Inspection·July 8, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included Alzheimer’s disease and stroke (lack of oxygen to the brain). Record review of Resident #26’s annual MDS assessment, dated 04/21/25, indicated Resident #26 was with BIMS of 3, which indicated severely impaired cognition. He used a wheelchair daily for mobility. Residents Affected - Few Record review of Resident #26's care plan, updated on 07/07/25 after surveyor intervention, indicated Resident #26 had a behavior problem, resident spits on the wall, floor bed rails and drops food in chairs and spits food. The goal indicated the resident will have fewer episodes of spitting on the walls, bed, and floor. During an observation on 07/06/25 at 11:00 a.m., Resident #26‘s wheelchair and wheelchair cushion had food particles and food smeared on the sides of the wheelchair, foot pedals and on tires. The cushion had a beige substance smeared and appeared to be dry and was flaking. During an interview and observation on 07/7/25 at 12:30 p.m., Resident #26’s family said she never saw his wheelchair and cushion without food smears and food particles. The wheelchair and cushion had food smears and food particles. The foot pedals had food particles. She said she had not complained about the condition of the wheelchair or the cushion to the facility. During an interview on 07/8/25 at 10:00 a.m., the DON said night shift was responsible for washing wheelchairs and cushions. Her expectation was for all the wheelchairs to be cleaned each week on the night shift. She said Resident #26’s wheelchair should have been cleaned on Saturday nights. She said the wheelchairs being dirty was not homelike and could cause infection control issues. During an interview on 07/08/25 at 11:00 a.m., the DON said both regular night shift CNAs were on vacation. She said the charge nurse this past weekend was LVN N and the UM was working on the night shift and provided direct resident care. She dialed the unnamed night shift CNAs, and we were unable to leave message. During an interview on 07/08/25 at 11:30 a.m., LVN N said she was responsible to ensure the CNAs cleaned the wheelchairs and cushion on the night shift. She said she did not notice Resident #26 wheelchair was dirty. During an interview on 07/8/25 at 3:15 p.m., the UM said she worked Saturday night (07/05/25) as an aide but she didn’t recall Resident #26 wheelchair being dirty or if it was washed. She said on the night shift the wheelchairs were washed weekly. A facility policy dated May 2017 and titled “Homelike Environment” indicated the following. …” Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. … 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 2 of 13 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 07/08/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 2 of 10 residents (Residents #13 and #34) reviewed for unnecessary medication. 1. The facility failed to monitor Resident #13 for side effects of the antianxiety medication, lorazepam (used to treat anxiety) routinely and PRN.2. The facility failed to ensure a stop date or reorder date was ordered for the PRN lorazepam for Resident #13. 3. The facility failed to ensure Resident #13 was monitored for side effects of the antipsychotic medication quetiapine fumarate (used to treat bipolar disorder).4. The facility failed to monitor Resident #34 for side effects of the antipsychotic medication Abilify (used to treat several mental health conditions).These failures could place residents at risk for adverse consequences and decline in health.Findings include:1. Record review of Resident #13's face sheet, dated 07/06/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), dementia (a group of thinking and social symptoms that interfere with daily function) and anxiety (intense, excessive and persistent worry and fear about everyday situations).Record review of Resident #13's admission MDS assessment, dated 05/30/25, documented a BIMS score of 00, which indicated severely impaired cognition. Resident #13 had diagnoses which included bipolar disorder, depression (a serious mental illness characterized by sadness and a loss of interest in activities) and anxiety. The assessment indicated Resident #13 received an antipsychotic and antianxiety medication during the last 7 days.Record review of Resident #13's MAR, dated 07/08/25, indicated Resident #13 received lorazepam 1 mg at bedtime for dementia and anxiety with a start date of 05/23/25, Quetiapine fumarate 25 mgs at bedtime for bipolar disorder with a start date of 06/03/25 and lorazepam 1 mg every 4 hours as needed for dementia and anxiety with a start date of 05/23/25 and no stop or reorder date.Record review of Resident #13's physician orders, dated 07/06/25, indicated Resident #3 was prescribed lorazepam 1 mg at bedtime for dementia and anxiety with a start date of 05/23/25, lorazepam 1 mg every 4 hours as needed for dementia and anxiety with a start date of 05/23/25 and no stop or reorder date and quetiapine fumarate 25 mg at bedtime for bipolar disorder with a start date of 06/03/25. The orders did not address monitoring the antianxiety or antipsychotic medication for side effects or a reorder or stop date for the PRN antianxiety medication.Record review of Resident #13's care plan, with a target date of 09/04/25, indicated Resident #13 was prescribed an antianxiety medication with interventions which included administer antianxiety medication as ordered by physician and monitor, document and report any adverse reactions every shift and monitor for side effects and effectiveness every shift Resident #13's care plan indicated she received psychotropic medication with interventions including administer as ordered by the physician, monitor for side effects and effectiveness every shift. Record review of Resident #13's electronic medical record, from 05/23/25 to 07/07/25, for Resident #13 did not indicate the nurses' documented monitoring of side effects of the routine or PRN antianxiety medication lorazepam or the psychotropic medication quetiapine fumarate with medication administration.During an observation and interview on 07/06/25 at 9:20 a.m., Resident #13 was sitting on her bed and said she was unsure what medication she took.2. Record review of Resident #34's face sheet, dated 07/06/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder) and Alzheimer's disease (a progressive disease that destroys memory and other important mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 3 of 13 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 07/08/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some functions). Record review of Resident #34's quarterly MDS assessment, dated 06/06/25, documented a BIMS score of 3, which indicated severely impaired cognition. Resident #34 had diagnoses which included Alzheimer's disease and schizoaffective disorder. The assessment indicated Resident #34 received an antipsychotic medication during the last 7 days.Record review of Resident #34's MAR, dated 07/08/25, indicated Resident #34 received Ability 2 mg daily for schizoaffective disorder with a start date of 05/31/25. Record review of Resident #34's physician orders, dated 07/06/25, indicated Resident #34 was prescribed Ability 2 mg daily for schizoaffective disorder with an order date of 07/02/25. The orders did not address monitoring of the antipsychotic medication for side effects.Record review of Resident #34's care plan, with a target date of 09/07/25, indicated Resident #34 was prescribed a psychotropic medication, Abilify with interventions including administer as ordered by the physician, monitor for side effects and effectiveness every shift.Record review of Resident #34's electronic medical record, dated 07/01/25 to 07/07/25, did not indicate the nurses' documented monitoring of side effects of or the psychotropic medication Abilify with medication administration.During an observation and interview on 07/06/25 at 8:40 a.m., Resident #34 was lying in bed and said she was unsure of what medication she took.During an interview on 07/08/25 at 10:00 a.m., LVN C said she was responsible for providing care for Resident #13 and she received lorazepam and quetiapine fumarate and should be monitored for side effects in the computer system and was not, it was overlooked. She said she was responsible for providing care for Resident #34 and she received Ability and should be monitored for side effects in the computer system and was not. LVN C said the nurse ordering the medication was responsible for adding monitoring into the computer system and the Unit Manager was the back up. She said she was educated to monitor psychotropic medication for side effects, but it was overlooked. She said the DON monitored the PRN medication for 14 day stop dates. LVN C said the resident risk of not monitoring psychotropic medication for side effects was the medication may not be effective and may not be the correct dose for the resident.During an interview on 07/08/25 at 10:30 a.m., the DON said the nurse ordering the medication was responsible for adding side effect monitoring into the computer system and the UM was the back up to double check and ensure all psychotropic medication was monitored for side effects. The DON said the nurses were educated on monitoring all psychotropic medication for side effects. She said these were overlooked. The DON said the resident risk of a psychotropic medication not monitored for side effects was the resident could have a side effect and staff be unaware. The DON said she was responsible for adding a 14 day stop date to Resident #13 's PRN lorazepam and the UM was the back to double check and ensure the stop date was added to the physician order. She said it was overlooked. The DON said her expectation was all psychotropic medication monitored for side effects and all PRN psychotropic medication had a 14 day stop date added into the computer system so they could be reevaluated by the physician as required.During an interview on 07/08/25 at 11:00 a.m., the Administrator said the nurse ordering the medication was responsible for adding the side effect monitoring into the computer system and the UM was the back up to double check and ensure all psychotropic medication was monitored for side effects. He said all nurses were educated on monitoring psychotropic medication for side effects and these were overlooked. The Administrator said the resident risk of a psychotropic medication not monitored for side effects was the resident could have a side effect and staff be unaware. He said the DON was responsible for adding a 14 day stop date to Resident #13 's lorazepam and the UM was a double check. He said the 14-day stop date was overlooked. The Administrator said his expectation was all psychotropic medication monitored for side effects and all PRN psychotropic medication had a 14 day stop date added into the computer system so they could be reevaluated by the physician as recommended.During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 4 of 13 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 07/08/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 07/08/25 at 12:45 p.m., the UM said the nurse ordering the medication was responsible for adding the side effect monitoring into the computer system and she was the back up to double check and ensure all psychotropic medication was monitored for side effects. She said the DON was responsible for adding a 14-day stop date to PRN psychotropic medication and she was the back up to ensure all PRN psychotropic medication had a 14 day stop date. She said she did a 24-hour audit on all admissions during the morning meeting to ensure all orders were put in the computer system correctly and the monitoring for side effects and 14-day stop date were added to all PRN psychotropic medication. She said she was educated on monitoring psychotropic medication for side effects and ensuring a 14-day stop date was added to all PRN psychotropic medication. The UM said they were overlooked. She said the resident risk of was the possibility of the facility not being aware of an adverse reaction a resident may have.Record review of the facility's, policy, dated November 2017. titled, Medications indicated, . b. patients must not receive PRN psychotropic medication orders unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record and are limited to 14-days. If longer than 14-days, the physician must document their rational in the patient's medical record and are indicate the duration for the PRN order. c. PRN orders for antipsychotic medications are limited to 14-days and cannot be renewed unless the physician evaluates the patient for the appropriateness of the medication.8. Behaviors and side effects of the use of medication must be monitored and documented for Patient/Residents receiving psychotropic medication. Event ID: Facility ID: 675120 If continuation sheet Page 5 of 13 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 07/08/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 each resident in a nursing facility was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID were evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 8 residents (Resident #1) reviewed for PASRR screenings. The facility failed to submit a new PL1 screening to TMHP (a group of contractors that administer Texas Medicaid on behalf of the Texas Health and Human Services Commission) dated 03/06/25, which indicated Resident #1 had positive evidence of mental illness. This failure could place residents at risk of not receiving specialized services. Findings include:Record review of Resident #1's face sheet, dated 07/06/25, indicated a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses of generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities and symptoms that interfere with daily life).Record review of Resident #1's PASRR Level 1 Screening, dated 09/29/23, indicated Resident #1 was negative for mental illness, intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. Record review of Resident #1's PASRR Level 1 Screening, dated 03/06/25, indicated Resident #1 was positive for mental illness, negative for intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. There was no PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's admission on [DATE] through 07/07/25.Record review of Resident #1's care plan, initiated on 05/02/25 indicated, Resident #1 received psychotropic medication for depression of bupropion with a goal to monitor and report adverse reactions. Record review of Resident #1's most recent significant change MDS assessment, dated 06/21/25, indicated Resident #1 was not PASRR positive and had a BIMS score of 7, which indicated severely impaired of cognition. Resident #1 had diagnoses which included major depressive disorder and anxiety.Record review of Resident #1's physician orders, dated 07/18/25, indicated she was prescribed bupropion HCL 150 mgs XL (antidepressant medication) every day for major depressive disorder with a start date of 04/01/25. During an observation and interview on 07/06/25 at 9:48 a.m., Resident #1 was lying in bed and said she was treated well and received needed care and services. During an interview on 07/07/25 at 11:29 a.m., the MDS Nurse said she was responsible for all PASRR forms in the facility and was educated on PASRR completion. She said her back up was the Regional MDS Coordinator. The MDS Nurse said Resident #1 was considered PASRR negative but had a PL1 dated 03/06/25 which indicated she was positive for mental illness uploaded into the facility's computer system but not sent into TMHP through Simple LTC (long term care software that facilitates claims data analysis and regulatory compliance, reimbursement optimization and quality measurement for healthcare practices). She said she would send in a 1012 form (Mental Illness/ dementia resident review- form used to determine if a resident initially assessed as not needing further evaluation for Mental illness or dementia requires a more in-depth assessment based on new information or changes in their condition) and new positive PL1 immediately. She said the PL1 was overlooked and should have been sent into TMHP on admission. The MDS Nurse said the resident risk of a resident's positive PL1 not sent into TMHP was a resident's needs may not be met. She said the positive PL1 was overlooked before she was hired on 04/01/25.During an interview on 07/08/25 at 10:30 a.m., the DON said the MDS Nurse was responsible for all PASSR forms in the facility and was educated on correctly completing PASRR forms. She said the Regional MDS Coordinator was the back up. The DON said Resident #1's PL1 form Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 6 of 13 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 07/08/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. She said the resident risk was a potential lack of services for the resident. The DON said her expectation was every resident had a PL1 form completed on admission and uploaded into the Medicaid system and if it was positive for the resident to receive needed services. During an interview on 07/08/25 at 11:00 a.m., the Administrator said the MDS Nurse was responsible for all PASSR forms in the facility and the Regional MDS Coordinator was the back up. He said the MDS Nurse was educated on completion of PASRR forms and Resident #1's PL1 form was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. The Administrator said the resident risk was a potential lack of services. The Administrator said his expectation was every resident had a PL1 form completed on admission and uploaded into the Medicaid system and if it was positive for the resident to receive needed services. During an interview on 07/08/25 at 4:17 p.m., the Regional MDS Coordinator said the MDS Nurse was responsible for all PASSR forms in the facility, and she was the back up. She said she spot checked MDSs and PASRR forms and would cover the facility if the MDS Nurse was out on leave. The Regional MDS Coordinator said the MDS Nurse was educated on completion of PASRR forms. She said Resident #1's PL1 form was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. She said the resident risk was a resident may not receive PASRR services she should be receiving.Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions . o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State Record review of the facility's, undated, policy titled PASRR Process 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 submits the PL1 and becomes the gate keeper of all things PASRR. Event ID: Facility ID: 675120 If continuation sheet Page 7 of 13 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 07/08/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the medication error rate was less than five percent or greater. The facility had a medication error rate of 7.79% based on 2 errors out of 26 opportunities, which involved 2 of 6 residents (Residents #6 and #49) and 2 of 3 staff observed during medication administration reviewed for medication error. 1. The facility failed to ensure LVN A administered Dorzolamide Solution 2% Ophthalmic (eye drops) per facility policy to Resident #49. 2. The facility failed to ensure LVN B did not administer Levothyroxine 75 MCG to Resident #6 on an empty stomach. These failures could place residents at risk of unwanted side effects and not receiving the therapeutic dosage of medications. Residents Affected - Few Findings include: 1. Record review of Resident #49's face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and open-angle glaucoma (a chronic eye condition where the eye’s drainage canals gradually clog, leading to a slow increase in the intraocular pressure). Record review of Resident #49's Quarterly MDS assessment, dated 04/18/25 indicated a BIMS score of 10, which indicated Resident #49's cognition was moderately impaired. Record Review of Resident #49's physician orders dated July 2025 indicated Dorzolamide Ophthalmic Solution 2% instill 1 drop each eye two times daily for glaucoma. Record review of Resident #49's medication administration record (MAR) dated 07/08/25 indicated Dorzolamide ophthalmic solution 2% instill one drop in both eyes two times a day for Glaucoma at 7:00 a.m. and 7:00 p.m. During an observation of medication pass on 07/07/25 at 7:18 a.m., LVN A instilled Dorzolamide ophthalmic solution 2% one drop into the inner corners of each eye. During an interview on 07/08/25 at 11:14 a.m., LVN A said she always administered eye drops to the inner corners of the eyes and was careful not to place the drop directly on the eyeball. She said Resident #49 usually pulled his own lower lid down, but he had not done so today. She said even on days when he did pull his lower eye lid down, she still administered his eye drops into the inner corners of his eyes. She said she did not know what facility policy said about administering eye drops. She said the facility watched her give medications including eye drops and had never instructed her she should administer the drops differently. 2. Record review of Resident #6's face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a syndrome characterized by tremor, bradykinesia (slowness of movement) , rigidity, and postural instability) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #71 's quarterly MDS assessment dated [DATE] indicated a BIMS score of 4, which indicated Resident #6’s cognition was severely impaired. Record review of Resident #6's physician orders dated July 2025 indicated Levothyroxine Sodium 75 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 8 of 13 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 07/08/2025 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 0759 MCG give one tablet by mouth one time a day for low thyroid hormone. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's MAR dated 07/08/25 indicated Levothyroxine Sodium 75 MCG give one tablet by mouth one time a day for low thyroid hormone at 8:00 a.m. Residents Affected - Few During a medication pass observation and interview on 07/08/25 at 8:05 a.m., LVN B administered the following medications to Resident #6 orally: - Benztropine 1mg 1 tablet - Famotidine 20mg 1 tablet - Iron 325mg 1 tablet - Haloperidol 1mg 1 tablet - Levothyroxine Sodium 75MCG 1 tablet - Oxcarbazepine 200mg 1 tablet - Paliperidone ER 3mg 1 tablet - Vitamin D 325MCG 1 tablet - Clonazepam 1mg 1 tablet LVN B said Resident #6 had just finished his breakfast. During an interview on 07/08/25 at 11:55 a.m., LVN B said Levothyroxine should always be given on an empty stomach for best absorption. She said she usually gave Resident #6’s medications before breakfast, but she had been running late and gave all his medications after he had eaten. She said giving the Levothyroxine with breakfast and other medications could interfere with the medication's absorption and it might not be as effective. During an interview on 07/08/25 at 3:05 p.m., the DON said the facility policy was to instill eye drops by averting the lower lid and instilling the drop into the pocket created by averting the lower eye lid. She said the Pharmacy Consultant for the facility watched medication pass with the nurses quarterly. She said she had called the Pharmacy Consultant, and she said she was surprised because she had observed LVN A administering eye drops by averting the resident's lower eye lid and instilling the drop into the pocket. She said that when the facility changed to the electronic medical record (EMR) systems on April 1st, 2025, all thyroid medications had been rescheduled to be given at 8:00 a.m. She said the former EMR system had all thyroid medications scheduled to be given at 6:00 a.m. She said she reviewed all resident's records and corrected the scheduling error for all thyroid medications. She said he was the direct supervisor of all nursing staff. She said she expected all medications to be given according to facility policy, medication recommendations, physician orders, and the 6 rights of medication administration. She said the possible negative outcome of administering eye drops into the inner corners of the eyes and thyroid medications with other medications on a full stomach was decreased absorption of the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 9 of 13 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 07/08/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility’s undated policy titled Medication Administration indicated … *Use index or middle finger to pull down the eye lid and instill drop into lower lid conjunctival sac. You can no longer drop onto the eyeball” … Record review of Synthroid.com indicated … “The way you take Synthroid (Levothyroxine) can affect how much your body is getting. … Take Synthroid once a day, every day at the same time before breakfast. Only take Synthroid with water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water.” … Event ID: Facility ID: 675120 If continuation sheet Page 10 of 13 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 07/08/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 residents room reviewed for food safety (room [ROOM NUMBER]) in that: The refrigerator located in room [ROOM NUMBER] was not monitored for expiration/used by dates. This failure could place residents at risk for food illnesses. Findings included:During an observation and interview on 07/06/2025 at 09:30 a.m., revealed the following expired items in Resident #2's personal refrigerator:-one 18-ounce bottle of mayonnaise with expiration date of 06/16/2025;- one 9-ounce package of ham lunch meat with expiration date of 07/02/2025;-one 15-ounce bottle of sandwich spread with expiration date of 12/02/2024;-one 13 -ounce bottled cold coffee drink with expiration date of 02/03/2025;-two 8-ounce supplemental milk shake with expiration date of 02/01/2025;-one 15-ounce bottle of mayonnaise with expiration date of 06/11/2025; and-one 20-ounce strawberry Jell-O with expiration date of 04/04/2024. Resident #2 said her family brought her the items. She said the nursing staff would hand her whatever items she requested. Resident #2 said she did not know who was responsible to oversee items in the refrigerator for expiration dates. The Regional Clinical Director of Services was present and disposed of the expired items. She said they should not have remained available after the expiration date on each item. Consumption could lead to food-borne illnesses. During an interview on 0708/2025 at 2:00 p.m., the DON said nursing staff were expected to check items for expirations weekly. She said all food from outside should be dated when opened and discard when reached expiration date. Consumption of expired food or drink could cause negative adverse effects including gastrointestinal symptoms. Record review of the facility policy, dated November 2016, and titled Patient/Resident Food from Outside indicated the following:1) Patients/Residents may accept food from family and visitors as part of their foodchoices.2) The facility staff should monitor foods being brought to Patients/Residents to ensurethe food items do not place the Patient/Resident at risk for choking based upon anyphysician ordered restrictions.3) Food or beverages brought in from the outside will be dated. Food items placed [NAME] common refrigerator/freezer will also be labeled with the patient's/resident's nameand room number.4) The facility staff should monitor and assist Patients/Residents and visitors with safefood handling practices to ensure avoidance of food borne illnesses.5) Food or beverages in the original container that is past the manufacturer's expirationdate will be discarded by the facility staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 11 of 13 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 07/08/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1of 1 kitchens reviewed for effective pest control in that: Numerous flies were observed throughout the kitchen during the noon meal preparation time on 07/07/2025. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.Findings included: During observations and interviews on 07/07/2025 from 11:00 - 12:00 noon, during meal preparation and serving, numerous flies were swarming throughout the preparation area. Flies were observed landing on steamtable, cabinets, near handwashing sink, and near food cart. Six or 7 flies were killed with flyswatter within this period. [NAME] D and dietary aide E acknowledged the numerous flies and said the flies would come in through the side exit door of the kitchen which was approximately 10 yards from the rear exit door to the facility. They added the flies seemed to come inside more after it had rained. They said facility staff were constantly going in and out of the back door because it would lead to the laundry area, parking lot, and the garbage dumpster. During an interview on 07/07/2025 at 09:45 a.m., the DM (dietary manager) said she had been aware of flies in the kitchen area. She said she had requested the kitchen staff not use the side exit door from kitchen due to it being near the rear exit door of facility. She said she had requested the facility to obtain a fly trap wall sconce for the kitchen. She said a potential negative outcome would be cross contamination of food, possibly causing food-borne illnesses. She said should an insect land on the food, it would have to be thrown out and possibly delay meals for the residents. During a confidential interview with members of the Resident Council on 07/07/2025 at 10:00 a.m., the Resident Council said they had observed numerous flies in dining room on occasion. They said they sometimes would swat flies at mealtimes. Resident Council members said obviously the facility pest control was ineffective. During observations and interview on 07/08/2025 at 08:00 a.m., the maintenance supervisor acknowledged the facility had concerns with flies outside the rear exit of facility which also led to side entrance door to kitchen. He said there were 3 fly trap light wall sconces throughout facility. Observations were made of the 3 fly trap wall sconces with these results:#1 located at rear exit door - the sticky strip was missing;#2 located in closed hallway leading from Hall 400 to exit door near laundry; and #3 located in common area in front lobby of facility - the sticky strip was missing.The maintenance supervisor said without the sticky strip in the wall sconces, the flies were less likely to be trapped and eliminated. He said the facility had a pest control service that would come to facility monthly. He said he was responsible for ensuring sticky strips were intact as well. Record review of the facility contracts revealed a contract, undated, for pest control service was in place. Record review of the pest control visit logs indicated the pest control service visited the facility monthly with last visit 06/25/2025.During an interview on 07/08/2025 at 8:30 a.m., the Administrator said the pest control service came out monthly to service the fly trap sconces. He said the most recent service was 06/25/2025 and at that time he had requested a 4th sconce to be delivered. The administrator said the fly trap sconces work by ultraviolent light and sticky pads that were designed to trap any insect that flies and lands on the strip including flies, bugs, wasps, etc. During an interview on 07/08/2025 at 2:00 p.m., the DON said her expectations were for there to no flying insects or rodents in the kitchen or dining area. She said the facility had fly traps located in specific areas. She said a negative outcome would be flies or insects getting into resident food. She said it would be unsanitary, cross contamination, and could potentially cause symptoms related to stomach issues. Record review of facility policy dated May 2008 titled Pest Control indicated facility shall maintain an effective pest control policy. 1. This facility maintains an on-going pest control Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 12 of 13 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 07/08/2025 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 0925 program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675120 If continuation sheet Page 13 of 13