Health inspection·September 27, 2023

F 0582 Level of Harm - Minimal harm or potential for actual harm old male and admitted to the facility initially on 10/14/22 and re-admitted on [DATE] with diagnoses including hypertension (high blood pressure), dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), history of cerebral infarction (also called a stroke-results from a disruption of blood flow to the brain), Major depression (persistent sadness), heart disease, difficulty in walking, cognitive communication deficit, and weakness. Residents Affected - Few Record review of Resident #25's quarterly MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. The MDS indicated a BIMS score of 12 which indicated Resident #25 had moderate cognitive impairment. The MDS indicated Resident #25 required limited to extensive assistance of 1 person for most activities of daily living. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #25 received Medicare Part A Skilled Services on 4/29/23 and his last covered day of Part A services was 6/22/23. The SNF Beneficiary Protection Notification Review indicated the facility/provider initiated the discharge from Medicare Part A Services due to Resident #25 had reached his maximum potential per the therapist. During an interview on 9/26/23 at 10:15 AM, the MDS Coordinator said all she had were NOMNCs for Resident #10 and Resident #25. The MDS Coordinator said she did not have SNF ABN letters. The MDS Coordinator said there was a check list she followed, and she thought she only had to complete an SNF ABN letter for Part B Medicare. During an interview on 9/27/23 at 1:29 PM, the MDS Coordinator said she had worked at the facility for almost 22 years and had been the MDS Coordinator since 2011. The MDS Coordinator said she was responsible for completing the SNF ABN/NOMNC letters. The MDS Coordinator said the SNF ABN letters should be completed 24-72 hours prior to the last treatment of the covered day. The MDS Coordinator said the SNF ABN letter showed when the resident's last covered day of skilled services would end. The MDS Coordinator said if the resident decided to stay in the facility, they could appeal it. The MDS Coordinator said they have not been doing the SNF ABN letters for Medicare Part A covered services. The MDS Coordinator said she didn't know she had to give the SNF ABN letter for Medicare Part A and had only been issuing the NOMNC letter to the residents. The MDS Coordinator said the therapist would fill out the SNF ABN letter and give it to her to have signed, but the therapist had only been doing them on the Medicare Part B residents. The MDS Coordinator said she had a guidance sheet and she had misinterpreted it to only need the SNF ABN letters on the Medicare Part B residents. The MDS Coordinator said from her knowledge now after reviewing the guidelines, Resident #10 and Resident #25 should have had a SNF ABN letter issued. During an interview on 9/27/23 1:35 PM with the Contract Therapist, she said she had only been completing a SNF ABN letters on Medicare Part B residents and giving the form to the MDS Coordinator. The Contract Therapist said she did not know she needed to complete the SNF ABN letters for residents on Medicare Part A services. During an interview on 9/27/23 at 2:38, the Resident Family Advocate provided the surveyor with SNF ABN letters for Resident #10 and Resident #25. The Resident Family Advocate said she had called the family members of the two residents about the SNF ABN letters, but she did not document the conversations. The Resident Family Advocate said she did not know what dates she spoke to the family members, and she did not know she needed to document the conversations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 2 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The surveyor was provided an undated SNF ABN letter for Resident #10 on the last day of the survey, 9/27/23, by the Resident Family Advocate. Review of Resident #10's SNF ABN letter indicated beginning 08/24/23, Resident #10 may have to pay out of pocket for care if she did not have other insurance that may cover those costs. The SNF ABN indicated the care of physical therapy and occupational therapy had an estimated cost of over $300 with the reason Medicare may not pay was due to the resident may not qualify for skilled services under Medicare guidelines. The SNF ABN indicated Resident #10 chose option 3, which indicated she did not want the care listed and she understood she was not responsible for paying and could not appeal to see if Medicare would pay. The SNF ABN indicated Resident #10, nor her representative signed the form. There was incomplete documentation in the additional information section of Resident #10's SNF ABN that reflected, notified by phone. There was no documentation on Resident #10's SNF ABN letter or in her chart to indicate who was notified, what date the person who was notified was called, or what the conversation included. The surveyor was provided an undated SNF ABN letter for Resident #25 on the last day of the survey, 9/27/23, by the Resident Family Advocate. Review of Resident #25's SNF ABN letter indicated beginning 6/23/23, Resident #25 may have to pay out of pocket for care if he did not have other insurance that may cover those costs. The SNF ABN indicated the care of physical therapy and occupational therapy had an estimated cost of over $300 per day with the reason Medicare may not pay was due to resident may not qualify for skilled services under Medicare guidelines. The SNF ABN indicated Resident #25 chose option 3, which indicated he did not want the care listed and he understood he was not responsible for paying and could not appeal to see if Medicare would pay. The SNF ABN indicated Resident #25, nor his representative signed the form. There was incomplete documentation in the additional information section of Resident #25's SNF ABN letter that reflected, notified by phone. There was no documentation on Resident #25's SNF ABN letter or in his chart to indicate who was notified, what date the person who was notified was called, or what the conversation included. During an interview on 9/27/23 at 3:30 PM, the ADM said he had worked at the facility for 6 years. The ADM said the SNF ABN letter should be issued to the resident if their Medicare Part A service ends, and the resident chooses to stay in the facility was what he just read after staff brought it to his attention. The ADM said I guess you heard what happened, the process had been for the contracted therapy service to complete the SNF ABN letters and then give it to the MDS Coordinator, but the therapist was confused on when the SNF ABN letters should be completed and had only been completing the SNF ABN letter for the Medicare Part B residents. On 9/27/23 at 1:20 PM, the DON said there was not a policy related the SNF ABN letters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 3 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 1 of 14 residents reviewed for assessments. (Resident #15) Residents Affected - Few The facility failed to ensure to code Resident #15's use of an anti-anxiety on his MDS. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident #15's face sheet dated 09/25/23 indicated Resident #15 was a [AGE] year-old male and admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses including paranoid schizophrenia (is a severe, lifelong brain disorder that causes people to interpret reality abnormally), dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #15's consolidated physician's order with a start date of 07/27/23 indicated Lorazepam (is used to treat anxiety) 1MG, give 1 tablet by mouth one time a day related to anxiety disorder. No end date noted. Record review of Resident #15's annual MDS assessment dated [DATE] indicated Resident #15 was usually understood and usually understood others. The MDS indicated Resident #15 had a BIMS score of 02 which indicated severe cognitive impairment and required supervision for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene but limited assistance for bathing. The MDS did not indicate Resident #15 received an antianxiety. Record review of Resident #15's care plan dated 11/18/21 indicated Resident #15 was currently prescribed psychotropic medications and was at risk for Tardive dyskinesia (tongue protrusion, facial grimacing, lip smacking and rapid eye blinking), photosensitivity (is heightened skin sensitivity), dry mouth, constipation, orthostatic hypotension (is a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), rapid heartbeat, and urinary retention. Interventions included administer psychotropics as prescribed and obtain informed consent from the resident and/or family. During an interview on 09/27/23 at 2:30 p.m., the MDS Coordinator said she was responsible for MDSs. She said Resident #15 was on Ativan (Lorazepam) and it was an antianxiety medication. She said when she completed MDS assessments, she reviewed consolidated physician's orders and MARs. She said she did not know how she missed coding Resident #15's antianxiety medication on the MDS. She said the DON signed the MDSs when completed before she submitted it. She said corporate did an audit quarterly to ensure she was coding correctly. She said it was important to have accurate assessment because CMS required it and it showed quality monitors. During an interview on 09/27/23 at 3:30 p.m., the DON said Resident #15 was on Ativan (Lorazepam) which was an antianxiety medication. She said Resident #15's MDS should have been coded that he received an antianxiety. She said she signed the MDS before they were submitted to verify it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 4 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 completed. She said she would start reviewing the MDS for accuracy from now on. She said the corporate MDS Coordinator did audits on the MDSs submitted to as an oversight. She said the MDS needed to be accurate to make sure the correct care was being provided. During an interview on 09/27/23 at 3:53 p.m., the ADM said the MDS Coordinator was responsible for the accuracy of residents' MDSs. He said he expected the information transmitted to be correct. He said the DON reviewed the MDS and signed it was complete. He said the corporate MDS Coordinator performed audits to oversee the submission of accurate MDSs. Record review of an undated facility MDS Policy for MDS assessment Data Accuracy indicated the purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the residents who are familiar with his/her physical, mental, and psychosocial well-being .the MDS is a core set of screening, clinical, and functional status elements .which forms the foundation of a comprehensive assessment .the assessment accurately reflects the resident's status FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 5 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 6 of 14 residents reviewed for ADLs (Residents #4, Resident #30, Resident #31, Resident #37, Resident 42, Resident #45). Residents Affected - Some The facility did not clean or trim Resident #4, Resident #37, and Resident 42's fingernails. The facility failed to ensure Resident #45 did not have facial hair. The facility failed to ensure Resident #4, Resident #30, and Resident #31 received schedule shower/bed baths. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of Resident #4's face sheet dated 09/25/23 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and muscle weakness. Record review Resident #4's annual MDS assessment dated [DATE] indicated Resident #4 sometimes understood and sometimes understood others. The MDS indicated Resident #4 was rarely/never understood and unable to complete the BIMS assessment. The MDS indicated Resident #4 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #4 required total dependence for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. Record review of Resident #4's care plan dated 07/08/21 indicated Resident #4 was at risk for altered skin integrity. Intervention included showers at least 3 times a week or bed bath. The care plan indicated Resident #4 had poor cognition, unable to dress without assistance, bathe properly, and handle mechanics of toileting. Interventions included shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. The care plan further reflected Resident #4 was also at risk for other complication of eyes, feet, skin related to diabetes. Intervention included for charge nurse to assess for and/or perform nail care on Sundays. Record review of Resident #4's ADL sheet dated 07/01/23-07/31/23 indicated Resident #4's bath schedule days were Tuesdays', Wednesday's, and Saturdays' on the evening shift. The ADL sheet indicated Resident #4 missed 5 (07/01/23, 07/08/23, 07/11/23, 07/13/23, 07/20/23) out of 13 schedule shower days. No refusals were documented. Record review of Resident #4's ADL sheet dated 07/01/23-07/31/23 indicated Resident #4's weekly nail care was on Sunday's. The ADL sheet indicated Resident #4 did not receive nail care on scheduled or nonscheduled days. No refusal were documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 6 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #4's ADL sheet dated 08/01/23-08/31/23 indicated Resident #4's bath schedule days were Tuesday's, Wednesday's, and Saturdays' on the evening shift. The ADL sheet indicated Resident #4 missed 5 (08/08/23, 08/10/23, 08/26/23, 08/29/23, 08/31/23) out of 14 schedule shower days. No refusals were documented. Record review of Resident #4's ADL sheet dated 08/01/23-08/31/23 indicated Resident #4 nail care weekly was on Sundays. The ADL sheet indicated Resident #4 did not receive nail care on scheduled or nonscheduled days. No refusal documented. Record review of Resident #4's ADL sheet dated 09/01/23-09/30/23 indicated Resident #4 bath schedule days were Tuesdays, Wednesdays, and Saturdays on the evening shift. The ADL sheet indicated Resident #4 missed 6 (09/02/23, 09/09/23, 09/14/23, 09/16/23, 09/21/23, 09/23/23) out of 11 schedule shower days. No refusals documented. Record review of Resident #4's ADL sheet dated 09/01/23-09/30/23 indicated Resident #4 nail care weekly was on Sundays. The ADL sheet indicated Resident #4 did not receive nail care on scheduled or nonscheduled days . No refusal documented. On 09/27/23 at 2:40 p.m., Resident #4's shower sheets for 07/01/23-07/31/23 were requested from the DON. The shower sheets were not received prior to exit. Record review of Resident #4's shower sheet for 08/01/23-08/31/23 indicated Resident #4 received a shower with fingernails not trimmed on: *08/10/23 at 2:30 p.m. *08/12/23 at 3:10 p.m. *08/15/23 at 2:15 p.m. *08/19/23 at 4:30 p.m. On 09/27/23 at 2:40 p.m., Resident #4's shower sheets for 09/01/23-09/26/23 were requested from the DON. The shower sheets were not received prior to exit. During an observation on 09/25/23 at 9:49 a.m., revealed Resident #4 was in the bed with a hospital gown on. Resident #4's room smelled of urine. Resident #4 had medium length nails with brown substance underneath. 2. Record review of Resident #30's face sheet dated 09/25/23 indicated Resident #30 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness. Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated Resident #30 was usually understood and usually understood others. The MDS indicated Resident #30 had a BIMS of 03 which indicated severe cognitive impairment and had no rejection of care. The MDS indicated Resident #30 required extensive assistance for personal hygiene and bathing. Record review of Resident #30's care plan dated 05/18/23 indicated Resident #30 had poor cognition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 7 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was unable to dress without assistance, bathe properly, and handle mechanics of toileting. Interventions included to assist the resident with all ADL's unable to perform independently, shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. Record review of Resident #30's ADL sheet dated 08/01/23-08/31/23 indicated Resident #30's scheduled bath days were Tuesdays', Wednesdays', and Saturdays' on the evening shift. The ADL sheet indicated Resident #30 missed 9 (08/01/23, 08/05/23, 08/08/23, 08/12/23, 08/19/23, 08/22/23, 08/26/23, 08/29/23, 08/31/23) out of 14 schedule shower days. No refusals were documented. Record review of Resident #30's ADL sheet dated 09/01/23-09/30/23 indicated Resident #30 bath schedule days were Tuesdays', Wednesdays', and Saturdays' on the evening shift. The ADL sheet indicated Resident #30 missed 9 (09/02/23, 09/07/23, 09/09/23, 09/14/23, 09/16/23, 09/19/23, 09/21/23, 09/23/23) out of 11 schedule shower days. No refusals documented. Record review of Resident #30's shower sheet for 08/01/23-08/31/23 indicated Resident #30 received showers on: *08/10/23 at 4:00 p.m. *08/12/23 at 2:10 p.m. *08/15/23 at 3:30 p.m. *08/19/23 at 2:15 p.m. On 09/27/23 at 2:40 p.m., Resident #30's shower sheets for 09/01/23-09/26/23 were requested from the DON. The shower sheets were not received prior to exit. During an observation on 09/25/23 at 9:57 a.m., revealed Resident #30 was in the dining room at the table with her head on the table. Resident #30's hair was oily and in a ponytail. 3. Record review of Resident #31's face sheet dated 09/27/23 indicated Resident #31 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes (a group of diseases that result in too much sugar in the blood (high blood glucose)) and need for assistance with personal care. Record review of Resident #31's quarterly assessment dated [DATE] indicated Resident #31 was understood and usually understood others. The MDS indicated Resident #31 was rarely/never understood and unable to complete the BIMS. The MDS indicated Resident #31 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #31 required limited assistance for personal hygiene and bathing. Record review of Resident #31's care plan dated 03/17/21 indicated Resident #31 had poor cognition and mental deficit and did not recognize the need to dress or groom self appropriately. Interventions included shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. Record review of Resident #31's ADL sheet dated 08/01/23-08/31/23 indicated Resident #31's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 8 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scheduled bath days were Tuesday's, Wednesday's, and Saturday's on the evening shift. The ADL sheet indicated Resident #31 missed 11 (08/01/23, 08/05/23, 08/08/23, 08/12/23, 08/15/23, 08/17/23, 08/19/23, 08/22/23, 08/26/23, 08/29/23, 08/31/23) out of 14 schedule shower days. No refusals documented. Record review of Resident #31's ADL sheet dated 09/01/23-09/30/23 indicated Resident #31 bath schedule days were Tuesdays, Wednesdays, and Saturdays on the evening shift. The ADL sheet indicated Resident #31 missed 7 (09/09/23, 09/09/23, 09/14/23, 09/16/23, 09/19/23, 09/21/23, 09/23/23) out of 11 schedule shower days. No refusals documented. Record review of Resident #31's shower sheet for 08/01/23-08/31/23 indicated Resident #31 received showers on: *08/10/23 at 3:15 p.m. *08/12/23 at 2:40 p.m. *08/15/23 at 3:00 p.m. *08/19/23 at 3:30 p.m. n 09/27/23 at 2:40 p.m., Resident #31's shower sheets for 09/01/23-09/26/23 were requested from the DON. The shower sheets were not received prior to exit. During an observation on 09/25/23 at 9:39 a.m., revealed Resident #31 was sitting in the dining room participating in group activities. Resident #31 had oily hair. During an observation on 09/25/23 at 8:00 a.m., revealed Resident #31 was eating breakfast in the main dining room. Resident #31 had oily hair. 4. Record review of Resident #37's face sheet dated 09/27/23 indicated Resident #37 was a [AGE] year-old male admitted to the facility on [DATE], and a readmission on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was sometimes understood and sometimes understood others. The MDS indicated Resident #37 had unclear speech and moderate difficulty hearing. The MDS indicated Resident #37 short-and-long term memory recall, normally able to recall staff names and faces and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #37 required supervision for personal hygiene and limited assistance for bathing. Record review of Resident #37's care plan dated 03/17/21 indicated Resident #37 had mild to moderate cognitive/mental deficit and did not recognize the need to dress or groom himself appropriately. Intervention included shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. Record review of Resident #37's ADL sheet dated 09/01/23-09/30/23 indicated Resident #37's weekly nail care was on Sunday's. The ADL sheet indicated Resident #37 did not receive nail care on scheduled or nonscheduled days No refusals were documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 9 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 09/25/23 at 10:05 a.m., revealed Resident #37 was sitting on the sofa in the main living room area. Resident #37 had medium length nails with a dark brown substance underneath them. 5. Record review of Resident #42's face sheet dated 09/25/23 indicated Resident #42 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), open wound (is an injury involving an external or internal break in body tissue, usually involving the skin) of right buttock and need for assistance with personal care. Record review of Resident #42's quarterly assessment dated [DATE] indicated Resident #42 was usually understood and sometimes understood others. The MDS indicated Resident #42 was rarely/never understood and unable to complete the BIMS. The MDS indicated Resident #42 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #42 did not reject care. The MDS indicated Resident #42 required extensive assistance for personal hygiene and bathing. Record review of Resident #42's care plan dated 05/20/21 indicated Resident #42 had poor cognition, was unable to dress without assistance, bathe properly, handle mechanics of toileting. Intervention included shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. Record review of Resident #42's ADL sheet dated 09/01/23-09/30/23 indicated Resident #42's weekly nail care was on Sunday's. The ADL sheet indicated Resident #42 did not receive nail care on scheduled or nonscheduled days. No refusals were documented. During an observation on 09/25/23 at 10:20 a.m., revealed Resident #42 was sitting in her wheelchair in the main living area. Resident #42 had medium length nails with a scant amount of brown substance underneath them. 6. Record review of Resident #45's face sheet dated 09/25/23 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), need for assistance with personal care and muscle weakness. Record review of Resident #45's quarterly MDS assessment dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45 was rarely/never understood and unable to complete the BIMS. The MDS indicated Resident #45 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #45 did not reject care. The MDS indicated Resident #45 required supervision for personal hygiene and limited assistance for bathing. Record review of Resident #45's care plan dated 03/17/21 indicated Resident #45 had mild to moderate cognitive/mental deficit and did not recognize the need to dress or groom himself appropriately. Interventions included shampoo, shower/bath at least 3 times a week, fingernails and toenails cleaned and checked. Record review of Resident #45's ADL sheet dated 09/01/23-09/30/23 indicated Resident #45 received scheduled baths on Monday's, Wednesday's, and Friday's. Unable to determine if facial grooming was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 10 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 provided. Level of Harm - Minimal harm or potential for actual harm During an observation on 09/25/23 at 10:11 a.m., revealed Resident #45 walked up and said, I'm tired. On Resident #45's upper lip was 5-6 medium length blonde hairs were seen. Residents Affected - Some During an interview on 09/27/23 at 1:30 p.m., CNA A said CNAs were responsible for grooming residents. She said women should be shaved when hair was noticed on their face. She said showers or bed baths were done 3 times a week on day and night shifts, as needed, or resident/family preference. She said CNAs should make sure residents' nails were clean and clipped unless they were diabetics. She said ADLs should be documented in the ADL book. She said nail care was scheduled on Sunday's. She said resident refusals were documented in the ADL book, on the shower sheet, and the nurse should be notified. She said it was important for residents to be groomed and no smell. She said too long nails could cut the skin. She said not being groomed could make the resident feel bad or depressed. She said it was the CNAs responsibility to take care of the dependent residents. During an interview on 09/27/23 at 1:48 p.m., LVN B said CNAs were responsible for providing ADLs to the residents. She said it was the LVNs responsibility to make sure it was getting done. She said she checked the appearance of the residents to see if ADL care was done. She said CNAs documented ADL care in the ADL book and shower sheets. She said if a resident refused, CNAs should write it on the shower sheet and notify the nurse She said the LVN should then try to encourage the resident to accept care. She said nails were scheduled to be taken care of on Sunday's and as needed. She said facial hair should be taken care of with shower or bed baths. She said it was important for general hygiene, prevent skin breakdown and spreading germs. During an interview on 09/27/23 at 2:10 p.m., CNA C said she had worked at the facility for 11 years and worked the 7a-4p shift. She said CNAs were responsible for ADL care and bed bath or shower should be done on 3 times a week. She said nails should be cleaned and cut every day or every Sunday. She said facial hair should be taken care of with showers. She said CNAs documented ADLs in the ADL book and on a shower sheet. She said if a resident refused, CNAs should tell the nurse and document in the ADL book and on the shower sheet. She said ADL care was important to prevent body odor. During an interview on 09/27/23 at 2:58 p.m., CNA D said she had been working at the facility for 10 months. She said she worked on the secured unit. She said a lot of the residents refused ADL care. She said CNAs tried their best to follow the shower schedule. She said ADLs were documented in the ADL book by the CNAs and the nurses filled out the shower sheets. She said if a resident refused, it should be documented in the ADL book and nurse's note. She said CNAs were responsible for nail care also. She said it was important to document refusals, so staff know we tried to give the resident a bath or nail care. During an interview on 09/27/23 at 3:30 p.m., the DON said CNAs were responsible for ADLs. She said CNAs should document in the ADL book and on a shower sheet. She said resident refusals should be documented in the ADL book with a R on the day. She said nail care was scheduled for every Sunday and as needed. She said facial hair should be taken care of with showers and as needed. She said charge nurses ensured residents were getting scheduled ADL care. She said the facility's current process to ensure residents were getting ADL care and making sure CNAs were documenting was broken. She said she felt like the resident were getting showers, but CNAs were not documenting. She said ADL care was important to maintain the resident hygiene, keep the skin health, and decreased skin breakdown. During an interview on 09/29/23 at 3:53 p.m., the ADM said he expected ADLs to be done per the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 11 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some schedule and as needed. He said CNAs should provide the ADL care and the LVNs should make sure it was being done. He said ADL care should be monitored by the nursing administration also. He said he expected the shower sheets to be turned in the ADON. He said not getting showers, facial grooming, or nail care could affect how the resident felt. Record review an undated facility Activities of Daily Living (Daily Life Functions) procedure indicated .basic responsibility: licensed nurse and nursing assistant .purpose .to assist resident in achieving maximum function .to improve quality of life Record review of a facility Bath (Shower) procedure dated 04/30/17 indicated .basic responsibility: licensed nurse and nursing assistant .purpose .to cleanse and refresh the resident .to observe the skin .to provide increased circulation Record review of an undated facility Shaving the Resident procedure indicated .basic responsibility: licensed nurse and nursing assistant .purpose .to remove facial hair and improve the resident's appearance and morale FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 12 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents reviewed for transfer. (Residents #4) The facility failed to ensure CNA A and CNA D performed a safe mechanical lift transfer (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for Resident #4. This failure could place residents at risk of injury from accident and hazards. Findings included: Record review of Resident #4's face sheet dated 09/25/23 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), repeated falls, acquired absence of left leg above knee and muscle weakness. Record review Resident #4's annual MDS assessment dated [DATE] indicated Resident #4 sometimes understood and sometimes understood others. The MDS indicated Resident #4 was rarely/never understood and unable to complete the BIMS. The MDS indicated Resident #4 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #4 required total dependence for bed mobility, transfers (2 plus persons assist), dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident #4 was not steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS revealed Resident #1 had functional limitation in range of motion on both side in the upper and lower extremities. The MDS revealed Resident #4 used a wheelchair as a mobility device. Record review of Resident #4's care plan dated 08/17/23 indicated Resident #4 had a history of falls. Interventions included transfer via Hoyer lift and 2 assist, use drawsheet on bed, and 2 assist with bed mobility and dressing. During an observation on 09/26/23 at 1:35 p.m., revealed CNA A and CNA D removed Resident #4 from her wheelchair using a mechanical lift. CNA D pushed the mechanical lift underneath Resident #4's bed with the legs on the base of the machine closed. CNA D lowered Resident #4 on the bed using the mechanical lift. CNA D did not widen the legs on the base of the lift before lowering Resident #4. During an interview on 09/27/23 at 1:30 p.m., CNA A said there were no issues with Resident #4's mechanical lift transfer that happened yesterday (09/26/23). She said the legs on the base of the lift were supposed to be closed when under the bed and lowering the resident. She said she had been instructed by the maintenance man who worked on the lift to close the legs when lowering the resident onto the bed. She said, Is that not, right? She said she could not recall what the training sheet for mechanical lift indicated to do when lowering the resident onto the bed. During an interview on 09/27/23 at 1:48 p.m., LVN B said when a resident was transferred by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 13 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 mechanical lifted and lowered onto the bed, the legs were supposed to be spread open. She said it stabilized the machine and resident better. She said if a mechanical lift transfer was not done correctly, injuries could happen. She said CNAs were checked off for proper mechanical lift transfer. During an interview on 09/27/23 at 2:10 p.m., CNA C said the legs on the mechanical lift should be open when lifting or lowering a resident. She said it was more stable with the legs open. She said falls could happen if transfers were not done right. During an interview on 09/27/23 at 2:58 p.m., CNA D said she had been employed at the facility for 10 months. She said the legs on the lift were supposed to be back together when under a bed and lowering a resident. She said she had been trained on mechanical lift transfers by CNA A. She said accidents could happened if transfers were not done right. During an interview on 09/27/23 at 3:30 p.m., the DON said CNA A checked off new hires on mechanical lift transfers. She said she trained CNA A on how to do a proper mechanical lift transfer. She said she instructed CNA A to open the base legs under the bed and when lowering the resident. She said she did not know why she listened to someone else about lift transfers. She said the legs needed to be wide to provide balance and support. She said if not done correctly, the lift could become unbalanced, and a resident could fall. During an interview on 09/27/23 at 3:53 p.m., the ADM said the mechanical lift legs should be opened when lowering a resident to the bed from the wheelchair. He said nursing administration should ensure CNAs were doing proper transfers. He said nursing administration did competencies for all types of transfers on hire and annually. He said improper use of the mechanical lift during a transfer could make it unbalanced and an accident could happen. Record review of a facility in-service How to use a Hoyer lift/Hoyer lift Skills Check off, given by CNA A, dated 02/06/23 indicated .positioning the lift for use .with the legs of the base open and locked CNA A and CNA D signed the in-service roster. Record review of CNA D's Transfer, Two Person Hoyer (Mechanical)Lift- Check off dated 08/09/23 indicated .position lift over the bed .spread the legs of the lift to the widest open position to maintain a broad base of support . this CNA/LVN demonstrates competency of transferring a resident with a Hoyer lift Competency form was signed by CNA A Record review of an undated facility Assisting with Transfers and Reposition policy indicated .purpose .safe handle, reposition, transfer and protect Resident and the staff from injury during transfers and repositioning FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 14 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired food was not thrown away. 2. Food was not labeled or dated. 3. The kitchen refrigerators and freezers had various food particles not cleaned off. These deficient practices could place residents who received meals from the main kitchen at risk for food borne illness. The findings were: During an observation on 09/25/23 at 9:10 a.m., it was observed that two packages of tostadas with an expiration date of 1/17/2023 were stored in the pantry. Dry alfredo sauce that was opened and stored in a gallon sized zip top bag was not labeled or dated. 4 bags of lettuce in the beginning stages of rotting, browning, and slimy in appearance were not labeled or dated. One bag of lettuce had a hole in the plastic bag it was stored in with tape covering the hole in the bag that was still partially open. Four kitchen refrigerators and freezers were dirty in appearance with unknown food particles smeared on the front metal doors and vents. The milk refrigerator had a layer of unknown stains on the side of the refrigerator. The kitchen in general had unknown particle splatters on several other surfaces including walls, refrigerators and freezer appliances, and tables. During an interview on 09/27/2023 at 10:50 a.m., the Dietary Manager stated that all food in the kitchen that had been opened should be labeled and dated. She stated that staff should label and date so that food can be thrown out three days after opening. She stated that she expects that any food that is expired should be thrown away. She stated that if there were tostada shells in the pantry past their expiration date then they should have been thrown away as food is not allowed to serve food past its expiration date. She stated that lettuce that was browning and rotting should have been thrown away. She stated that every shift staff should inspect food and throw away any food that cannot be served to residents. She stated that she expects her staff to clean all surfaces inside of the kitchen including refrigerators and freezers. She stated that the refrigerator doors and handles should not be dirty. During an interview on 09/27/2023 at 2:05 p.m. the Administrator stated that he expects that staff should have followed safe food handling and storage policies. He stated that he expects that staff should have thrown away expired and unusable food. He stated that he expects that staff should have cleaned the equipment and surfaces in the kitchen including the refrigerators and freezers. He stated that he expects staff should have labeled and dated food appropriately to follow federal and state guidelines. Review of the facility policy dated 2019, Food Storage revealed: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 15 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0812 Level of Harm - Minimal harm or potential for actual harm methods designed to prevent contamination or cross contamination. Food should be dated as it is placed on the shelves if required by state regulation. All refrigerator units will be kept clean and in good working conditions at all times. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 16 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Provide and implement an infection prevention and control program. 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 an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1of 2 residents reviewed for incontinent care and 10 of 23 residents observed during meal tray pass. (Resident #4, Resident #30, Resident #31, Resident #42, Resident #44, Resident #45, Resident #47, Resident #48, Resident #257, and Resident #258) Residents Affected - Some The facility failed to ensure CNA D changed her gloves at appropriate times during incontinence care on Resident #4. The facility failed to ensure CNA D, MA E, and NA G performed hand hygiene after assisting residents with meal set up prior to assisting the next resident. The facility failed to ensure CNA D and NA G performed hand hygiene after touching their face, coughing into their hands, and scratching their heads prior to handling residents' meal trays and assisting with their meal set up. The facility failed to ensure NA G practiced proper infection control measures when she cleaned a chair soiled with feces by cleaning the dirty seat area followed by the clean back of the chair with the same disinfectant wipes without gloves. The facility failed to ensure HA F performed hand hygiene after handling a resident's personal items and then delivering meal trays to other residents and then assisting with meal set ups. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #4's face sheet dated 9/25/23 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and muscle weakness. Record review Resident #4's annual MDS assessment dated [DATE] indicated Resident #4 sometimes understood and sometimes understood others. The MDS indicated Resident #4 was rarely/never understood and unable to complete the BIMS assessment. The MDS indicated Resident #4 had short-and-long term memory recall and moderately impaired cognitive skill for daily decision making. The MDS indicated Resident #4 required total dependence for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident #3 was always incontinent of urine and bowel. Record review of Resident #4's care plan dated 7/08/21 indicated Resident #4 was at risk for altered skin integrity. Interventions included assess every 2 hours and as needed for incontinent care and provide incontinent care with warm soap and water or peri wash. During an observation on 9/26/23 at 1:35 PM, revealed CNA D performed incontinent care on Resident #4 with CNA A's assistance. During the incontinent care, the wipes fell off the bedside tray onto the Resident #4's floor. CNA D picked up wipes off the floor and then continued to clean Resident #4's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 17 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some peri area without changing her gloves. Resident #4 had feces in her brief. CNA D finished cleaning the resident then helped CNA A turn and reposition Resident #4 without changing her gloves. During an interview on 9/27/23 at 1:30 PM, CNA A said after Resident #4's wipes fell on the floor, CNA D should have changed her gloves. CNA A said CNA D should have changed gloves after cleaning the resident before she turned and repositioned Resident #4. She said changing gloves was important for infection control. She said not changing gloves during incontinent care could cause the resident to get an infection. During an interview on 9/27/23 at 1:48 PM, LVN B said gloves should be changed after something falls on the floor and picked it up. She said gloves should be changed after wiping a resident before turning and repositioning. She said it was important for infection control and to prevent the spread of germs. During an interview on 09/27/23 at 2:58 p.m., CNA D said she should have thrown the wipes away after they fell on Resident #4's floor. She said should have then removed her gloves, washed her hands, then got new gloves. She said she should have changed her gloves before repositioning Resident #4. She said she should have changed gloves to prevent cross contamination and prevent feces or urine getting on the bedding. She said not changing her gloves could cause urinary tract infection or infection. She said infections can cause resident to get confused. During an interview on 9/27/23 at 3:30 PM, the DON said CNA D should have changed her gloves after picking up the wipes when they fell on the floor or left the wipes on the floor and used something else. She said CNA D should have changed her gloves after cleaning the resident and before repositioning and turning Resident #4. She said not changing gloves correctly was an infection control issue. She said residents could get an infection from not changing gloves during incontinent care. She said an infection could cause altered mental status. She said it was important for the resident's overall wellbeing. During an interview on 9/27/23 at 3:53 PM, the ADM said he expected the nursing staff to perform incontinent care correctly. He said LVNs and nursing administration should be ensuring it was happening. He said if incontinent care was not done correctly resident could get bladder or urinary tract infections. Record review of CNA D's Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 9/19/23 indicated CNA D demonstrated competency in providing perineal care (peri-care) for female. The evaluation was signed off by CNA A. 2.Record review of Resident #30's face sheet dated 9/27/23 indicated Resident #30 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), weakness, difficulty walking, and lack of coordination. Record review of Resident #30's quarterly MDS dated [DATE] indicated Resident #30 was usually understood and usually understood others. The MDS indicated a BIMS score of 03 which indicated Resident #30 had severe cognitive impairment. The MDS indicated Resident #30 required supervision to extensive assistance of 1 person for most activities of daily living. The MDS indicated Resident #30 was frequently incontinent of bladder and was always continent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 18 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #31's face sheet dated 9/27/23 indicated Resident #31 was a [AGE] year-old female admitted to the facility initially on 2/21/19 and re-admitted on [DATE] with diagnoses including dementia, diabetes (high sugar level in the blood), and abnormality of gait. Record review of Resident #31's quarterly MDS dated [DATE] indicated Resident #31 was understood and usually understood others. The MDS indicated she was not able to participate in the BIMS assessment which indicated Resident #31 had severe cognitive impairment. The MDS indicated Resident #31 required supervision to limited assistance of 1 person for most activities of daily living. 4. Record review of Resident #42's face sheet dated 9/27/23 indicated Resident #42 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, weakness, hypertension, and a history of pneumonia (infection in lungs). Record review of Resident #42's quarterly MDS dated [DATE] indicated Resident #42 was usually understood and sometimes understood others. The MDS indicated she was not able to participate in the BIMS assessment which indicated Resident #42 had severe cognitive impairment. The MDS indicated Resident #42 required limited to extensive assistance of 1-2 persons for most activities of daily living. 5. Record review of Resident #44's face sheet dated 9/27/23 indicated Resident #44 was an [AGE] year-old male admitted to the facility initially on 9/14/21 and readmitted on [DATE] with diagnoses including dementia, diabetes, and depression (persistent sadness). Record review of Resident #44's quarterly MDS dated [DATE] indicated Resident #44 was understood and understood others. The MDS indicated a BIMS score of 05 which indicated Resident #44 had severe cognitive impairment. The MDS indicated Resident #44 required supervision to limited assistance of 1 person for most activities of daily living. 6. Record review of Resident #45's face sheet dated 9/27/23 indicated Resident #45 was a [AGE] year-old female admitted to the facility initially on 6/03/21 and readmitted on [DATE] with diagnoses including dementia, weakness, hypertension, and difficulty in walking. Record review of Resident #45's quarterly MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated she was not able to participate in the BIMS assessment which indicated Resident #45 had severe cognitive impairment. The MDS indicated Resident #45 required supervision to limited assistance of 1 person for most activities of daily living. 7. Record review of Resident #47's face sheet dated 9/27/23 indicated Resident #47 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's (progressive mental deterioration due to degeneration of the brain), dementia, hypertension, and depression. Record review of Resident #47's quarterly MDS dated [DATE] indicated Resident #47 was understood and understood others. The MDS indicated a BIMS score of 03 which indicated Resident #47 had severe cognitive impairment. The MDS indicated Resident #47 required supervision to limited assistance of 1 person for most activities of daily living. 8. Record review of Resident #48's face sheet dated 9/27/23 indicated Resident #48 was a [AGE] year-old male admitted to the facility initially on 11/01/22 and readmitted on [DATE] with diagnoses including Parkinson's disease (progressive disease of the nervous system resulting in imprecise movements), hypertension, heart failure, weakness, and lack of coordination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 19 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #48's MDS dated [DATE] indicated Resident #48 was understood and usually understood others. The MDS indicated a BIMS score of 04 which indicated Resident #48 had severe cognitive impairment. The MDS indicated Resident #48 required total assistance of 1-2 persons for most activities of daily living. 9. Record review of Resident #257's face sheet dated 9/27/23 indicated Resident #257 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, depression, diabetes, and hypertension. Record review of Resident #257's admission MDS dated [DATE] indicated Resident #257 was usually understood and usually understood others. The MDS indicated a BIMS score of 08 which indicated Resident #257 had moderate cognitive impairment. The MDS indicated Resident #257 required extensive assistance of 1 person for most activities of daily living. 10. Record review of Resident #258's face sheet dated 9/27/23 indicated Resident #258 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including blood clot to left lower extremity, weakness, diabetes, depression, and hypertension. Record review of Resident #258's admission MDS dated [DATE] indicated Resident #258 was usually understood and usually understood others. The MDS indicated a BIMS score of 10 which indicated Resident #258 had moderate cognitive impairment. The MDS indicated Resident #258 required extensive assistance of 1 person for most activities of daily living. During an observation on 9/25/23 beginning at 11:58 AM, revealed CNA D wiped her face with her hand and did not use hand sanitizer or wash her hands prior to delivering food to Resident #31. CNA D then wiped her nose/face with the collar of her shirt and continued to deliver a meal tray to Resident #45 and CNA D did not sanitize or wash her hands. CNA D then wiped her face with the back of hand/wrist and continued to deliver a meal tray to Resident #25 and did not use sanitizer or wash her hands. CNA D assisted each resident with set up by opening juices and removed plastic coverings from cakes and drink cups. MA E delivered a meal tray to Resident #44 and did not use sanitizer or wash her hands between residents after assisting the previous resident with meal set up. During an observation on 9/25/23 beginning at 12:14 PM, revealed Resident #258 was sitting in her chair with her bedside table in front of her. HA F delivered Resident #258's meal tray. HA F handled Resident #258's bottles of soda and moved things on Resident #258's bedside table and tried to find something in Resident #258's closet at the resident's request. HA F then delivered a meal tray to Resident #257 and assisted the resident with opening juices and removing plastic coverings from cake and cups. HA F then delivered a meal tray to Resident #48 and assisted him with meal set up by opening juices, removing plastic coverings from cake and cups, and handing him his silverware. HA F did not sanitize or wash hands between residents after handling personal items and assisting the residents with meal set up. During an observation on 9/26/23 beginning at 12:43 PM, revealed CNA D took Resident #30 to the resident's room to clean/change her due to Resident #30 had a bowel movement while sitting at the dining table prior to the meal being served. Resident #30 was observed to have bowel movement that soaked through her clothing. NA G went and got some disinfectant wipes and came back to Resident #30's chair with no gloves on and wiped the seat section of chair with the wipes and NA G then wiped the back of the chair down with the same wipes. NA G then sanitized hands and walked down the hallway and grabbed her collar and coughed into it and as NA G was headed back to the dining area, she coughed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 20 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some into her hand, and then she went and sat down and begun to assist Resident #45 with her meal by feeding the resident. As more trays were delivered to the memory care unit, NA G got up to assist with passing meal trays and NA G scratched her head and then delivered a meal tray to Resident #47 and removed the plastic covering from the pie, removed plastic covering from the drink cup, and took the paper off the straw and placed the straw in Resident #47's drink. NA G did not use hand sanitizer or wash her hands after scratching her head and prior to handling Resident #47's meal items. During an observation on 9/26/23 beginning at 12:25 PM, revealed CNA D wiped her face/nose, then coughed into her hand and then went and got a chair and placed it at a resident table. CNA D then wiped her face again and then picked up Resident #42's bowl of green food and handed it to Resident #42. CNA D then wiped her face again with her hand and then scratched her head and readjusted her glasses and then touched Resident #47's pie plate. CNA D did not use hand sanitizer or wash her hands after wiping her face multiple times, coughing into her hand, scratching her head, or adjusting her glasses prior to handling the residents' meal items. During an interview on 9/27/23 at 1:50 PM, HA F said she had worked at the facility for a year but had only been the HA for 3 months. HA F said she should sanitize hands prior to passing the meal trays to the residents. HA F said she should have sanitized her hands prior to delivering the next resident's tray after handling the residents' personal items and assisting the residents with their meal set up. HA F said she remembered she did not sanitize her hands after removing items from Resident #258's bedside table and then dug through her closet and then proceeded to deliver meal trays to Resident #257 and Resident #48 and assisted them with their meal set up. HA F said she was aware that she could pass bacteria to other residents, and it could make them sick, by not sanitizing her hands appropriately. During an interview on 9/27/23 at 1:55 PM, NA G said she had worked at the facility for 6 months. NA G said she sanitized her hands prior to passing meal trays and tried to do it in between residents. NA G said after sanitizing her hands 3 times, she washed her hands. NA G said she sanitized her hands after coughing and would step away from the residents if she needed to cough. NA G said if staff did not sanitize or wash hands after coughing in hand, touching contaminated surfaces, they could pass germs to residents and make the residents sick. NA G said it was hectic during meal service . NA G said she did not know to clean the clean back area of the chair first and then the dirty seat area, but she said she should have worn gloves while cleaning the chair that had bowel movement on it. During an interview on 9/27/23 at 2:04 PM, MA E said she was also a CNA. CMA E said she had worked at the facility for four years. CMA E said staff should sanitize their hands prior to passing a meal tray and between each resident. CMA E said if they did not sanitize their hands properly, it could spread germs between residents. CMA E said she usually tried to keep hand sanitizer in her pocket, but Monday was so hectic, and she was just trying to get everyone their meal trays. During an interview on 9/27/23 at 2:10 PM, LVN B said she had worked at the facility since 2013. LVN B said staff should sanitize the hands before, during, and after meal pass. LVN B said staff should sanitize their hands in between each resident due to infection control purposes. LVN B said staff should sanitize their hands any time after touching their face, coughing into their hands, prior to handling residents' meal trays. LVN B said by not sanitizing your hands appropriately, staff could transfer germs or infection to the residents. During an interview on 9/27/23 at 2:58 PM, CNA D said she had worked at the facility for ten months. CNA D said staff should sanitize their hands after touching other residents and between passing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 21 of 22 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 455879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marshall Manor West 207 W Merritt St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some each tray to each resident. CNA D said they should sanitize their hands after touching their face, scratching their head, or coughing into their hands. CNA D said it was important to sanitize their hands appropriately to not spread germs to the residents. CNA D said she just realized during the interview that she touched her face multiple times and did not sanitize her hands and CNA D said she should have. During an interview on 9/27/23 at 3:22 PM, the DON said she had worked at the facility for 17 years. The DON said staff should sanitize their hands prior to starting meal pass and in between anytime hands were soiled, if touched their face or hair, or if touched a contaminated surface. The DON said staff should not have to sanitize their hands between residents if hands were not visibly soiled or have not touched a resident. The DON said it was cold, flu, and COVID-19 season and by not sanitizing hands appropriately could pass germs to residents. During an interview on 9/27/23 at 3:30 PM, the ADM said he had worked at the facility for six years. The ADM said he would expect staff to sanitize their hands after touching their faces or handling anything of the residents'. The ADM said if staff were not sanitizing their hands after touching their face, coughing into their hands, or handling anything of the residents', they could spread germs to the residents. Record review of an In-service dated 1/13/23 titled Prevention and Control of Infection revealed . perform hand hygiene in the following clinical situations: before having direct contact with patients; after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; after contact with a patient's intact skin; after contact with inanimate objects in the immediate vicinity of the patient CNA D and MA E had signed the in-service. Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised 4/01/20 revealed . the facility considered hand hygiene the primary means to prevent the spread of infections . personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water . before and after direct contact with resident . when hands were visibly dirty or soiled with blood or other body fluids . after handling items potentially contaminated with blood, body fluids, or secretions . in most situations, the preferred method of hand hygiene was with an alcohol-based hand rub . if hands were not visibly soiled, use alcohol-based hand rub . before and after direct contact with residents . before preparing or handling medication . after contact with objects in the immediate vicinity of the residents . Record review of the facility's policy titled Infection Control dated revised 1/04/11 revealed . facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . objectives of the infection control policies and practices were to . prevent, detect, investigate, and control infections in the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455879 If continuation sheet Page 22 of 22