Inspection·May 3, 2023

F 0550 During an interview on 05/03/23 at 09:35 AM the ADM said he expected all residents sitting at the same table to be served their meal so they can eat together. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 2 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #18) Residents Affected - Few * The facility incorrectly coded Resident #18's antiplatelet as an anticoagulant on his MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of a face sheet dated 05/03/23 indicated Resident #18 was a [AGE] year-old male admitted on [DATE]. His diagnoses included long term use of antithrombotic/antiplatelets (blood thinning medications but not anticoagulants). Record review of the physician orders dated March 2023 indicated Resident #18 received clopidogrel 75 mg daily starting on 03/24/23. Record review of an MDS with ARD date 03/31/23 indicated Resident #18 received an anticoagulant for 5 days of the 7 day look back period. During an interview on 05/03/23 at 10:50 AM the MDS nurse said Resident #18 was on the clopidogrel, so he was coded on an anticoagulant because she thought the medication was an anticoagulant. When she looked up the medication it was classified as an antiplatelet. She said it was not an anticoagulant and was coded incorrectly. She said she was responsible for ensuring the information was correct. She said the wrong information could have medications not financially covered. When a policy was requested the MDS nurse said she was not aware of a policy they just followed the MDS manual. During an interview on 05/03/23 at 01:25 PM the interim DON said she would expect the MDSs to be filled out correctly by staff who obtained information from the residents' charts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 3 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 of 15 residents reviewed for PASARR (Preadmission Screening and Resident Review). *The facility did not complete a new PASARR Level 1 Screening (a preliminary assessment) completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine if a person has, or is suspected of having, a mental illness, intellectual disability or related condition) when Resident #4 was diagnosed with schizoaffective disorder (combination of schizophrenia (serious mental illness) and mood disorder) on 12/19/22. *The facility did not complete a new PASARR Level I Screening (a preliminary assessment) completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine if a person has, or is suspected of having, a mental illness, intellectual disability or related condition) when Resident #7 was diagnosed with major depression and psychotic disorder on 10/26/21. This failure could place the residents at risk for not receiving PASARR care and services. Findings included: 1. Record review of Physician orders dated May 2023 indicated Resident #4, admitted [DATE], was [AGE] years old with diagnoses of schizoaffective disorder. Record review of the 5-day MDS assessment dated [DATE] indicated Resident #4 had verbal or physical behaviors towards others 1 to 3 days and diagnosis of schizoaffective and had received antipsychotic medications 7 times in the last 7 days. Record review of care plan dated 1/30/2022 to present indicated Resident #4 had verbal aggression, physical aggression and resistance to care and was currently taking psychotropic medications for his diagnosis of schizoaffective disorder. Record review of a PASARR Level I dated 01/29/22 indicated Resident #4 did not have a mental illness, intellectual disability or developmental disability. Record review of a pharmacy note to the attending physician dated 12/15/22 indicated the physician had given Resident #4 a new diagnosis of other schizoaffective disorder. During an interview and observation on 05/03/23 at 8:32 a.m., the MDS nurse said the diagnosis of schizoaffective disorder must have been placed in his record in error. The MDS nurse was viewing the electronic record and said yes, he was given the diagnosis on 12/19/22 and she was unaware of this new diagnosis . She said when a new diagnosis was given the nurses should have told her of the changesThe MDS nurse said there should have been a new screen sent to LHMA (Local Mental Health Authority) when that diagnosis was given to Resident #4. She said the possible negative outcome of not updating the PASARR Level I and notifying LMHA could be the resident does not receive the needed services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 4 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/03/23 at 11:50 a.m., the administrator said her expectation was for the MDS nurse, to send a new PASARR level 1 when required. 2. Record review of physician orders dated May 2023 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of psychotic disorder with known hallucinations and major depressive disorder, recurrent, severe with psychotic symptoms. The resident had orders for a psychiatric evaluation dated 3/11/21. Record review of the most recent MDS dated [DATE] indicated Resident #7 had hallucinations and delusions occur every 1 to 3 days, had a diagnosis of depression and received antipsychotic medications 7 times in the last 7 days. Record review of care plans dated 10/11/20 to present indicated Resident #7 had short term memory problems and was currently taking psychotropic medications for depression with psychotic features and psychotic mood disorder. Record review of a psychiatric note dated 10/26/21 indicated Resident #7 had a diagnosis of moderate major depressive disorder. Record review of a PASARR Level I dated 10/27/20 indicated Resident #7 did not have a mental illness, intellectual disability or developmental disability. During an interview on 05/03/23 at 11:07 a.m., the MDS nurse said she was not aware a PASARR had to be updated when a resident received a new psychotic disorder diagnosis. She said the only PASARR Level I Resident #7 had was the one dated 10/27/20. She said a new PASARR Level I was not completed when the resident was diagnosed with psychotic disorder and major depression on 10/26/21. She said the possible negative outcome of not updating the PASARR Level I and notifying LMHA (Local Mental Health Authority) would be the resident could possibly not receive the needed services. During an interview on 05/03/23 at 11:10 a.m., the interim DON said not having a correct PASARR in place could cause the resident to not receive the appropriate PASARR services. She said her expectations was for Resident #7 to have a current and correct PASARR in place . The interim DON said Resident #7 was seeing people outside of her room when there was no one there, so we did have to have her evaluated and seen by the psychiatrist. She was diagnosed with psychotic disorder on 10/26/21. During interview and record review on 05/03/23 at 11:30 a.m., the MDS nurse said the only information in the PASARR transmission portal was the PASARR Level I from 10/27/20. Review of the Simple system (an online system to transmit required PASARR forms to the LMHA) indicated there was no documentation to indicate Resident #7 received a PASARR Level I assessment after the resident was diagnosed with psychotic disorder on 10/26/21. The undated . PASARR Process policy indicated: . PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI)/Intellectual or Developmental Disability (IDD) are cared for properly. PCC (Person Centered Care) update and print Positive PASRR list and review at least 1 x week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 5 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 15 residents (Resident #7) reviewed for ROM (range of motion). The facility did not have a treatment in place for Resident #7's contractures of the left hand to prevent further decline in ROM. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated May 2023 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of cerebral infarction (stroke), lack of coordination and muscle wasting/atrophy. The resident was admitted to Hospice services on 11/18/21. Record review of the most recent MDS dated [DATE] indicated Resident #7 had a decrease in range of motion to one side of the upper extremities. The resident had not received physical or occupational therapy. Record review of care plans dated 10/11/20 to present indicated Resident #7 had short term memory problems, required extensive assistance for bathing and dressing, and had contractures, which placed the resident at risk for skin breakdown. The contracture care plan interventions indicated to monitor for increased pain/stiffness . The most recent occupational therapy note dated 9/15/21 to 10/15/21 indicated Resident #7 received therapy services to the upper extremities with discharge instructions included no restorative was indicated and and 24 hour care maintance. The most recent Nursing Restorative Care Program notes dated 2/01/21 to 2/26/21 indicated Resident #7 completed the program with good response. The note indicated the plan of care was appropriate and the program was to continue. During observations and interview on 05/01/23 at 10:51 a.m., Resident #7 had contractures to the last three fingers of the left hand. The 3 fingers were contracted downwards to the bottom of the palm of the hand. The pointer finger was partially contracted inward at the 1st and 2nd joint. The resident could not move the 3 fingers when asked to do so by the surveyor. The resident was not interviewable and could only answer simple yes/no questions. The resident said no, when asked by the surveyor if the left contracted hand was painful. There was not a handroll in place to the left contracted hand. During observations on the following dates, Resident #7 did not have a handroll to the left contracted hand: *05/01/23 at 10:51 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 6 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 *05/02/23 7:49 a.m.; and Level of Harm - Minimal harm or potential for actual harm *05/02/23 03:20 p.m. Residents Affected - Some During an interview on 05/02/23 at 3:28 p.m., the therapy services supervisor said Resident #7 was on Hospice services and the Hospice would not order therapy services for the resident. She said residents on Hospice services did not usually receive therapy. She said residents with contractures should receive strengthening and stretching exercises and carrots or handrolls should be used. During observation of Resident #7 and interview on 05/02/23 at 3:47 p.m., the therapy services supervisor said Resident #7 did have contractures of the left hand and needed a handroll to prevent further contractures. She said the last time she assessed the resident; it was for a fall and she did not assess her hand. She said the possible negative outcome of not placing a handroll in the resident's contracted hand could be a decrease in ROM and pain. During observation of Resident #7 and interview on 05/02/23 at 3:50 p.m., LVN A said Resident #7's left hand was contracted, and the resident did need a handroll in her hand to prevent further contractures. She said the possible negative outcome of not having a handroll in the resident's hand would be a further decrease in the resident's ROM or possible wounds with infection. During an interview on 05/02/23 at 4:00 p.m., the interim DON said her expectations were for the residents to avoid a decline in their ROM. She said the possible negative outcome of not having a handroll in Resident #7's contracted hand could be a possible decline in ROM. The DON said the resident had not had therapy services or restorative services since 2021. During an interview on 05/02/23 at 4:05 p.m., the administrator said her expectations were for the resident's ROM to be maintained. She said Resident #7 should have a handroll placed in the contracted hand. She said the residents should be seen by restorative to prevent further decline. During an observation on 05/03/23 at 1:14 p.m., after surveyor intervention, Resident #7 was lying in bed with a handroll to the left hand. A Range of Motion policy dated July 2014 indicated: . Objective- to prevent contractures, to maintain normal range of motion, to increase joint motion to the best possible range, to stimulate circulation and to prevent deformities, and any contractures from becoming worse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 7 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding by 1 of 2 nurses administering medications through a percutaneous endoscopic gastrostomy (PEG) tube. (LVN A) * LVN A did not check placement of Resident #32's PEG tube (a tube going into the stomach through the abdomen to administer medications and liquid nutrition) placement prior to flushing with water and administering medications. This failure could place residents with PEG tubes at risk for abdominal pain, vomiting, or hospitalization. Findings included: During an observation on 05/02/23 09:30 AM of medication administration for Resident #32 LVN A removed Hyoscyamine (helps to control spasms in the gut) 0.125 mg 1 tablet, Metoclopramide (used to treat heartburn) 10mg 1 tablet, Senna S (used to treat constipation) 8.6 mg 1 tablet; crushed the pills individually, and placed them in separate medication cups with 10-15 cc of H2O added. She then removed Probiotic (used to inprove gut microbes) 250 mg 1 capsule, opened and emptied the contents in a separate medication cup, and added 10-15 cc of water. She then poured Docusate Sodium (stool softener) liquid 10cc liquid into a separate medication cup. LVN A entered the resident's room without her stethoscope. She checked for the PEG tube for gastric content residual but did not check for placement of the PEG tube. The PEG tube was flushed with 30 cc of water before the medication administration, each medication was administered through the PEG tube with 15 cc of water flush between each medication, and the PEG tube was flushed with 30 cc of water after the medication administation was complete. During an interview on 05/02/23 at 10:30 AM LVN A said she would not have done anything different with Resident #32's medication administration or the PEG tube procedure. During an interview on 05/03/23 at 01:25 PM the interim DON said placement of PEG tubes were done by inserting air through the tube with air per their policy and procedure. She said if placement was not checked then the resident could be getting water, meds, or feedings between the stomach and the abdominal wall. Record review of the facility policy Medication Administration Through A Feeding Tube Policy and Procedure updated March 2019 indicated .Procedure: Check feeding tube for placement (refer to procedure for confirming placement) Record review of the facility policy Confirming Placement of Feeding Tube updated March 2019 indicated .Purpose: To ensure proper position of the tube in the stomach; to prevent feeding from entering the lungs Procedure: Place the stethoscope just below the xiphoid process and instill 10-25 cc of air FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 8 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 11 residents (Resident #6) and in 2 of 2 medication carts (100/200 hall nurse cart and 300/400 hall medication aide cart) reviewed for pharmacy services. * Resident #6 had 2 sets of hold parameters for her verapamil (blood pressure medication). LVN C held Resident #6's verapamil without verifying which set of parameters were correct. * The facility had a medication error rate of 4%. * The facility did not dispose of expired medications from the 100/200 hall nurse cart and 300/400 hall medication aide cart. These failures could place residents at risk of not receiving necessary medications, not receiving the intended therapeutic benefits of their medications, and a decline in health. Findings included: 1. Record review of the face sheet indicated Resident #6 was an [AGE] year-old female admitted on [DATE]. He diagnoses included high blood pressure. Record review of the physician orders for May 2023 indicated Resident #6 had a physician order dated 02/15/23 for verapamil 180 mg tablet twice daily with blood pressure and/or pulse hold: systolic (upper number) blood pressure less than 120 to hold; diastolic (lower number) blood pressure less than 60 to hold; and pulse less than 60 to hold. There was also blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold. During an interview on 05/03/23 at 09:21 AM MA C said Resident #6 had 2 sets of hold parameters for the Verapamil. She said she had reported this to the nurse several times, but it still had not been fixed. During an interview on 05/03/23 at 09:25 AM LVN E reviewed Resident #6's physician order and said Resident #6 had 2 sets of hold parameters. During an interview on 05/03/23 at 09:26 AM the ADON reviewed Resident #6's physician orders and said Resident #6 should not have 2 sets of hold parameters. 2. During an observation and interview on 05/02/23 at 03:12 PM LVN C checked Resident #6's blood pressure. The reading was 160/72. She said she was holding Resident #6's Verapamil 180mg due to blood pressure parameters to hold if the lower number was less than 80. Record review of physician orders for May 2023 indicated Resident #6 had a physician order dated 02/15/23 for verapamil 180 mg tablet twice daily with blood pressure and/or pulse hold: systolic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 9 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (upper number) blood pressure less than 120 to hold; diastolic (lower number) blood pressure less than 60 to hold; and pulse less than 60 to hold. There was also blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold. During an interview on 05/03/23 at 09:42 AM the ADON said Resident #6's physician ordered blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold originally in September 2022. She said he made rounds on 02/15/23 and changed them to the blood pressure and/or pulse hold: systolic blood pressure less than 120 to hold; diastolic blood pressure less than 60 to hold; pulse < 60 Hold. She said she clarified this with the physician. She said the LVN should have clarified which set of hold orders were valid and the Verapamil should not have been held otherwise medication could be held when it should be given. Observation of medication reconciliation of medication pass and record review of physician orders on 05/03/23 at 08:35 AM indicated 1 error out of 25 opportunities resulted in a 4% medication error rate. 3. During an observation and interview on 05/03/23 at 12:50 PM of the Nurse Cart for the 100/200 Hall with the ADON indicated the following: * a bottle if Senna Tab 8.6 expired 04/23; and * a bottle of Fish Oil 500mg expired 04/23. The ADON said nurses should be checking the medications for expiration dates when they pass medications. During an observation and interview on 05/03/23 at 12:55 PM of the Medication Aide Cart for the 300/400 Hall with MA B indicated the following: * a card of Hyoscyamine 0.125mg expired 11/18/22 * a bag of meds with the following: * a bottle of Vitamin C 1000mg expired 01/20; * a bottle of Hyoscyamine 0.125 mg expired 08/03/22; * a bottle of Haldol 2mg tab expired 08/03/22; * a bottle of Promethazine 25mg expired 08/03/22; * a bottle of Nitroglycerine 0.4mg expired 02/08/23; * a bottle of Bisacodyl 10mg 08/03/22. MA B said MA/Medication Nurse should always check medications for expiration dates. She said expired medications were to be pulled and given to the DON. She said the bag of medication was what a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 10 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 family brought from home and should have been sent home with them. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/03/23 at 01:25 PM the interim DON said she expected nurses to check medications when brought from home upon admission. She said nurses and MAs were to check the carts for expired medications, they were to be removed from the cart, and brought to her for destruction. Residents Affected - Some Policies were requested on 05/01/23 upon entrance but were not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 11 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety. Residents Affected - Many * There were unlabeled, undated, and unsealed containers of food items stored in the refrigerator and dry goods storage. * The facility failed to ensure the DM did not handle uncovered food plates with his bare hands. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: 1. During an observation and interview with Dietary Manager (DM) (who identified foods) on 5/01/23 beginning at 9:37 a.m. of the refrigerators and dry goods storage in the kitchen revealed the following: Refrigerator/Cooler #1 *Bag of lettuce left open with lettuce exposed was unlabeled (identifying what it was) and undated (when opened or when to discard), DM stated, this lettuce will be thrown away because it was not sealed properly, labeled, or dated. Refrigerator/Cooler #2 *Bag of chopped celery open to air with brown patches visible on celery not labeled or dated. *1/2 onion laying half outside sandwich bag with no label or date on bag. *One peeled cucumber partially sliced in sandwich bag with no label or date. DM stated, all the vegetables would be thrown away because they were not labeled, dated, or sealed properly. Dry Goods Storage *Packet of chicken country gravy dry mix cut open on the top and left open to air. *Bag of flour-like substance open to air with no identifying label. Dated 09/03/21. DM threw away both sacks and said the flour-like substance was breadcrumbs and had not been used in a very long time. He said he had not seen the sack on the shelf, and it should have already been thrown away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 12 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 During an interview on 05/01/23 at 9:47 a.m., the DM stated he checks food storage two times weekly when making food orders, but he was not checking enough. He said he was responsible for assuring foods were labeled, dated, and stored appropriately. DM said all kitchen staff had been trained on labeling, dating, and sealing foods when stored. He said all foods should be labeled identifying the food and dated when opened to ensure food was not served to residents after it expired. He said he would re-educate his staff to label, date, and seal foods after opening. During an interview on 05/03/23 at 9:30 a.m., Administrator stated the food in the kitchen must be sealed and labeled and dated properly. The Administrator said she was the DM's direct supervisor, and he was responsible for ensuring/monitoring foods were stored properly. She said an in-service was completed with kitchen staff on 05/01/23 re-educating staff on sealing, labeling, and dating food items after opening. She said she made rounds in the kitchen and viewed storage of food and the unlabeled, undated, and open foods was not how foods are normally stored at the facility. When asked for a possible negative outcome for opened foods being unlabeled, undated, and not sealed properly she said it was out of the normal. She said there was no possible negative outcome because it had not happened before and would not happen again. Record Review of the facility's policy titled Food Storage revised 03/2019, documented the following: Procedure .4. Plastic containers storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled, including the date the package was opened. 15. d. All foods should be covered, labeled and dated. Texas Food Establishment Rules documented . 228.66 (b) Food storage containers, identified with common name of food. Except for containers holding food than can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with common name of the food. 2. During observations of the lunch meal on 05/01/23: * at 12:33 PM DM exited the kitchen with an uncovered plate containing a grilled cheese sandwich. He was touching the plate on the top edge with his bare hand. * at 12:44 PM DM exited the kitchen with an uncovered plate containing a piece of pie. He was touching the plate on the top edge with his bare hand. During an interview on 05/02/23 at 05:20 PM the DM said dietary staff were only to wear gloves when carrying food plates out of the kitchen. He said food plates were to be covered when coming out of the kitchen except when serving to the dining room. He said uncovered plates were not to be touched with bare hands. He said he did not realize he did not have a glove on when touching the top edge of the plates. According to the FDA Food Code 2022 dated January 18, 2023: 3-3 Protection From Contamination After Receiving 3-301. Preventing Contamination by Employees. 3-301.11 Preventing Contamination from Hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 13 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 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 (A) FOOD EMPLOYEES shall wash their hands as specified under § 2-301.12. Level of Harm - Minimal harm or potential for actual harm (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 14 of 15 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 675120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodville Health and Rehabilitation Center 102 N Beech St Woodville, TX 75979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 2 of 9 staff reviewed for infection control. Residents Affected - Few ( LVN D, and LVN E) * The facility failed to ensure LVN D and LVN E cleaned and disinfected glucometers appropriately after resident use. These failures could place residents at risk of infections or diseases. Findings included: During an observation on 05/02/23 at 11:44 AM LVN E after conducting a fingerstick blood sugar cleaned the glucometer with a designated wipe for 15 seconds. She then placed the glucometer in the basket and placed it on the nurse cart. During an observation on 05/02/23 at 11:50 AM the wipe container indicated contact time was 2 minutes. During an interview on 05/02/23 at 12:15 PM LVN E said she would not have done anything different with the procedure. During an observation on 05/02/23 at 04:20 PM LVN D after conducting a fingerstick blood sugar cleaned the glucometer with a designated wipe for 15 seconds. She then placed the glucometer in the basket and placed it on the nurse cart. During an observation on 05/02/23 at 04:35 PM LVN D after conducting a fingerstick blood sugar cleaned the glucometer with a designated wipe for 15 seconds. She then placed the glucometer in the basket and placed it on the nurse cart. During an interview and observation on 05/02/23 at 04:40 PM LVN D said she was to wipe the glucometer with the wipe she was provided after conducting a fingerstick for blood sugar level and then wait 5 minutes before doing another finger stick for blood sugar level because the wipe had a 5-minute contact time. She then said she should wrap the glucometer with the wipe and leave it on for the 5 minutes. After reading the information on the cleaning wipe container she said the cleaning wipe had a 2-minute wait time and not 5 minutes. During an interview on 05/03/23 at 10:46 AM the interim DON said she expected the nurses to clean the glucometers according to contact time of the disinfectant being used. She said there were no residents with blood borne pathogens. Record review of a Glucose Monitoring Policy and Procedure dated January 4, 2016 indicated Procedure: Allow adequate time for disinfectant to dry (machine should be dry when it is picked up after cleaning) refer to manufacturer's guideline FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 15 of 15