Health inspection·March 13, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/12/2024 at 2:26 PM CNA J said she was outside on break smoking when Resident #13 heard her mention she was going to get cigarettes. Resident #13 asked CNA J if she would get her cigarettes too. CNA J said she bought Resident #13 cigarettes with Resident #13's card and returned her card back and cigarettes the same day. During an interview on 03/12/2024 at 2:26 PM Laundry aide R said Resident #13 wanted to go home to check on her house. Laundry aide R said Resident #13 said she needed a battery for her car, so Resident #13 bought a battery and cables for the battery. Laundry aide R said Resident #13 did not need the cables, so Resident #13 returned the cables back to the store. The store returned the money back to the card for the cables. Laundry aide R said Resident #13 had the receipts. Laundry aide R said she took Resident #13 to her home on 7/21/23. Laundry aide R said Resident #13 paid for her items by herself, and she did not touch Resident #13's card. During an interview on 03/13/2024 at 9:14 AM Social Services said Resident #13 told her she had given some employees her card to make purchases for her. Social Services said Resident #13 thought employees had made other purchases. During an interview on 03/13/2024 at 9:45 AM the DON stated, I remember a little of it. I don't know the exact timeline, but I remember Resident #13 had charges on her card that she did not know where they came from. Her and the Social worker looked at her statements. There were 2 employees that used to buy things for her, and she let them borrow money. She may have given them gas money for going for her. They were both terminated for being out of compliance. During an interview on 03/13/2024 at 1:30 PM Administrator said Resident #13 had let CNA J use her debit card. The Administrator said Resident #13 lent the card to Laundry aide R. The Administrator said both staff members knew they were not to take money from a resident. The Administrator said he thought this was misappropriation and it was not allowed for an employee to take money from residents. The Administration said the facility terminated the two staff members due to this incident. Record review of the facility's undated Abuse Investigation and Reporting Policy and Investigation Incidents of Theft and/ or Misappropriation of Resident Property, states Residents have the right to be free from theft and/or misappropriation of personal property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 2 of 7 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 03/13/2024 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, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately for 1 of 3 residents reviewed for abuse and neglect. (Resident #24). Transportation Driver A failed to report when Resident # 24 was not properly strapped into the facility transportation van resulting in a fall from wheelchair. This failure could place residents all resident transported by the facility at risk for pain, physical harm, diminished quality of life or serious injury. Findings included: Record review of a face sheet dated 3/13/2024 revealed Resident # 24 was a [AGE] year-old male admitted on [DATE] with diagnoses including Type II Diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), End Stage Renal Disease (chronic kidney disease when the kidneys are no longer working to meet your body's needs) with dependence on renal dialysis (a treatment that helps the body remove extra fluid and waste products from the blood) , and Atrial Fibrillation ( an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #24 was understood and understood others. The MDS revealed a BIMS score of 10, indicating moderate cognitive impairment. The MDS indicated Resident #24 required moderate assistance with ADLs. Record review of a care plan dated 8/16/2023 revealed Resident #24 was legally blind with impaired mobility, left above the knee amputation (AKA) , seizures, renal failure with dialysis 3 times a week, poor endurance, poor safety awareness, poor diabetes management, and poor cardiac status. Resident # 24's care plan revealed he was at risk for bleeding due to use of anticoagulant- antiplatelet (medications used that reduce blood clotting in an artery or vein or the heart) use. Record review of facility training dated 8/7/2023 and titled Boarding Wheelchair Bound Resident into Van checklist indicated Transportation Driver A was checked off by Transportation Driver F. Record Review of facility training dated 8/7/2023, titled Individual safety responsibilities: Authorized Driver indicated 18. Incidents: Report any incident to supervisor immediately was signed and dated by Transportation Driver A. Record Review of facility training record titled Securing wheelchair in van check off dated 8/7/2023 indicated Transportation Driver A met expectations to following: 1. Explain to resident how the wheelchair will be secured. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 3 of 7 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 03/13/2024 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 Roll the wheelchair onto the lift backwards. Level of Harm - Minimal harm or potential for actual harm 3. Lock the wheelchair. Residents Affected - Few 4. Tell the resident you are going to raise the lift. 5. Roll the resident into the van, positioning between floor anchorages. 6. Secure the back strap restraints to the wheelchair making sure the hooks are secured inside to the outside. 7. Secure the front strap restraints to the wheelchair making sure the hooks are secured inside to the outside. 8. Secure the seat restraints across the lap, making sure the shoulder strap was secure. 9. Double check all strap restraints to ensure they are secure. Record review of Transportation Driver A completed Securing wheelchair van check off . dated 8/7/2023, Individual safety responsibilities: Authorized driver . 18. Incidents: Report any incident to supervisor immediately .Critical Element checklist . Record review of hospital record dated 9/5/2023 indicated resident arrived at the emergency department via ambulance after a fall from wheelchair while being loaded into the wheelchair van. Resident # 24 reported he struck his head on the right side, right shoulder and was currently on blood thinners. Resident # 24 reported he was rolled in the wheelchair transport van and fell on his right side and hit his head. Hospital records indicated Resident # 24 fell from 3 to 5 ft on concrete. Resident # 24 received CT scan of head and brain revealing no acute intracranial findings, 3 view x-rays of the right shoulder indicated mild degenerative changes without acute osseous findings (no abnormal findings) of the right shoulder. Record review of an incident report dated 9/5/2023 at 4:00 pm, indicated a [AGE] year-old male Resident # 24 fell out of wheelchair inside of the transportation van. The incident report indicated Resident # 24 had pain 5 out of 10 to back of head and neck and was sent to the local hospital for further evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 4 of 7 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 03/13/2024 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 Record Review of Transportation Driver A's written statement dated 9/5/2023 indicated she rolled Resident # 24 on the van and locked the wheels down in the back. Transportation Driver A proceeded to pull out of the parking lot and then identified Resident # 24 going back. The Transportation Driver A revealed she backed down and got help to get Resident # 24 back in his seat and looked at his head to ensure he did not hit his head. The statement indicated Resident #24 was fine but was scared a little. Residents Affected - Few Record review of Transportation Driver A's second written statement dated 9/5/2023 indicated Resident #24 was assisted on van and locked down the wheelchair. Transportation driver A admitted she did not use the lap belt and only applied the locks on the wheelchair. The Transportation Driver A indicated she proceeded to drive away and started up an incline and Resident # 24 flipped over and out of his chair. Resident #24 was lying on his back at the time. Transportation Driver A got Resident #24 up and a passerby assisted Resident #24 back in his wheelchair. The Transportation Driver A looked over Resident #24 to make sure he was ok, then buckled him up with the lap strap and transported him back to the facility. Record Review of Facility investigation summary dated 9/5/2023 at 5:00 p.m., the DON interviewed Resident # 24 and identified Transportation Driver A as the driver. Resident #24 recalled Driver A and an unidentified lady from the parking lot assisted him back in his wheelchair. Transportation Driver A completed her training prior, demonstrated to the ADM how to properly secure residents and ensure van lift and all straps and fasteners were in working order. Transportation Driver A was removed from transportation pending further investigation. On 9/6/2023 at 10:30 a.m., Transportation Driver A admitted she failed to secure the lap belt, because she was just going a short distance. She acknowledged receiving training prior to her first transport and denied notifying anyone at the facility of the incident. During review of Progressive Disciplinary action form dated 9/6/2023 , Transportation Driver A was placed on suspension with approval of ADM during investigation of violations with 1st written notice. The progressive disciplinary action indicated employee did not ensure resident safety in van which caused an incident of the resident falling backwards. Record review of Inservice dated 9/6/2023 indicated Neglect was The failure to provide goods and services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness . Any injury of unknown origin should be investigated for abuse and neglect immediately . The Administrator/Abuse coordinator, DON, ADON and supervisor should be notified immediately . Any unusual occurrence must have incident report completed .Anytime an injury occurs: Fall with injury, any skin tear or bruising or injury, make sure you report to your supervisor .If you cannot determine how something occurred or resident cannot tell you how injury occurred, then it is reportable to the state, so make sure to let the supervisor know .All allegations of abuse or neglect should be reported immediately to administrator . Record review of Intake , with a priority date of 09/07/23 indicated a self-report was made by the facility on 09/05/23 at 7:11 p.m. concerning the incident where Resident #24 tipped backwards while being transported from dialysis requiring assistance from van driver and a passerby. Record review of Personal change notice dated 9/7/2023 indicated Transportation Driver A was terminated due to employee had an incident with a resident while transporting in van. Record review of a facility investigation dated 09/07/23 revealed on 9/5/2023, LVN #E received a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 5 of 7 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 03/13/2024 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 phone call at approximately 4:45 p.m., from dialysis inquiring about Resident #24. The caller inquired to LVN E if Resident #24 was feeling ok after falling in the van. The facility was unaware of incident at time of call. A head-to-toe assessment was completed. No visible injuries noted. Resident #24 was complaining of 5 out of 10 pain to the back of his head. The resident representative was notified, and Resident #24 was sent to the emergency room for further evaluation. The imaging and assessment from the hospital were negative for injury. During an interview on 3/13/2024 at 9:49 a.m., Resident #24 said he was leaving dialysis and Transportation Driver A had secured the back straps to secure his wheelchair but did not secure the front straps on his wheelchair. Resident #24 said he was blind but could is aware of what the driver is doing. Resident #24 said Transportation Driver A went up the hill exiting the dialysis driveway and it caused his wheelchair to flip backwards. Resident #24 said a passerby stopped and assisted him back into his wheelchair. He said Transportation Driver A secured the wheelchair correctly and returned to the facility. Resident #24 denied any injuries and denied feeling sore or fearful. Resident #24 said he was sent to the emergency room for further evaluation. During an interview on 3/13/2024 at 11:59 a.m., the DON said she initiated the incident investigation on 9/5/2023, all staff were retrained and in-serviced on ANE. The DON said she was not sure when the checkoffs for the van and the process was started after another incident. The DON said she expects staff to report immediately any incident and she was made aware of this incident after Resident #24 returned to the facility and the dialysis facility called to check on the resident. She said once the incident was known, Resident #24 was sent to the emergency room for further evaluation. During an interview on 3/13/2024 at 12:26 p.m., the ADM said the facility completed an in-service on Abuse, Neglect and Exploitation and he expects all straps, harnesses, and seatbelts to be secured on the van and the bus when residents are transported. The ADM said he expects transportation drivers to perform daily checklist of equipment prior to transporting residents and the drivers should not transport a resident if equipment was not functional. The ADM said he was made aware of a broken strap on the lift gate on the van and the van was currently placed out of service until fixed. The ADM said they are currently looking for the part and attempting to fix it. The ADM said he expects staff to report any incidents to him immediately. During an interview on 3/14/2024 at 2:02 p.m., Transportation driver B said he has been employed since 3/11/2024. Transportation driver B said the ADM did a ride along with him for 1 day. Transportation Driver B said there was a pre-inspection checklist that he performs prior to use of the facility vehicle. He said the pre-inspection is to be performed before loading residents. The transportation driver B said the lift securement strap was working on the previous day and he noticed the lift harness was broken when he already had his 2 residents loaded. He said he received a phone call from ADM after loading the residents and he notified ADM of the lift harness not functioning. Transportation Driver B said the lift harness had nothing to do with the residents and it was just an extra precaution. He said there was no way a resident could tip over or roll off the lift with the 8-inch panel that raises up on the back of the van. Record review of the facility's abuse investigation and reporting dated December 2016 indicated .all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported .all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designess, to the following persons or agencies: the State licensing/certification agency responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 6 of 7 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 03/13/2024 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 surveying/licensing the facility .suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours if the alleged events have resulted in serious bodily injury; if event that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455646 If continuation sheet Page 7 of 7