Health inspection·February 24, 2023

F 0558 not reach his call light. Level of Harm - Minimal harm or potential for actual harm During an observation on 02/14/2023 at 8:30 a.m., Resident # 11's call light was laying on the floor inaccessible to Resident #11. Residents Affected - Some During an observation on 02/14/2023 at 11:52 a.m., Resident # 11's call light was laying on the floor inaccessible to Resident #11. During an interview on 2/15/23 at 2:00 p.m., DON stated that he expects that residents will have access to call lights while in their bed. He stated that a resident could be placed at risk for harm if they were unable to call for help. During an interview on 2/15/23 at 105 p.m., the Administrator indicated that he would expect that all residents had access to their call lights while in their room. He stated that the call light should be within reach of the resident. He stated that each resident's needs should be taken into account when determining if a resident could reach their call light. He stated that their facility will use the pad call light for a resident that does not have the ability to push a call light button. Record review of the facility's policy and procedure titled Answering Call Light undated indicated that the purpose of this policy was . The purpose of this procedure is to ensure responses to the resident's requests and needs Make sure the call light is in reach of the resident when in bed or siting in the wheelchair or recliner in their room Some residents may not be able to use the call light. Keep it placed near the resident in case you need to summon help. These residents will need to be checked more frequently than others. Record review of the face sheet dated 02/16/23 revealed Resident #40 was [AGE] year-old male admitted on [DATE] with diagnoses including muscle weakness (decreased strength in the muscles), lack of coordination, difficulty walking, muscle wasting and atrophy (the wasting (thinning) or loss of muscle tissue), history of falling, and need for assistance with personal care. Record review of the quarterly MDS dated [DATE] revealed Resident #40 was understood and understood others. The MDS revealed Resident #40 had a BIMS of 08 which indicated mild cognitive impairment and required extensive assistance for bed mobility, transfer, dressing, toilet use, and bathing. The MDS revealed Resident #40 had limited range of motion to upper and lower extremities on one side. Record review of Resident 40's care plan dated 12/27/22 revealed potential to have falls. Resident #40 received multiple medications. Resident #40 have history of falls prior to admission. Resident #40 have chronic atrial fibrillation (is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart) anemia (a low number of red blood cells), weakness late effects of cerebrovascular accident (stroke; damage to the brain from interruption of its blood supply) with poor safety awareness and diagnosis of dementia (progressive or persistent loss of intellectual functioning), and history of seizures (is a sudden, uncontrolled burst of electrical activity in the brain). Interventions included encourage to use call light and to ask for assistance as needed, keep call light and frequently used items in reach, and 2 staff weight bearing assistance with transfers. During an observation on 02/13/23 at 11:04 a.m., Resident #40 was lying in bed with nasal cannula on his face. Resident #40's call light was laying on the floor near his nightstand table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 2 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 Level of Harm - Minimal harm or potential for actual harm During an observation on 02/13/23 at 2:26 p.m., Resident #40 was lying in bed with nasal cannula on his face. Resident #40's call light was draped over his nightstand table not within reach. During an observation on 02/14/23 at 08:25 a.m., Resident #40 was lying in bed with nasal cannula on his face. Resident #40's call light was laying on the floor near his nightstand table. Residents Affected - Some During an observation on 02/14/23 at 4:11 p.m., Resident #40 was lying in bed with nasal cannula on his face. Resident #40's call light was laying on the floor near his nightstand table. During an interview on 02/15/23 at 3:30 p.m., LVN F said Resident #40 could use his call light. She said Resident #40 call light should be always in reach to get assistance and all staff should make sure it was. LVN F said nurses and aides should check for placement during rounds, passing out medications, water, and snacks, or after providing care. She said if resident are unable to perform ADLs independently, then they need a way to get help. During an interview on 02/15/23 at 3:53 p.m., CNA G said Resident #40 could and did use his call light. She said she has arrived for her 3pm-11pm shift and found Resident #40's call light on the floor. CNA G said she made sure to wrap the cord around the half rail to help it not fall on the floor. She said Resident #40's call light needed to be within reach in case he needed something. CNA G said it was primarily the aide's responsibility to keep call lights within reach because they had the most contact with residents. She said but anyone who came into the room and noticed the call light on the floor should place it within reach or notify nursing staff. During an observation and interview on 02/15/23 at 4:08 p.m., Resident #40 was sitting up in his bed with his call light wrapped around half rails, within reach. Resident #40 said sometimes his call light is on the floor or not within reach which happened a few times a week. He said he has needed help before, and his call light was on the floor but could not remember when it happened. Resident #40 said he just had to wait until someone showed up. He said his call light was on the floor on Monday (02/13/23) and Tuesday (02/14/23) of this week. During an interview on 02/15/23 at 4:13 p.m., CNA/CMA H said Resident #40 could use his call light. She said Resident #40's call light should always within reach to get help. CNA/CMA H said when call lights are not within reach, needs are not met, or falls could happen. She said all nursing staff should make sure resident's call lights are within reach. During an interview on 02/16/23 at 8:40 a.m., the Unit Manager C said Resident #40 resided on her unit. She said Resident #40 could use his call light to get assistance or help. She said all staff should make sure call lights were in reach during every 2-hour rounds. The Unit Manager C said call lights are for getting help or assistance so needed to be within reach. Record review of the face sheet dated 02/16/23 revealed Resident #240 was [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side, and ataxia (impaired balance or coordination, can be due to damage to brain, nerves, or muscles). Resident #240 was admitted to the facility less than 21 days ago. No MDS for Resident #240 was completed prior to exit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 3 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #240's baseline care plan dated 02/08/23 revealed alert/oriented with confusion at times and soft voice. The baseline care plan revealed history/potential for falls d/t mechanical lift with no interventions noted. The baseline care plan revealed bed mobility assists of 2 staff, dependent on staff, transfer via mechanical lift, walking/mobile per wheelchair, dependent on staff, toileting assist and grooming/hygiene of 1 staff, and dependent on staff for bathing. Resident #240's was admitted to the facility less than 21 days ago. No comprehensive care plan for Resident #240 was completed prior to exit. During an observation and interview on 02/13/23 at 12:01 p.m., Resident #240 was sitting is his wheelchair slumped forward, head hanging down with his left arm hanging down the outside of the wheelchair. Resident #240 had beads of sweat noted to the top of his head and labored breathing. Resident #240 said he needed help to scoot up in the wheelchair but could not find his call light. Resident #240 call light was attached to the top portion of his jacket and the open, top portion was covering the call light. The call light was attached to his stroke affected side (left) and Resident #240 could not lift his arm up reach it. Resident #240 said he was too tired to reach with his right hand to grab the call light on his left shoulder. During an interview on 02/15/23 at 2:07 p.m., CNA B said Resident #240 had left sided weakness from a stroke. She said she would place Resident #240's call light on his right side because he had more mobility on that side. CNA B said it was important to have call lights within reach to prevent falls and so residents can get help. She said it was the CNAs responsibility to make sure call lights were within reach when they got the resident up and any staff member who goes in the room should also check for placement. CNA B said on 02/13/23, she did not have Resident #240 but did go in the room to help pull him up. She said Resident #240's left arm was hanging down on the outside of his wheelchair probably causing him to slide out of the chair. CNA B said she did not recall where the call light was when she arrived in Resident #240's room. She said CNA K was assigned to Resident #240 but therapy had recently dropped him off in his room so he could eat lunch. During an interview on 02/15/23 at 2:34 p.m., Unit Manager D said she answered Resident #240's call light on 02/13/23. She said Resident #240 had a stroke which affected the left side of his body. The Unit Manager D said when she arrived in Resident #240's room, the call light was attached to the left side of his body, not within reach. She said resident's call lights should be within reach to get help. The Unit Manager D said when call lights are not within reach, residents needs could not be met. She said it was everyone's responsibility to make sure call lights are within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 4 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #4) residents reviewed for abuse. Residents Affected - Few The facility staff did not immediately report the state agency Resident #4's outcry that she was abused. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin. Findings included: Record review of the facility's Abuse Investigation and Reporting policy dated 6/01/21 indicated, All allegations of abuse will be referred to the Abuse Committee for interventions .Mistreatment or abuse of any nature including neglect, verbal, mental, social, sexual or physical abuse will not be tolerated and any employee who is found guilty of abusing a resident is subject to immediate discharge with referral to the local enforcement agency and State Regulatory Agency All allegations of abuse will be referred to the Abuse Committee for interventions reporting and follow-up with local and state agencies Record review of Resident #4's face sheet dated 12/26/22 indicated Resident #4 was a [AGE] year-old female, admitted to the facility on [DATE]. Shows that Resident #4 is diagnosed with Stable Angina, Chronic diastolic heart failure compensated, Emphysema, Hypertension, Osteoarthritis hands, Degenerative Disk Disease Lumbar and neck, Closed fracture of right hip, Bipolar Depression and grief daughter passed away, History of psychosis. Record review of Resident #4's care plan undated indicated Resident #4 will, I may recall something I have seen on TV or dream about and think it is real Record review of the MDS dated [DATE] indicated Resident #4 showed a BIMS (Brief interview for mental status) score of 12 which shows mild impairment to understand. The MDS indicated Resident #4 extensive assistance with mobility. Record review of Resident #4's nursing progress note (missing note from charts provided to state agency anonymously by an anonymous individual) documented by LVN L dated 12/28/22 at 12:00 p.m. indicated, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to lift leg off bed when said nurse made resident aware that she was indeed lifting leg off mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time During an interview with Resident #4 on 02/16/2023 at 8:28 a.m. She stated that about one year ago a black man picked her up by her wrists and ankles and threw her against a wall. She said it happened last January. She said that she did not know his name except he was huge and fat. She said he weighed about 600 pounds. She said she did not go to a hospital when this happened. She said she is not hurt. She said she has not seen that man since it happened. She said she did not know his name. She stated that she did not have any marks or bruising on the visible areas of her body. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 5 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN L on 02/23/2023 at 3:13 PM she stated that she worked on A wing with Resident #4 and she worked with her last December of 2022. She said that she knew that Resident #4 had some falls in December but she does not remember the exact date. She said that she believed she had more than one fall in December. She said that she is not sure if Resident #4 alleged any abuse by a staff in December. She said that the nurses note 12/28/22 at 12:00 p.m. that says, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to lift leg off bed when said nurse made resident aware that she was indeed lifting leg off mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time. was signed by her on 12/28/2022 at 12:00 p.m. She said that she does not know why this nurses note was missing from the charts. She said that the protocol for reporting abuse is to speak to the Administrator or the DON. She said that she reported this incident to LVN M which is her unit manager. During an interview with LVN M on 02/23/2023 at 4:00 p.m. she stated that she never received a report from LVN L stating that Resident #4 was assaulted by a staff. During an interview on 2/23/23 at 12:02 p.m. the DON said the administrator was responsible for reporting incidents to the state agency. The DON said some incidents should be reported within 2 hours and other incidents should be reported within 24 hours. The DON said she would have to look up what incidents needed to be reported when. The DON said Resident #4 was admitted to the hospital when she started at the facility. The DON said the importance of incidents being reported in a timely manner to ensure resident safety. I do not know why LVN L failed to report this allegation. The DON stated he was not aware of this incident until he was made aware by the state agency on 2/16/23. During an interview on 2/24/23 at 11:33 a.m. the Administrator said the types of incidents that should be reported to the state agency included falls with injury, abuse, neglect, resident to resident altercations, and injury of unknown origin. The Administrator said incidents should be reported to the state agency within 24 hours depending on the severity. The Administrator said the facility had a 2-hour window for most reportable incidents, unless the facility was trying to determine what was going on. All staff in the facility is required to report in these time frames. The Administrator said that if a staff was told by a resident, they should have reported the incident to him the abuse coordinator. If an incident was reported to a supervisor, then that supervisor should report to him as well. He believes that LVN L did not report this incident because Resident #4 has a history of making false reports. The Administrator stated he was not aware of this allegation until the state agency informed him of the details on 2/16/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 6 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 it was determined the facility failed to ensure all alleged violations involving neglect and abuse were reported immediately or within 2 hours for 1 of 10 residents (Resident #4) reviewed for reporting in that: The facility failed to report to the State agency Resident #4 had alleged abuse on 12/28/2022. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin. Findings Include: Record review of Resident #4's face sheet dated 12/26/22 indicated Resident #4 was a [AGE] year-old female, admitted to the facility on [DATE]. Shows that Resident #4 is diagnosed with Stable Angina, Chronic diastolic heart failure compensated, Emphysema, Hypertension, Osteoarthritis hands, Degenerative Disk Disease Lumbar and neck, Closed fracture of right hip, Bipolar Depression and grief daughter passed away, History of psychosis. Record review of the MDS dated [DATE] indicated Resident #4 showed a BIMS (Brief interview for mental status) score of 12 which shows mild impairment to understand. The MDS indicated Resident #4 extensive assistance with mobility. Record review of Resident #4's nursing progress note (missing note from charts provided to state agency anonymously by an anonymous individual) dated 12/28/22 at 12:00 p.m. indicated, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to lift her leg off bed when said nurse made resident aware that she was indeed lifting leg off mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time Record review of Resident #4's care plan undated indicated Resident #4 will, I may recall something I have seen on TV or dream about and think it is real During an interview with Resident #4 on 02/16/2023 at 8:28 a.m. She stated that about one year ago a black man picked her up by her wrists and ankles and threw her against a wall. She said it happened last January. She said that she did not know his name except he was huge and fat. She said he weighed about 600 pounds. She said she did not go to a hospital when this happened. She said she is not hurt. She said she has not seen that man since it happened. She said she did not know his name. She stated that she did not have any marks or bruising on the visible areas of her body. During an interview with LVN L on 02/23/2023 at 3:13 PM she stated that she worked on A wing with Resident #4 and she worked with her last December of 2022. She said that she knew that Resident #4 had some falls in December but she does not remember the exact date. She said that she believed she had more than one fall in December. She said that she is not sure if Resident #4 alleged any abuse by a staff in December. She said that the nurses note 12/28/22 at 12:00 p.m. that says, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to lift leg off bed when said nurse made resident aware that she was indeed lifting leg off (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 7 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time. was signed by her on 12/28/2022 at 12:00 p.m. She said that she does not know why this nurses note was missing from the charts. She said that the protocol for reporting abuse is to speak to the Administrator or the DON. She said that she reported this incident to LVN M which is her unit manager. Residents Affected - Few During an interview with LVN M on 02/23/2023 at 4:00 p.m. she stated that she never received a report from LVN L stating that Resident #4 was assaulted by a staff. She stated she was not made aware of this allegation until the state agency informed her of the details at the present time. During an interview on 2/23/23 at 12:02 p.m. the DON said the administrator was responsible for reporting incidents to the state agency as well as himself if the Administrator is not available. The DON said some incidents should be reported within 2 hours and other incidents should be reported within 24 hours. The DON said the importance of incidents being reported in a timely manner to ensure resident safety. The DON said that if a staff was told by a resident they were abused by another staff then they should have ensured the immediate safety of the resident, ensure the resident was physically well, and the report the allegation of abuse to the administrator. The DON stated he was not aware of this incident until he was made aware by the state agency on 2/16/23 During an interview on 2/24/23 at 11:33 a.m. the Administrator said the types of incidents that should be reported to the state agency included falls with injury, abuse, neglect, resident to resident altercations, and injury of unknown origin. The Administrator said incidents should be reported to the state agency within 24 hours depending on the severity. The Administrator said the facility had a 2-hour window for most reportable incidents, unless the facility was trying to determine what was going on. All staff in the facility is required to report in these time frames. The Administrator said that if a staff was told by a resident, they should have reported the incident to him the abuse coordinator. If an incident was reported to a supervisor, then that supervisor should report to him as well. He believes that LVN L did not report this incident because Resident #4 has a history of making false reports. The Administrator stated he was not aware of this allegation until the state agency informed him of the details on 2/16/2023 Record review of the facility's Abuse Investigation and Reporting policy dated 6/01/21 indicated, Mistreatment or abuse of any nature including neglect, verbal, mental, social, sexual or physical abuse will not be tolerated and any employee who is found guilty of abusing a resident is subject to immediate discharge with referral to the local enforcement agency and State Regulatory Agency FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 8 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse, for one Resident (#4), of five residents reviewed for abuse, in that: Residents Affected - Few Resident #4 made an allegation of physical abuse by staff. The facility did not thoroughly investigate the allegation. There was no evidence of interviews with pertinent staff or other residents regarding the allegation. This failure could place the resident at risk for uninvestigated allegations of abuse, neglect, and injuries of unknown origin. Findings included: Record review of the facility's Abuse Investigation and Reporting policy dated 6/01/21 indicated, All allegations of abuse will be referred to the Abuse Committee for interventions .Mistreatment or abuse of any nature including neglect, verbal, mental, social, sexual or physical abuse will not be tolerated and any employee who is found guilty of abusing a resident is subject to immediate discharge with referral to the local enforcement agency and State Regulatory Agency The facility will conduct an investigation of an alleged abuse/neglect or injury of unknown origin, violation of social media, and misappropriation of resident property in accordance with state law Record review of Resident #4's face sheet dated 12/26/22 indicated Resident #4 was a [AGE] year-old female, admitted to the facility on [DATE]. Shows that Resident #4 is diagnosed with Stable Angina, Chronic diastolic heart failure compensated, Emphysema, Hypertension, Osteoarthritis hands, Degenerative Disk Disease Lumbar and neck, Closed fracture of right hip, Bipolar Depression and grief daughter passed away, History of psychosis. Record review of Resident #4's care plan undated indicated Resident #4 will, I may recall something I have seen on TV or dream about and think it is real Record review of the MDS dated [DATE] indicated Resident #4 showed a BIMS (Brief interview for mental status) score of 12 which shows mild impairment to understand. The MDS indicated Resident #4 extensive assistance with mobility. Record review of Resident #4's nursing progress note (missing note from charts provided to state agency anonymously by an anonymous individual) dated 12/28/22 at 12:00 p.m. indicated, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to lifteft leg off bed when said nurse made resident aware that she was indeed lifting leg off mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time During an interview with Resident #4 on 02/16/2023 at 8:28 a.m. She stated that about one year ago a black man picked her up by her wrists and ankles and threw her against a wall. She said it happened last January. She said that she did not know his name except he was huge and fat. She said he weighed about 600 pounds. She said she did not go to a hospital when this happened. She said she is not hurt. She said she has not seen that man since it happened. She said she did not know his name. She stated that she did not have any marks or bruising on the visible areas of her body. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 9 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0610 Level of Harm - Minimal harm or potential for actual harm During an interview with CNA (V) on 02/16/2023 at 9:30 a.m. she stated that she has not been told that Resident #4 alleged that she was being physically abused by a male staff. She stated that she has never seen Resident #4 fall or seen her laying on the floor. She stated that she does not have any concerns for Resident #4 She stated that she has not heard that a staff picked Resident #4 up and threw her against a wall. Residents Affected - Few During an interview with CNA (W) on 02/23/2023 at 2:50 p.m., stated that he has worked at Marshall Manor since December of 2022. He stated that he started the week before Christmas. He stated that he worked on A wing. He stated that he worked the 3:00 p.m. to 11 p.m. shift. He stated that he did not work with Resident #4 any while working at Marshall Manor after his first day with her. He stated that after the first week of him working at Marshall Manor Resident #4 said she was not comfortable with a male staff and LVN M said for him to not work with Resident #4 any longer and he would not be scheduled to work with Resident #4. He stated that if he did work on the hall Resident #4 is on he was to not work with Resident #4 directly. He stated that he has worked in Resident #4's room before but if Resident #4 needed direct care another nurse or CNA would assist her. He stated that he is not allowed to do direct care with Resident #4. He stated that he is allowed to do simple tasks like answer her call light or get her a soda. He stated that he does come into contact with Resident #4 while working. He stated that he is not allowed to be hands on with resident #4. He stated that he did not know if he worked on 12/28/2022. He stated that he does not know if Resident #4 says anything that is inappropriate. He stated that she has not said anything to make him angry. He stated that she has never said anything racist to him before. He stated that he does know that Resident #4 says some racist remarks. He said that she has never made any of those racist remarks in front of him before. He said that the remarks do not make him angry. He stated that he has never harmed Resident #4. He stated that he has never picked Resident #4 up or have been rough with her. He stated that he doesn't have anything else that I want to share. He stated that today is the first day that he has learned that Resident #4 said he abused her. During an interview with LVN L on 02/23/2023 at 3:13 p.m., PM she stated that she worked on A wing with Resident # 4 and she worked with her last December of 2022. She said that she knew that Resident #4 had some falls in December but she does not remember the exact date. She said that she believed she had more than one fall in December. She said that she is not sure if Resident #4 alleged any abuse by a staff in December. She said that the nurses note 12/28/22 at 12:00 p.m. that says, Called to room to answer resident call light. Upon entering room resident stated that she could not move leg. But was able to left leg off bed when said nurse made resident aware that she was indeed lifting leg off mattress. Resident stated, Just go. I know you don't believe. Yall let that nigger throw me into the wall four times and nobody did a thing about it. Said nurse exited room at this time. was signed by her on 12/28/2022 at 12:00 p.m. She said that she does not know why this nurses note was missing from the charts. She said that the protocol for reporting abuse is to speak to the Administrator or the DON. She said that she reported this incident to LVN M which is her unit manager. During an interview with LVN M on 02/23/2023 at 4:00 p.m. she stated that she never received a report from LVN L stating that Resident #4 was assaulted by a staff. She stated she was not made aware of this allegation until the state agency informed her of the details at the present time. During an interview on 2/23/23 at 12:02 p.m. the DON said the administrator was responsible for reporting incidents to the state agency as well as himself if the Administrator is not available. The DON said some incidents should be reported within 2 hours and other incidents should be reported within 24 hours. The DON said the importance of incidents being reported in a timely manner to ensure resident safety. The DON said that if a staff was told by a resident they were abused by another staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 10 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete then they should have ensured the immediate safety of the resident, ensure the resident was physically well, and the report the allegation of abuse to the administrator. The DON stated he was not aware of this incident until he was made aware by the state agency on 2/16/23. During an interview on 2/24/23 at 11:33 a.m. the Administrator said the types of incidents that should be reported to the state agency included falls with injury, abuse, neglect, resident to resident altercations, and injury of unknown origin. The Administrator said incidents should be reported to the state agency within 24 hours depending on the severity. The Administrator said the facility had a 2-hour window for most reportable incidents, unless the facility was trying to determine what was going on. All staff in the facility is required to report in these time frames. The Administrator said that if a staff was told by a resident, they should have reported the incident to the abuse coordinator which is myself. If reported to a supervisor, then that supervisor should report to me as well. I believe that LVN L did not report this incident because Resident #4 has a history of making false reports. The Administrator stated he was not aware of this allegation until the state agency informed him of the details on 2/16/2023 Event ID: Facility ID: 455646 If continuation sheet Page 11 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 21 residents reviewed for assessments. (Resident #2 and Resident #26) in that: Residents Affected - Few Resident assessments for Resident #2 and Resident #26 did not reflect that each resident was PASSR positive. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of the face sheet dated 02/14/23 indicated Resident #2 was [AGE] years old and was admitted [DATE]. Record review of consolidated physician's orders dated 02/15/23 indicated the Resident #2 had diagnoses including renal failure (kidney failure), mild cognitive impairment, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of the most recent MDS dated [DATE] indicated Resident #2 was understood and understood others. Resident #2 had a BIMS score of 13 indicating the resident was cognitively intact. Section A1500 of the MDS indicated Resident #2 was not considered by the State level II PASSR process to have serious mental illness and/or intellectual disability or a related condition. Record review of a care plan initiated on 02/06/23 indicated Resident #2 had positive PASSR eligibility related to the resident's mental illness Major Depressive Disorder with inpatient treatment 11/23/18. The care plan indicated Resident #2 was eligible and would benefit from specialized services. Record review of a PASSR Evaluation dated 12/05/18 indicated Resident #2 met the PASSR definition of mental illness. 2. Record review of the face sheet dated 02/15/23 indicated Resident #26 was [AGE] years old and was admitted [DATE]. Record review of consolidated physician's orders dated 02/15/23 indicated the Resident #26 had diagnoses including paranoid schizophrenia (a disorder that affects a person's ability to thing, feel, and behave clearly. This includes delusions and hallucinations), social phobia (a chronic mental health condition in which social interactions cause irrational anxiety), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of the most recent MDS dated [DATE] indicated Resident #26 was understood and understood others. Resident #26 had a BIMS score of 15 indicating the resident was cognitively intact. Section A1500 of the MDS indicated Resident #26 was not considered by the State level II PASSR process to have serious mental illness and/or intellectual disability or a related condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 12 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a care plan initiated on 01/25/23 indicated Resident #26 had positive PASSR eligibility due to the resident's developmental disability. The care plan indicated Resident #26 was eligible for specialized services through the local mental health authority. Record review of a PASSR Evaluation dated 10/26/21 indicated Resident #26 met the PASSR definition of mental illness. During an interview on 02/14/2023 at 11:00 a.m., the MDS Coordinator stated Resident #2 was PASRR positive for mental illness. She said Resident #26 was PASRR positive for mental illness and intellectual disabilities. The MDS Coordinator stated it was an oversight on her part that Resident #2's 01/31/2023 annual MDS and Resident #26's 12/07/2022 annual MDS were not coded to reflect the PASRR positive status. The MDS Coordinator stated there was no potential negative outcome because the facility was aware both residents were PASRR positive, and they were receiving all of the benefits of that program. During an interview on 02/15/23 at 1:35 p.m., the DON said the MDS nurses were responsible for completing MDSs. He said he met with them daily to make sure the MDSs were complete and correct. He said the MDS was the resident's assessment. He said if the MDS was incorrect it could paint the wrong picture of the resident. He said they do hold PASSR meetings quarterly and monthly for PASSR positive residents with the resident's representative. He said the representative comes out to make sure the residents were receiving their services. During an interview on 02/15/23 at 2:52 p.m., the Administrator said the MDS Coordinator was the person responsible for completing the MDSs for each resident. He said he would have expected for the MDSs for Resident #2 and Resident #26 to have reflected they were PASSR positive. He said there were certain services PASSR provided, and the resident might not have access to those services. Review of an undated Resident Assessment (MDS) - Regulations provided by the facility indicated, .The facility much conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity .To ensure the resident receives necessary care and services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 13 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 21 residents (Resident #47) reviewed for range of motion and mobility, in that: Resident #47 who had a limited range of motion to unilateral lower extremities was not provided any treatment and services to prevent further decrease in ROM. This failure had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities. Findings Included: Record review of the face sheet dated 02/16/23 revealed Resident #47 was an [AGE] year-old female admitted [DATE] and readmitted on [DATE] with diagnoses including lack of physical exercise, muscle spasm (involuntary contractions of a muscle), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and pressure ulcer (bedsore) of unspecified heel. Record review of a physician order for Resident #47 written by LVN E dated 12/01/22 revealed Evaluate and treat PT/OT Record review of the admission MDS dated [DATE] revealed Resident #47 was understood and understood others. The MDS revealed Resident #47 had adequate hearing, clear speech, and adequate vision. The MDS revealed Resident #47 BIMS was 03 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, personal hygiene and total dependence for transfer, toilet use and bathing. The MDS revealed Resident #47 had functional limitation (interfered with daily functions or placed resident at risk of injury) in range of motion impairment to one side of upper and lower extremities. Record review of Resident #47's care plan dated 12/15/22 revealed at risk for complications related to my contractures. Interventions included encourage and assist me to participate in range of motion active and passive exercise as tolerated, monitor contractures per MD orders, observe for signs/symptoms of increased contractures. Record review of Resident #47's care plan dated 12/15/22 revealed the potential to have falls related to my poor balance and posture, limited range of motion with contractures and foot drop (right foot turns in). Intervention PT/OT screen and evaluate as needed. Record review of Resident #47's PT discharge summary completed by PT N with date of service 09/28/22-10/21/22 revealed . discharge reason exhausted benefits, prognosis to maintain current level of function=excellent with participation in Restorative Nursing Program .Progress and response to treatment: Patient has made consistent progress with skilled intervention . Record review of Resident #47's OT discharge summary completed by OT Q with date of service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 14 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0688 Level of Harm - Minimal harm or potential for actual harm 09/28/22-10/21/22 revealed . discharge reason: discharged per physician or case manager . prognosis to maintain current level of function= Good with consistent staff follow-through . Progress and response to treatment: Patient has made consistent progress with skilled intervention . Restorative Program Established/Trained=Restorative ADL Program .ADL program established/trained: bilateral upper extremities strengthening and endurance for dressing with reaching . Residents Affected - Few Record review of Resident #47's undated Restorative Training Form revealed bilateral upper extremities therapy exercise with 1.5 # wrist weights .Bilateral lower extremities range of motion exercise with 2.5# 3x15 with focus on functional bed mobility .dynamic sitting balance exercises . Record review of Resident #47's therapy screen dated 12/02/22 completed by COTA J revealed .re-admit . indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy: difficulty performing ADLs, difficulty with mobility, joint limitation/ contractures . right lower extremities range of motion .other: no change in above limitations post discharge from previous therapy service .no recent change/deficits noted . Record review of the list of residents on the restorative program as of 02/13/23 did not reveal Resident #47 on the list. During an observation and interview on 02/13/23 at 10:25 a.m., Resident #47 was lying in bed on her back with heel protectors on heels and pillow underneath. Resident #47 had limited range of motion to both legs and right foot turned inward. Resident #47 said she was not getting out of bed as much because of her bedsore. She said no one did range of motion exercise with her and she was not going to PT/OT either. During an observation and interview on 02/14/23 at 11:26 a.m., Resident #47 was lying in bed on her left side with heel protectors on her heels. Resident #47 had limited range of motion to both legs and right foot turned inward. She said no one exercised her today. During an interview on 02/15/23 at 3:53 p.m., CNA G said Resident #47 was repositioned every 2 hours, but she did not perform range of motion exercises. She said restorative therapy did things like that. During an observation and interview on 02/16/23 at 8:50 a.m., Unit Manager C and surveyor looked through Resident #47's paper chart to see what services should be provided for her decreased range of motion. Unit Manager C showed surveyor a physician order completed by LVN E and signed by a MD dated 12/1/22. Unit Manager C said she should be on therapy services. During an interview on 02/16/23 at 9:05 a.m., COTA J said she was the director of therapy services. She said all resident admitted into the facility has a screening performed by therapy. COTA J said she was not aware Resident #47 had an order from 12/1/22 for PT/OT to evaluate and treat. She said Resident #47 was screened by her on 12/2/22 and PT/OT was not indicated because her functional level was the same from when she was discharge from therapy on 10/21/22. COTA J said if she knew about the physician order for evaluation and treatment placed on 12/1/22, she would have discontinued it because of her screening results. COTA J said Resident #47 discharged home from the facility at the end of November 2022 and was readmitted beginning of December 2022. She said Resident #47 was placed on the restorative program for limited range of motion after discharge from therapy due to max potential reached. She said when Resident #47 was readmitted in December 2022 and PT/OT was not recommended, restorative therapy should have resumed. COTA J said she had not accessed Resident #47 since the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 15 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few screening on 12/2/22 and screenings were done quarterly. She said usually when a resident received therapy orders, a nurse called the department to inform them. COTA J said new admissions or residents receiving therapy were discussed during morning meetings and she could not recall Resident #47 being mentioned for therapy evaluation and treatment. She said she could not place Resident #47 on the restorative program because she was not on PT/OT services. COTA J said the nursing staff had to place the order for restorative. She said Resident #47's quarterly screening was not due until 03/02/23 but would evaluate her today (02/16/23). During an interview on 02/16/23 at 9:25 a.m. Unit Manager C said Resident #47 had decreased range of motion to her right lower extremities. She said therapy provided a list of residents on therapy services or had contractures and Resident #47 was not on the list. The Unit Manager C said the house supervisor, LVN E, helped with Resident #47's admission and took the verbal physician order. She said physician orders were given to someone in the MDS office to be place in the computer system and report was given or placed in the 24-hour communication book to inform staff of new orders. The Unit Manager C said therapy screened all admissions then an evaluation and treatment were performed. She said when Resident #47 discharged home in November 2022, she had reached her max potential through therapy services. The Unit Manager C said she thought Therapy, or the DON decided who received restorative therapy. She said she was not sure who wrote the restorative therapy training plan. Unit Manager C said CNAs should be evaluating resident's range of motion during ADLs. During an interview on 02/16/23 at 11:06 a.m., the DON said new admissions and residents receiving therapy were discussed in morning meetings. He said the facility also had therapy meetings every Thursday to discuss residents. The DON said he could not remember if Resident #47 was mentioned in either of these meeting. He said the nurses were responsible for ensuring physician orders are done. The DON said the therapy department performed the screens and evaluations, so they were responsible for recommendations of restorative therapy and developing the plans. He said the facility prided itself on providing therapy to all residents even if the resident did not have the right insurance to cover it. The DON said he did not know how Resident #47 got missed for PT/OT or restorative therapy. During an interview on 02/16/23 at 11:42 p.m., the ADM said the facility had meetings on Thursday to discuss skilled residents which Resident #47 was probably admitted non-skilled. He said Resident #47's physician order for PT/OT evaluation and treatment should have been addressed by therapy and nursing staff. On 02/16/23 at 12:00 p.m. and 12:05 p.m., unsuccessful attempts to reach LVN E by phone. Record review of a facility Restorative Nursing Services policy dated 07/21 revealed .residents will receive restorative nursing care as needed to help promote optimal safety and independence .restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies) .residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 16 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 received adequate supervision and assistance devices to prevent accidents for 1 of 21 residents (Residents #240) reviewed for accidents. The facility failed to perform a safe, proper mechanical lift for Resident #240. This failure could place residents at risk for decreased ADL function, physical and mental impairment. Findings included: Record review of the face sheet dated 02/16/23 revealed Resident #240 was [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side, and ataxia (impaired balance or coordination, can be due to damage to brain, nerves, or muscles). Resident #240 was admitted to the facility less than 21 days ago. No MDS for Resident #240 was completed prior to exit. Record review of Resident #240's baseline care plan dated 02/08/23 revealed alert/oriented with confusion at times and soft voice. The baseline care plan revealed history/potential for falls d/t mechanical lift with no interventions noted. The baseline care plan revealed bed mobility assists of 2 staff, dependent on staff, transfer via mechanical lift, walking/mobile per wheelchair, dependent on staff, toileting assist and grooming/hygiene of 1 staff, and dependent on staff for bathing. Resident #240's was admitted to the facility less than 21 days ago. No comprehensive care plan for Resident #240 was completed prior to exit. During an observation and interview on 02/13/23 at 12:01 p.m., Resident #240 was sitting in his wheelchair slumped forward with a lift pad underneath, head hanging down with his left arm hanging down the outside of the wheelchair. Resident #240 said he needed help to scoot up in the wheelchair but could not find his call light. The call light was placed within reach and Resident #240 pushed the button. The Unit Manager D arrived to answer the light then CNA B arrived. Resident #240 told Unit Manager D he wanted to scoot up in his wheelchair. CNA B and Unit Manager D attempted to pull Resident #240 up by the back of his pants twice. On the second attempt to pull Resident #240 by his pants, Resident #240 started to fall forward, out of his wheelchair. Unit Manager D placed her arm around Resident #240 to stop his forward motion. CNA B told Unit Manager D maybe they could get therapy to help stand him up since their way was not working. Unit Manager D told Resident #240 since they could not scoot him up in the wheelchair, they needed to put him back to bed. Unit Manager D went out into the hallway and asked CNA K to get the mechanical lift. CNA K arrived with the mechanical lift and placed the lift in front of Resident #240. CNA B said, the lift pad underneath his knees is too short. After they struggled to get the hooks of the lift pad to reach the s hook on the mechanical lift arm, CNA B and CNA K attached the bottom section of the lift pad with purple-colored hooks to the s hooks (lifting arm). When Resident #240 was lifted, his head was in the opening on the side instead of at the top of the lift pad. As Resident #240 was being lifted the strap from the lift pad started (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 17 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 - Minimal harm or potential for actual harm Residents Affected - Few to scrap the side of his face, the surveyor had to make the staff aware of the issue. CNA K placed the mechanical lift underneath the bed and lowered Resident #240 on his bed without locking the brakes. During an interview on 02/15/23 at 2:07 p.m., CNA B said she had worked at the facility since 2018. She said she worked the 7-3pm shift, primarily on the D hall where Resident#240 was. CNA B said the ways to lift a resident up in wheelchair was with the mechanical lift or their pants. She said the facility instructed the CNAs to use a gait belt. CNA B said when Resident #240 was transferred on 02/13/23, the lift pad was not underneath him good because he had slid down in his wheelchair. She said but once you lift residents their butts will slide in the right position. CNA B said she did not notice Resident #240 about to fall out of his wheelchair when they were attempting to pull him up by his pants. She said Resident #240 was lying sideways in lift sling when he was supposed to be straight to prevent them from possible falling out. CNA B said she did not remember the lift pad strap scrapping his face during the transfer. She said when Resident #240 was lowered to his bed, the brakes should have been locked on the mechanical lift. CNA B said she felt the transfer with Resident #240 was not too unsafe because three people were in the room to hopefully prevent something from happening. She said the facility had recently provided an in-service on transfers to the CNAs. During an interview on 02/15/23 at 2:34 p.m., Unit Manager D said a gait belt should have been used instead of Resident #240's pants to scoot him up in his wheelchair. She said the lift sling was not quite right underneath Resident #240 because they had to use the purple-colored hook on the lift sling. Unit Manager D said Resident #240's head was not properly positioned in the sling during transfer and his head sort of got caught by the sling strap. She said she recalled the surveyor calling out about the sling strap on Resident #240's face. Unit Manager D said the mechanical lift should be locked when lowering a resident, but she did not see if CNA K or CNA B locked the brakes. She said safe transfers prevented falls and injuries to the residents. On 02/15/23 at 3:30 p.m., unsuccessful attempt to interview CNA K by phone. During an interview on 02/15/23 at 3:53 p.m., CNA G said mechanical lifts were performed by 2-3 people depending on if the resident had a foley catheter. She said facility instructed the aides to use a gait belt for transfers to avoid skin friction. CNA G said the brakes should be locked on the mechanical lift when raising and lowering a resident. She said in was for safety in case of a fall. CNA G said a resident's head should be in a comfortable, straight position to avoid choking. She said the lift sling should have slack so the purple-colored hook would not be safe to use. During an interview on 02/16/23 at 8:30 a.m., Resident #240 said he was so tired on Monday (02/13/23), he was just happy to get back in bed. He said during the move somethings did not seem right, but he would not know for sure. During an interview on 02/16/23 at 11:06 a.m., the DON said Resident #240 could have been repositioned with lift pad or contact therapy for assistance. He said the use of the gait belt depended on the resident's strength. The DON said he expected the brakes to be locked when raising or lowering a resident. He said he expected the resident to be properly aligned in the sling to prevent friction. The DON said the mechanical lift should have been locked at when the CNAs lowered and raised Resident #240 from the wheelchair to the bed. He said Resident #240's head should have been centered in the mechanical lift sling not to the side. The DON said the Unit Managers were responsible for their staff's trainings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 18 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 - Minimal harm or potential for actual harm During an interview on 02/16/23 at 11:42 a.m., the ADM said mechanical lifts required 2-3 people for transfer. He said he expected the staff to use the appropriate size sling. The ADM said he expected the resident to be secured and safe. And the lift operated properly by staff. On 02/16/23 at 12:10 p.m., unsuccessful attempt to interview CNA K by phone. Residents Affected - Few Record review of CNA B's Transferring a Resident Using a Mechanical lift dated 08/19/22 revealed .this CNA/Nurse demonstrated competency of transferring a resident with a mechanical lift . Record review of CNA K's Training Trails dated 02/13/23 revealed .falls/transfer/unusual occurrences .when assisting with transfers, always use a gait belt . No competency for mechanical lift noted. Record review of an undated facility Transfer, Two Person Mechanical lift policy revealed .position wheelchair so that you can maneuver the lift safely from the bed to over the chair .lock wheels/brakes .place the widest part of the sling under the resident's buttocks and thigh, so that the lower edge of the seat is under the resident's knees . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 19 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care are provided such care, consistent with professional standards of practice for 2 of 5 residents reviewed for respiratory care (Resident #55 and Resident #21). Residents Affected - Few The facility did not ensure Resident #55's was oxygen concentrator filter was cleaned. RN R did not ensure Resident #21's nasal cannula (device that delivers oxygen to the nose) tubing was connected to the oxygen concentrator (source of oxygen). These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: 1.Record review of the consolidated physician orders dated 2/15/23 indicated Resident #55 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including anxiety disorder, heart failure, history of stroke, history of heart attack, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), COPD (Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the care plan revised on 1/5/23 indicated Resident #55 had COPD The care plan interventions included provide oxygen as directed and as needed per nursing judgement. During an observation on 2/13/23 at 10:51 a.m., Resident #55 was sitting in her recliner. Resident #55 had her nasal cannula on. The filter on Resident #55's oxygen concentrator had several clumps of thick dust on it. During an interview on 2/13/23 at 11:00 a.m., LVN S said nurses cleaned the oxygen concentrator filters on Saturday nights. LVN S said it was important to ensure oxygen concentrator filters were clean to prevent the resident from having increased respiratory problems. During an observation on 2/14/23 at 10:31 a.m., Resident #55 was sitting in her recliner. Resident #55 had her nasal cannula on. The filter on Resident #55's oxygen concentrator had several clumps of thick dust on it. During an observation and interview on 2/15/23 at 10:15 a.m., Resident #55 was sitting in her recliner. Resident #55 had her nasal cannula) on. The filter on Resident #55's oxygen concentrator had several clumps of thick dust on it. During an interview on 2/15/23 at 3:37 p.m., LVN T said she cared for Resident #55 on 2/11/23 (a Saturday). She probably did not clean the filter on Resident #21's oxygen concentrator because it (the concentrator) probably had a plastic bag over it. LVN T clarified that when an oxygen concentrator was not in use a bag was placed over it and Resident #55 does not often wear oxygen. She said the concentrator should have been cleaned before the bag was placed over the concentrator and checked to ensure it was cleaned before use. LVN T said it was important to ensure oxygen concentrator filters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 20 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 were clean to prevent the resident from having respiratory complications. Level of Harm - Minimal harm or potential for actual harm 2. Record review of the consolidated physician orders dated 2/15/23 indicated Resident #21 was readmitted to the facility on [DATE] with diagnoses including COPD. Residents Affected - Few Record review of the MDS dated [DATE] indicated Resident # 21 understood and made himself understood. The MDS indicated Resident # 21 had a moderate cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident # 21 had active diagnoses of respiratory failure. The MDS indicated # 21 had had shortness of breath or trouble breathing with exertion and when lying flat. The MDS indicated Resident # 21 had received oxygen therapy while a resident during the 14 day look back period. Record review of the care plan dated 1/23/23 indicated Resident # 21 had a compromised cardiac function and diagnosis of heart failure. The care plan indicated Resident 21 required the use of oxygen. The care plan interventions included, administer oxygen as ordered. Record review of the active physician order with a start date 1/13/23 instructed Resident # 21 to be administered oxygen via a nasal cannula continuously at 2L/in (liters per minute). Record review of the active physician order with a start date of 1/13/23 indicated Resident # 21 was to wear her CPAP (continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open while you sleep) machine while she slept and was to have it removed when she woke. During an observation on 2/13/23 at 10:04 a.m., the surveyor stood outside of the room of Resident # 21. RN R asked Resident #21 if she was short of breath. The surveyor was unable to hear Resident #21's response to RN R. RN R left the room and immediately returned with an SPo2 monitor (a monitor that measures oxygen saturation of the blood). During an observation and interview at 2/13/23 at 10:08 a.m., the surveyor entered Resident # 21's room. Resident #21 laid in her bed and wore a nasal cannula. When asked if she was short of breath, she responded by nodding her head yes. Resident # 21 displayed no signs or symptoms of respiratory distress (her breathing was even and unlabored). The nasal cannula tubing was not connected to the oxygen concentrator. The CPAP tubing was connected to the oxygen concentrator. During an observation and interview on 2/13/23 at 10:17 a.m. LVN S stood at the bedside of Resident # 21. Resident # 21 told LVN S she did not feel the oxygen coming through the nasal cannula. LVN S disconnected the CPAP tubing and connected the nasal cannula tubing to the oxygen concentrator. Within seconds Resident # 21 said she could feel the oxygen coming from the nasal cannula. LVN S said Resident #21 wore the nasal cannula during the day and the CPAP at night. During an interview on 2/13/23 at 10:19 a.m., LVN S said the nurse assigned to Resident # 21 may not have realized the CPAP was connected to the concentrator while she (# Resident 21) slept and the tubing needed to be switched. LVN S said RN R should have checked to ensure the nasal cannula tubing was secured to the oxygen concentrator. During an interview on 02/13/23 at 10:23 a.m., Resident #21 indicated she felt better and was not short of breath. Resident # 21 said she wore the CPAP at night and the nasal cannula while she was awake. Resident # 21 said she had not been awake for very long and indicated she had not had the nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 21 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cannula tubing on very long. Resident # 21 could not quantify the amount of time she had been awake. Resident # 21 said she did not think her nasal cannula tubing had ever been disconnected from her oxygen concentrator while she wore it in the past (before the occurrence today 2/13/23) because she felt the oxygen coming through the nasal cannula. Record review of the nursing note dated 2/13/23 written by RN R at 11:00 a.m. indicated at the time of the surveyors' observation on 2/13/23 at 10:04 a.m., Resident #21 reported to her (RN R) she did not feel oxygen coming through the nasal cannula tubing. The note indicated Resident #21's oxygen saturation was 96% (a normal oxygen saturation is 95%-100%) and that she adjusted tubing machine and it appears to be working as usual. During an interview on 2/15/23 at 3:00 p.m., LVN U said she was the unit supervisor (of the unit Resident #21 resided on). LVN U said RN R should have checked to ensure the nasal cannula tubing was connected to the concentrator. She said there was no system in place to ensure the nasal cannula tubing was connected to the oxygen concentrator but was sure RN R would not make the same mistake as LVN S had instructed her on the need to ensure CPAP tubing was disconnected in the mornings (when not used) and the nasal cannula tubing was connected to the concentrator. LVN U said it was important to ensure the nasal cannula tubing was connected to the oxygen concentrator to ensure Resident's that required oxygen supplementation were getting oxygen. LVN U said there was not a daily system in place to ensure oxygen concentrator filters were cleaned. LVN U said she tried to ensure nurses the filters were cleaned weekly. LVN U said she was going to add checking oxygen concentrator filters to her daily rounds. LVN U said it was important for oxygen concentrator filters to be cleaned to prevent respiratory infections and respiratory complications. During an interview on 2/15/23 at 3:37 p.m. RN R said she was a new nurse and been working at the facility as a new nurse since October 2022. RN R said she did not realize Resident #21's CPAP tubing was connected to the oxygen concentrator at night and assumed the nasal cannula tubing remained connected to the oxygen concentrator all the time. RN R said LVN S instructed her after the situation (after the occurrence of the nasal cannula tubing not having been connected on 2/13/23) to ensure for Resident #21, the CPAP tubing was disconnected once she (Resident #21) awake and the nasal cannula tubing was connected. During an interview on 2/16/23 at 9:20 a.m., the DON said he expected nurses to ensure oxygen concentrators filters were cleaned weekly on the Saturday night shifts. The DON said if the oxygen concentrator filter was covered with a plastic bag (not used) he would not have necessarily expected the nurse to have cleaned the filter. The DON added, the nurse that initiated the oxygen therapy should have checked the oxygen concentrator filter before or shortly after beginning the oxygen administration. The DON said himself and the Administrator performed rounds just about daily and could not say why the dirty oxygen filter was missed. The DON said it was important to ensure oxygen filters were cleaned to prevent respiratory complications. The DON said RN R was a new nurse and had completed her skills check off list before working on the floor. The DON said he could not say if checking to ensure CPAP tubing was disconnected from the oxygen concentrator and ensuring the nasal cannula tubing was connected to the oxygen concentrator was part of the skills check off. The DON said there was no system in place to monitor this (CPAP tubing was disconnected from the oxygen concentrator and the nasal cannula tubing was connected to the oxygen concentrator) but said he would find a solution to eliminate the opportunity for error. The DON said perhaps placing two oxygen concentrators in the resident room, each designated for CPAP/nasal cannula tubing would be a solution. The DON said it was important to ensure nasal cannula tubing was connected to the oxygen concentrator to ensure residents received oxygen and remained free of respiratory complications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 22 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/16/23 at 9:30 a.m., the Administrator said he expected nurses to follow policy and procedure with regards to cleaning oxygen concentrator filters. The Administrator said he expected nurses to ensure that oxygen tubing was connected to the oxygen source when oxygen was administered to a Resident. Record review of RN R Skills Checklist dated 10/10/22 indicated had completed her skills check off, which included training over the CPAP generator. The skills check off did not specifically address disconnecting an oxygen source from the CPAP after a resident woke and connecting the nasal cannula to the oxygen concentrator. Record review of the facility policy and procedure, revised October 2010, titled, Oxygen Administration, found it stated, Purpose: The purpose of this procedure is to provide guidance for safe oxygen administration .(7) check the tubing connected to the oxygen cylinder to assure it is free from kinks .(12) Check the mask, tank humidifying jar etc., to be sure they are in good working order and securely fastened . Record review of the undated facility checklist tilted Checklist 2: Care, Cleaning and Disinfection of high flow nasal cannula, found it stated, . (2) Check and change air and dust filters every 3 months and clean regularly as recommended . Record review of the undated facility procedure titled, IC 0622.00 Cleaning Oxygen Concentrator, found it stated, . (2) Clean the particle filter * Begin by removing the filter per manufacturer's instructions * Fill a tub or sink with warm water and a mild dishwashing soap * Dip the filter into the solution tub or sink * Use a wet cloth to remove excess dirt and dust * Rinse the filter to remove any excess soap * Let the filter air-dry or place on thick towel to absorb excess water . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 23 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Residents #51) Residents Affected - Some The facility failed to address comment/concerns to remove pressure dressing after treatment on Resident #51's communication report form from dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of the face sheet dated 02/15/23 revealed Resident #51 was a [AGE] year-old male admitted on [DATE] with diagnoses including dependence on renal dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), chronic kidney disease (longstanding disease of the kidneys leading to renal failure.), end stage renal disease (is the final, permanent stage of chronic kidney disease), arteriovenous fistula (are abnormal connections between arteries and veins) and cerebral infarction (stroke). Record review of the annual MDS dated [DATE] revealed Resident #51 was understood and understood others. The MDS revealed Resident #51 had a BIMS of 09 which indicated moderate cognitive impairment and required extensive assistance for ADLs. The MDS revealed Resident #51 received dialysis while a resident of this facility and within the last 14 days. Record review of the care plan dated 02/06/23 revealed Resident #51 was at risk for complications related to renal failure. Resident #51 received hemodialysis (refers to the mechanical treatment of blood to clean it of impurities and excess fluids when the body's kidneys aren't working properly) 3 times weekly at a local dialysis center. Goal initiated on 12/21/20 revealed no hospitalization will occur related to my diagnosis of renal failure thru next review. Interventions included assess shunt site for sign/symptoms of infection every shift, keep right upper arm shunt (aids the connection from a hemodialysis access point to a major artery) site clean and dry, has had several shunt revisions due to clotting problems and remove pressure dressing to right upper arm shunt site after return from dialysis treatment. Record review of Resident #51's dialysis communication report (sent with the resident after each dialysis appointment) dated 02/01/23 revealed problems or concerns: TAKE OFF Bandage after TREATMENT! Record review of Resident #51's dialysis communication report dated 02/03/23 revealed status post arteriovenous fistula-access pulling multiple clots . Record review of Resident #51's dialysis communication report dated 02/08/23 revealed problems or concerns: left bandage on arm! Please remove dressing after 24 hours Record review of Resident #51's dialysis communication report dated 02/10/23 revealed problems or concerns: Please ensure dressing is removed post dialysis During an interview on 02/15/23 at 8:38 a.m., the administrator of the local dialysis center said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 24 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #51 received treatment at the center. She said her main complaint with the facility was Resident #51's pressure dressings were not getting removed after treatment. The administrator of the dialysis center said Resident #51 arrived with his pressure dressing from his previous treatment at least once a week. She said it was important to not keep the same dressing on for an extended amount of time due to the risk of infection to Resident #51's shunt. The administrator of the local dialysis said the main reason the pressure dressing should not be left on for more than 24-hours was it increased the risk of forming blood clots (gel-like clumps of blood) in Resident #51's shunt. She said earlier this month (February), Resident #51 had to get a fistulagram (is a procedure that studies your dialysis fistulas. It can detect problems like clots or narrowing) procedure to remove clots and he also has had to get shunt replacements in the past due to clotting. She said the dialysis nurses write to remove the dressing on the facility communication form, but it does not stop it from happening. During an interview on 02/15/23 at 3:30 p.m., LVN F said Resident #51 had an arteriovenous fistula to his right arm. She said the facility communicated with the dialysis center with a communication form. LVN F said the facility started the form with pre dialysis information like vital signs, breakfast eaten, and results of checking the shunt for thrill and bruit (is an indication that the site is communicating well between arterial and venous circulations). She said the dialysis center filled the dialysis section with vital signs and medications during treatment, and problems or concerns. LVN F said the pressure dressing over the shunt was supposed to be left on for a few hours. She said she had never sent Resident #51 back to dialysis with the previously treatment pressure dressing still on. LVN F said leaving the pressure dressing on for more than 24 hours was an infection risk. She said leaving the pressure dressing on could also cause blood clots in the dialysis fistula. During an interview on 02/15/23 at 4:08 p.m., Resident #51 said the facility staff did not always remove the dressing from his arm after dialysis. He said when he went to dialysis the staff were not happy his dressing was still on his arm. During an interview on 02/16/23 at 9:25 a.m., Unit Manager C said the nurses were responsible for reading and addressing concerns from dialysis. She said she had not seen the dialysis communication notes about Resident #51 dressing being left on after treatment. Unit Manager C said the nurses should remove the dressing 3-4 hours after Resident #51 returned from dialysis treatment. She said the nurses on the 3-11 pm shift were the first shift to assess the site to see if the pressure dressing was able to be removed because Resident #51 did not return from dialysis until 2:30 p.m. Unit Manager C said leaving the pressure dressing on for an extended time risked blood clots forming. She said there was standard practice of removal time and nurses should have to sign off on the treatment administration record. During an interview on 2/16/23 at 10:24 a.m., The dialysis facility charge nurse indicated she had contacted the facility by phone at least 2 times in the past 3 months regarding Resident #51 returning to dialysis with the same dressing left in place from the previous dialysis appointment. The dialysis facility charge nurse said these calls were made after instructions on the dialysis communication sheet (sent with the resident after each dialysis appointment) regarding the removal of the dressing were repeatedly ignored. The dialysis facility charge nurse said she could not say who she had spoken to at the facility. During an interview on 02/16/23 at 11:06 a.m., the DON said the charge nurses were responsible for checking the communication note from the dialysis center and addressing the comments and concerns. He said the nurses should be removing the dressing after dialysis treatment. The DON said the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 25 of 26 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 455646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor Nursing & Rehabilitation Center 1007 S Washington Ave Marshall, TX 75670 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should remove the dressing but only if the bleeding had stop which may not be within 3-4 hours after treatment. He said the dressing should be removed within 24 hours. The DON said he had never received a phone call from the dialysis center complaining about the dressing being left on Resident #51's arm. He said the dressing being left on could cause contact dermatitis (is an allergic or irritant reaction) to skin from the tape and maybe risk of infection. The DON said after dialysis treatments a pressure dressing was placed over the shunt which could constricted the blood flow around the site. During an interview on 02/16/23 at 11:42 a.m., the ADM said he expected the nursing department to address the concerns the dialysis center reported on the communication sheet in a timely manner. He said he had received calls from the dialysis center but not related to Resident #51's pressure dressings not being removed before his next treatment. Record review of a facility's End-Stage Renal Disease, Care of a Resident with policy dated 09/10 revealed .residents with end-stage renal disease will be cared for according to currently recognized standards of care .education and training of staff includes, specifically .the care of grafts and fistulas .the resident's comprehensive care plan will reflect the resident's needs to dialysis care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 26 of 26