated 03/17/2023 reflected Resident #57 had an ADL self-care performance deficit. Resident #57 had diabetes mellitus. Observation on 04/04/2023 at 10:09 AM revealed Resident #57 was in her room lying in bed. Her nails on both hands were long and were jagged on the tips of the nails. There was brownish substance underneath the fore fingernail and the middle fingernail on her left hand and the middle fingernail and ring fingernail on her right hand. In an interview on 04/04/2023 at 10:11 AM, Resident #57 stated her nails needed to be trimmed and they were not smooth on the edges of her nails. She also stated her nails were dirty. She stated she did not know how her nails became dirty. She stated she was a diabetic (chronic, metabolic disease characterized by elevated levels of blood sugar) and a nurse was required to clean and trim her nails. She stated she did ask someone worked in nursing about her nails. She stated she did not recall the person's name. She stated she would clean her nails if she had a bowl of soap and water. Record Review of Resident # 10's face sheet, dated 04/05/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included need for assistance with personal care (actually performing a personal care task for a person), muscle wasting and atrophy, multiple sites ( decrease in size and wasting of muscle tissue), lack of coordination (prevents people from being able to control the position of their arms and legs or their posture) and, anoxic brain injury ( a complete lack of oxygen to the brain, short term symptoms such as dizziness or concentration problems, through to severe, long-term issues including vision, speech and memory). Record review of Resident #10's Quarterly MDS Assessment, dated 02/01/2023, reflected Resident #10 had a BIMS score of 10 which indicated his cognition was mildly impaired. Resident #10 needed supervision with ADLs. Record review of Resident #10's Comprehensive Care Plan, dated 03/15/2023 reflected Resident #57 had an ADL self-care performance deficit. Resident #57 had impaired visual function In an interview on 04/06/2023 at 7:55 AM the Administrator stated residents' nails were expected to be trimmed and cleaned as needed. Administrator stated the nursing staff was responsible to ensure the residents nails were trimmed and clean. The administrator stated if a resident were a diabetic a nurse would be responsible trimming or cutting residents fingernails or toenails. He also stated if resident's nails were long or jagged a resident had possibility of scratching themselves causing a skin tear. He stated resident's long nails needed to be avoided. He stated a resident may tear their nail off by getting the nail caught in their wheelchair or anything. He stated if a resident fingernail had blackish/brownish substance underneath their nails there was a possibility the substance had bacteria underneath their nails. With He stated if a resident picked up food with their hands the bacteria may transfer from their fingers onto the food. He also stated it was a possibility it may transfer bacteria onto the food and the resident may become physically ill with any type of food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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 0677 borne illness. He stated it was the nursing supervisor responsibility to monitor ADL care including nail care. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/06/2023 at 8:20 AM the Director of Nurses stated the cna's were responsible of cleaning and trimming/cutting residents nails except the residents with a diagnosis of diabetes. She stated any resident with a diagnosis of diabetes the nurse was responsible for all nail care including trimming and cleaning. She stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the residents nails. She stated if the resident were eating food with their hands there was a potential a resident could ingest bacteria transferred from their hands and/or fingernails onto their food. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. She also stated a resident could become ill with stomach issues and develop diarrhea or vomiting. She stated if resident nails were long and/ or jagged there was a possibility a resident may get their nails hung on something such as their wheelchair and could rip their nail off their finger. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection. Residents Affected - Some In an interview on 03/06/2023 at 8:35 AM, LVN A stated nurses gave nail care for all residents with a diagnosis of diabetes. She stated the cna's and nurses was responsible to monitor residents' nails. She stated residents' nail care was usually checked and the residents' nails were trimmed /cleaned on Sundays if needed. She stated the residents' nails were to be clean and trimmed during the week if anyone observed the nails being long and/or dirty. She stated a resident with uneven nails had a potential of developing a skin tear from scratching themselves with long/uneven nails. She stated if a resident had brownish/blackish substance on the tip of their finger and/ or underneath their fingernails there was a potential the substance may be feces or any type of bacteria. She stated a resident had a potential of aspiration if they swallowed portion of the substance. She also stated few of the residents did use their hands to eat instead of using utensils and there was a possibility the bacteria could transfer onto the food. She stated a resident may develop stomach infection or e coli. She also stated a resident may become nauseated causing a resident to vomit and/or have diarrhea. She stated it was a possibility a resident may need to be treated at the emergency room. In an interview on 04/05/2023 at 8:50 AM the CNA F stated residents nails were trimmed and cleaned usually on Sundays. She stated sometimes a resident fingernail required to be trimmed and cleaned throughout the week. She also stated anytime a staff observed a residents nails needed to be cleaned or trimmed they were to trim and clean the residents' nails except if the resident was a diabetic and these residents nails were clean and/ or trimmed by a nurse. She stated if a resident scratched themselves, it was a possibility a resident may develop a skin tear and an infection to the skin if their nails were dirty. She also stated if a resident's nails were dirty and they put their fingers in their mouth for any type of reason, a resident possible may become sick with stomach virus or stomach infection. She stated a resident may need to require medical care at the hospital. Record review of facility policy Nail Care, dated 2003, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nail care will be performed regularly and safely. The residents will be free from abnormal nail conditions. Immerse hands or feet in a basin of warm soapy water to cleanse and soften the nails for cleansing and trimming. Use a soft brush if necessary to cleanse under and around the nails. Remove debris (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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 0677 Level of Harm - Minimal harm or potential for actual harm from under the nails with an orange stick and pat dry. Smooth the nails with an emery board. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility must ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice one (Resident #39) of two oxygen concentrators reviewed for essential equipment. Residents Affected - Few The facility failed to change nasal cannula tubing of Resident #39 as ordered by the physician. This failure could affect the resident by increasing the risk of respiratory infection. Findings included: Review of Resident #39's face sheet dated 4/6/2023 revealed an [AGE] year-old female admitted to the facility 8/10/2021 with diagnoses of dementia, muscle wasting, chronic obstructive pulmonary disease, and anxiety. Review of Resident #39's Quarterly MDS dated [DATE] reflected, she had shortness of breath with exertion (e.g., walking, bathing, transferring) and received oxygen therapy. Review of Resident #39's physician orders dated 8/10/2021 revealed an order for oxygen administration at 2-3 liters per minute via nasal cannula. Further review revealed a physician order dated 8/10/2021, to change respiratory tubing, mask, bottled water, and clean filter every 7 days. Observation on 04/06/2023 at 2:30 p.m. revealed Resident #39's oxygen nasal cannula tubing worn by the Resident #39 with a date written on the tubing, 03/26/23. The distilled water connected to the concentrator was dated 04/01/23 on the humidifier bottle. Interview on 04/06/2023 at 3:45 p.m., LVN I was asked regarding the importance of changing the Resident's oxygen tubing. LVN I stated it is protocol for the Sunday night shift to change all the oxygen tubing. LVN I further state this deficiency can place the resident at risk for infection. Interview on 04/06/2023 at 04:00 p.m., the DON was asked regarding not changing oxygen tubing after 7 days as ordered by the physician. The DON stated that is protocol for the Sunday night shift to change all the oxygen tubing with a physician's order. The DON further stated this deficiency can place the resident at risk for infection. Interview on 04/06/2023 at 04:00 p.m., the Administrator was asked regarding the oxygen tubing not being changed. The Administrator stated this deficiency if there is a physician's order to change the oxygen tubing and the oxygen tubing is not changed as ordered. Review of facility policy titled, Changing Nasal Cannulas/Mask dated 10/11/2022, revealed Change the tubing (including any nasal progs or mask that is in use on one patient when it malfunctions or becomes visibly contaminated .If you have any active orders to change oxygen tubing, cannulas or mask; those will need to be discontinued. If not discontinued, you can get cited for failing to follow physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. The findings included: During an observation and record review on 4/4/2023 at 12:00 p.m., an inspection of the medication cart#1, revealed a form titled, Controlled Drugs-Audit Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 4/3/2023, and 4/4/2023 by LVN H. During an observation and record review on 4/5/2023 at 12:00 p.m., an inspection of the medication cart #2, revealed a form titled, Controlled Drugs-Audit Record (Narcotic count sheet at each change of nursing shift), with missing a signature for the following date of 4/4/2023 by CMA E. During an interview on 4/5/2023 at 2:30 p.m., CMA E for cart #1 stated she has been aware of the missing signature and stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. During an interview on 4/6/2023 at 2:40 p.m., LVN H for cart #2 stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. During an interview on 4/6/2023 at 2:40 p.m., the Director of Nursing DON was informed of the above findings. The DON stated she has acknowledged the possible noncompliance and stated that if not in compliance, that it can be a detriment to the residents. During an interview on 4/6/2023 at 4:00 p.m. with the Administrator was informed of the above findings. He has acknowledged the noncompliance and stated that it can be a detriment to the residents. Record review of the facility's policy titled, Medication Administration Procedures, dated 10/25/2017, revealed, .16. There shall be a narcotic audit at each change of shift to ensure against any discrepancy. Upon a correct audit, the nurses involved will sign the Narcotic Check List at the time of the audit, the nurses are to observe for correct count and correct medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (#35) of two residents observed for infection control in that: Residents Affected - Few After using the blood pressure machine on Resident #55, CMA D did not sanitize the Blood pressure machine prior to placing the blood pressure machine on Resident #35 to measure blood pressure. This deficient practice could place the facility's residents at risk of infection while having their blood pressure taken in the facility and could result in cross contamination of germs. The findings included: Review of Resident #55's BIMS revealed a score of 12 and a requirement for blood pressure to be taken prior to medication administration. Review of Resident #35's BIMS revealed a score of 10 and a requirement for blood pressure to be taken prior to medication administration. Observation on 04/05/2023 at 09:30 a.m., revealed CMA D taking Resident #55's blood pressure with a wrist blood pressure cuff prior to administering medication. After CMA D completed administering medication for Resident #55, CMA D took the same wrist blood pressure cuff and placed it on Resident #35 to take the blood pressure reading without cleaning the equipment. Further observation revealed that a container labeled sanitizing wipes was in the bottom drawer of the medication cart. Interview on 04/05/2023 at 09:45 a.m. with CMA D, was asked not sanitizing the blood pressure cuff between Resident #55 and Resident #35. CMA D revealed that she is aware of the importance of cleaning equipment between resident use, but she forgot to clean the blood pressure monitor before placing the wrist cuff on Resident #35. During an interview on 4/6/23 3:00 p.m., the DON stated she has acknowledged the noncompliance of not sanitizing the blood pressure cuff prior to use and stated that it is not in compliance as well as risk of infection to the residents. During an interview on 4/6/2023 at 04:00 p.m., the Administrator stated he has stated she has acknowledged the noncompliance of not sanitizing the blood pressure cuff prior to use and stated that it is not in compliance as well as risk of infection to the residents. Record review of the facility's policy titled, Fundamental of Infection Control Precautions, dated 3/2023, revealed, .6. Resident care equipment and articles .3. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant by the nursing assistant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676427 If continuation sheet Page 17 of 17