Health inspection·August 23, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care for Resident # 54. CNA I removed clean gloves from the pocket of her scrub top and placed gloves on both hands without washing or sanitizing her hands. CNA I opened the soiled brief on Resident # 54 and placed it between her legs. She was handed a wipe by CNA H, and she wiped down right side of perineal area front to back and placed wipe in the trash. She was handed a clean wipe by CNA H and wiped down left side of peri area from front to back and threw wipe in trash. She was handed a clean wipe by CNA H she wiped middle of peri area front to back and discarded the wipe in the trash. She rolled Resident #54 onto her right side and CNA H handed her a clean wipe. CNA I cleaned Resident # 54's buttock area from front to back using multiple wipes and placed them in the trash. CNA I removed the soiled brief and placed it in the trash. CNA I did not remove her soiled gloves, she then picked up the clean brief and started to place it under resident # 54, CNA H said, your gloves, and CNA I took off the soiled gloves and placed them in the trash. CNA I reached into her pocket and got a clean pair of gloves, put them on and continued incontinent care without washing her hands or sanitizing between glove change. CNA I and CNA H completed incontinent care on Resident #54 by securing the brief and repositioning her then they removed their gloves and placed them in the trash. They then went into the restroom and washed their hands. During an interview on 8/21/2023 at 9:00 AM, CNA I said she has worked at facility for two years but had been a CNA for thirty years. CNA H said she had worked at the facility for five years and had been a CNA since 2016. CNA I said she was trained a long time ago how to do incontinent care. CNA H said she was provided training before she started working on the floor. Both CNA I and CNA H said the facility did provide them training on infection control and incontinent care on hire. Both CNAs said the staffing coordinator was the one that perform check offs for skills. CNA I and CNA H said they did not sanitize their hands during glove changes during incontinent care. CNA I said the only time she performed hand hygiene was after she provided incontinent care to the resident. They said not sanitizing their hands could cause the residents to have infections. 2. Record review of an admission Record dated 8/23/2023 for Resident #12 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, acquired absence of right and left leg above the knee (missing both right and left legs), hypertension, and peripheral vascular disease (decreased blood flow to the lower legs). Record review of an Annual MDS assessment dated [DATE] for Resident #12 indicated she had moderate impairment in thinking with a BIMS score of 8. She was totally dependent with transfers and extensive assistance with toilet use using two-person physical assist. She was always incontinent of bowel and bladder. Record review of a care plan dated 3/13/2017 for Resident #12 indicated she had an ADL self-care performance deficit related to above the knee amputation with an intervention of toilet use: requires assistance to wash hands, adjust clothing, clean self. During an observation on 8/23/2023 at 9:10 AM CNA C and CNA D were present to provide incontinent care to Resident #12 and both nurse aides washed their hands and put on gloves. CNA C opened Resident #12's brief and placed it between her thighs. CNA C removed wipes from a plastic bag and wiped Resident #12's perineal area from front to back. Resident #12 had a large bowel movement that had leaked out of the brief onto the under pad. CNA C removed her gloves and placed them in the trash. CNA C went to the restroom in Resident #12' room and washed her hands and put on gloves on both hands. CNA C removed wipes from the plastic bag and gloves were visible soiled with feces and wiped Resident #12's perineal area multiple times until she was clean. CNA C removed her gloves and placed them in the trash and went to the restroom and washed her hands. CNA C placed gloves on both hands. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455745 If continuation sheet Page 2 of 6 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 455745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #12 was rolled onto her right side assisted by CNA D. The Staffing coordinator knocked at the door and entered the room to assist. Staffing coordinator instructed both CNA C and CNA D to be careful and not contaminate anything because Resident #12 had a large bowel movement. CNA D removed wipes from a plastic bag and wiped Resident #12's rectum multiple times until clean. CNA D removed the soiled brief and under pad and placed them in a plastic bag. CNA C did not remove her gloves and placed a clean brief and a draw sheet underneath Resident #12's buttocks. CNA D secured the brief and then reached into Resident #12's closet and picked out clothes for Resident #12 to wear. Staffing coordinator instructed CNA D to take out the soiled linens and place them in the hamper that was sitting outside in the hallway. CNA D opened the door with the dirty gloves and placed the soiled linens and removed her gloves and placed them in the hamper. CNA D reentered Resident #12's room and washed her hands. CNA C removed her gloves and placed them in the trash and washed her hands in the restroom. During an interview on 8/23/2023 at 9:48 AM, CNA C said she had been employed at the facility for 2 years. She said during the incontinent care provided to Resident #12, she should have changed her gloves the second they were soiled. She said CNA D should have washed her hands more and changed her gloves as soon as she finished wiping Resident #12. She said CNA D should not have kept gloves on to touch clothing items and the clean brief. She said residents could be at risk of infection. She said she had a competency skills check off last month on incontinent care. Record review of a perineal care for CNA C dated 7/5/2023 by Staffing Coordinator indicated she was competent with skills checkoff. During an interview on 8/23/2023 at 9:50 AM, with CNA D said she had been employed at the facility for 2 weeks and was currently in training. She said she was being training by CNA C. She said she had only been a nurse aide for a year, and this was her first job as a nurse aide. She said during the incontinent care provided to Resident #12, she should have removed her gloves before placing soiled linens in the hamper. She said she was nervous and forgot to change her gloves. She said residents could get sick or get an infection if she did not change her gloves that were dirty. 3. Record review of an admission Record for Resident #64 dated 8/22/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), dysphagia following cerebral infarction (difficulty swallowing following a stroke), dementia, and GERD (acid reflux disease). Record review of a Significant Change MDS Assessment for Resident #64 dated 6/14/2023 indicated she had severe impairment in thinking with a BIMS score of 3. She required extensive assistance with ADL's. She was always incontinent of bowel/bladder. Record review of a care plan for Resident #64 dated 8/27/2019 indicated she had an ADL self-care performance deficit related to left sided weakness secondary to CVA (stroke), non-ambulatory status with interventions of incontinent care: requires staff assistance x1 to promote max assist and prompting to cleanse, change brief, and to adjust clothing. She had bowel/bladder incontinence related to confusion, impaired mobility and physical limitations dated 5/1/2019 with interventions to use disposable briefs and change every 2 hours and prn (as needed). Check as required for incontinence. During an observation on 8/22/2023 at 9:10 AM, CNA A and CNA B were present to provide incontinent care to Resident #64. Both nurse aides washed their hands in the resident's bathroom and applied gloves. CNA A opened the brief of Resident #64 and pulled it down between her legs. CNA A wiped Resident #64's perineal area from front to back. Resident #64 had a bowel movement and CNA A used multiple (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455745 If continuation sheet Page 3 of 6 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 455745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wipes to clean the perineal area. CNA A removed her gloves and placed them in the trash along with the wipes. CNA A placed clean gloves on both hands without washing or sanitizing her hands. CNA A and CNA B rolled Resident #64 to her left side and CNA A cleaned Resident #64's rectal area using multiple wipes wiping from front to back. CNA A removed her gloves and placed them in the trash and placed clean gloves on without washing or sanitizing her hands. CNA A positioned a clean brief underneath Resident #64's buttocks and Resident #64 was rolled onto her back and brief secured. CNA A and CNA B removed their gloves and placed them in the trash and washed their hands. During an interview on 8/22/2023 at 9:25 AM, CNA A said she had been employed at the facility for 5 years and was assigned to hall six. She said she had skills checkoffs for competency in incontinent care a few months ago. She said she was taught by the ADON's to change gloves when going from dirty to clean and before placing a clean brief on a resident. She said she was supposed to sanitize her hands after glove changes during the incontinent care episode, but she did not. She said residents could be at risk of getting a UTI (urinary tract infection) if staff did not wash or sanitize their hands with glove changes. Record review of an Annual CNA Comprehensive Clinical Competency Review Skills Checklist for CNA A dated 1/8/2023 by the Staffing Coordinator indicated CNA A met the skills checklist requirements for perineal care. 4. Record review of an admission Record dated 8/22/2023 for Resident #34 indicated she admitted to the facility on [DATE] with diagnoses of acute osteomyelitis of right ankle and foot (bone infection), COPD (a group of disease that cause airflow blockage and breathing problems), and aphasia (loss of the ability to understand or express speech). Record review of a physician order dated 5/26/2023 for Resident #34 indicated to cleanse open area to right hallux (big toe) with normal saline or wound cleanser, pat dry periwound (around wound), apply silver alginate (used for infected wounds and moderate draining) and cover with dry, protective dressing daily, every day shift. Record review of a Quarterly MDS assessment dated [DATE] for Resident #34 indicated she was rarely/never understood. She required extensive assist with ADL's. She was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Record review of a Quarterly MDS assessment dated [DATE] for Resident #34 was not complete and in progress. Record review of a care plan dated 5/26/2023 for Resident #34 indicated he had the potential/actual impairment to skin integrity related to open area right hallux with an intervention to cleanse open area to right hallux with normal saline/wound cleanser. Pat dry periwound, apply silver alginate and cover with dry, protective dressing daily. Has osteomyelitis of right hallux with interventions to maintain standard precautions when providing resident care. During an observation on 08/22/2023 at 8:50 AM, the Treatment nurse was in the room of Resident #34 to provide wound care along with ADON J. Both the Treatment nurse and ADON J washed their hands and applied gloves. Wound supplies were observed on the bed of Resident #34 sitting on the fitted sheet at the foot of the bed which included: a package of gauze, normal saline bullets, silver alginate dressing, kerlix, gloves, scissors, and an abdominal pad. A dressing was noted to Resident # 34's right foot and the Treatment nurse cut the dressing off of Resident #34's foot and removed the dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455745 If continuation sheet Page 4 of 6 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 455745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm that was on the bottom of her right great toe and placed it in the trash along with her gloves. The Treatment nurse sanitized her hands and placed clean gloves on. ADON J left the room and brought back in a tray with wax paper on top and placed the wound supplies that were on the bed on the tray. The Treatment nurse cleaned the wound and followed physician orders. The Treatment nurse placed her gloves in the trash and washed her hands. ADON J removed her gloves and placed them in the trash and washed her hand. Residents Affected - Some During an interview on 8/22/2023 at 9:28 AM, the Treatment nurse said she had been employed at the facility for 4 years. She said she provided wound care to the residents in the facility Monday-Friday. She said she had been wound care certified since 2020. She said she should have placed the wound care supplies on a bedside tray or on wax paper to keep the supplies clean. She said she normally used the tray but did not during the observation. She said residents could be at risk of infection if supplies were placed on things that were not clean. Record review of a skills checklist for treatments for Treatment nurse dated 8/3/2023 by the DON indicated she demonstrated competency. During an interview on 8/23/2023 at 9:45 AM, the Staffing Coordinator said she had been employed at the facility since 2011. She said she was responsible for competency skills check offs for the nurse aides in the facility along with the DON and ADON's and they were conducted on hire and annually. She said CNA D had only been employed at the facility for 2 weeks and was not checked off on her skills. She said CNA D was due for a skills check off next Monday 8/28/2023 on pericare (cleaning the private areas of a resident). She said during the incontinent care that was provided to Resident #12, both CNA C and CNA D should have placed an under-pad over the area to prevent contamination since Resident #12 had a large bowel movement. She said that both aides should have had wipes in one plastic bag instead of different bags. She said CNA D should have discarded her gloves when soiled and washed her hands. She said CNA C and CNA D should have changed their gloves more often and should not have touched any items because gloves were contaminated. She said she had checked off CNA I on hire on 9/17/2021 and annually on 9/10/2022. She said she had checked CNA H on date of hire 1/12/2018 and her annual was completed on 1/8/2023. She said on hire the CNAs were trained for two weeks and if she did not feel they were ready she would ask the DON for more time with them. She said residents could be at risk of infection if staff did not follow infection control protocols. During an interview on 8/23/2023 at 9:55 AM the DON said she was aware of the infection control issues with staff. She said the ADON's, Staffing Coordinator and herself were responsible for conducting competency skills check offs with the staff in the facility. She said the facility would start check offs with a mannequin that had male and female parts for demonstration. She said the nurses and aides were checked off annually and as needed. She said residents could be at risk for infections and UTI's (urinary tract infections). She said she started education with staff yesterday 8/22/2023 on pericare, and sanitizing hands between glove changes. She said the treatment nurse knew better and should not have had her supplies on the bed. She said the treatment nurse never went into a room without a red tray that had wax paper and her supplies on it. During an interview on 8/23/20203 at 11:35 AM the Administrator said he was aware of the issues with infection control. He said he expected the staff to follow their policy as it stated and to use clean supplies while providing wound care. He said going forward the facility was going to initiate another training for staff on pericare and was going to utilize an outside source for training on wound care. He said all staff would be trained on hand hygiene. He said residents could be at risk for infection if staff did not follow their policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455745 If continuation sheet Page 5 of 6 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 455745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a facility policy titled Hand/Hygiene with a revised October of 2022. indicated, .Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . Record review of a facility policy titled Infection Control Policy/Procedure Subject: Wound Care and Treatment Guidelines with a revised date of 5/2007 indicated, .It is the policy of this facility to provide excellent wound care to promote healing. 4. Supplies should be placed on a clean surface or use a barrier as a clean barrier . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455745 If continuation sheet Page 6 of 6