Inspection·December 14, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Braden scale for predicting Pressure score risk done on 11/17/22 revealed a score of 16 indicating, Resident #9 was at risk of developing a pressure injury. Record review of Resident #9's progress notes did not reveal any notification to the physician about the new wound identified by charge nurse on 11/26/22 until 12/02/22 at the IDT (Interdisciplinary team) meeting. During a phone interview on 12/14/22 at 1:50p.m., LVN C said she did not measure, do a skin assessment, or notify the doctor about the new identified pressure ulcer on 11/26/22. LVN C said she did not notify the physician because she used the physician standing orders (written protocol that authorize designated members of the healthcare team to complete certain task without having to obtain a physician order). When asked where this surveyor could find the standard orders LVN C indicated she did not have any standing orders, but this is what the physician would usually say. LVN C said she should have measured, documented, and notified the doctor, but she did not. During an interview on 12/14/22 at 2:00p.m., the DON said she became aware of the new skin issue on 11/28/22 and she notified the doctor but did not chart about the notification. The DON said she thought she had charted about notifying the physician but upon review of the nurse notes revealed she did not. The DON said she could not prove she notified the physician because there was no documentation. The DON said the nurse who charted on the new orders should have documented about the wound, completed a skin assessment, an incident report and notified the doctor. The DON said she or the ADON should have followed up and made sure all the above protocols were followed. The DON said failure to follow the policy could results in wound deterioration. During an interview on 12/14/22 at 2:14p.m., the administrator said he did not know the correct clinical process for skin, but the DON was responsible to make sure the skin process was followed. The ADM said failure to follow the policy could lead to a resident's skin injury to worsen or even develop new skin issues. Record review of policy Change in resident status/condition revised February 2021 indicated, Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. #8 The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 2 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a baseline care plan withing 48 hours of admission that included the instructions need to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 (Resident #84) of 4 (new admits) newly admitted residents reviewed for baseline care plans. The facility failed to ensure Resident #84's baseline care plan was completed timely and included his pressure injury care. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: Record review of a face sheet dated 12/13/2022 indicated Resident #84 was [AGE] years old, admitted on [DATE] with the diagnosis of Covid-19, pneumonia, heart attack, and respiratory failure. The face sheet did not reveal Resident #84 had a pressure injury. Record review of the physician orders dated 12/09/22 12/13/2022 indicated Resident #84 Did not have a wound care ordered for his pressure injury until 12/12/2022. received oxygen at 2-4 liters per a nasal cannula to keep his oxygen saturation at greater than 92%. Record review of the Admission/re-admission Evaluation which includes the baseline care plan for Resident #84 revealed the assessment was started on 12/09/22 at 4:45 p.m. by LVN A and was closed on 12/12/2022 at 3:26 p.m. by the ADON. Record review of an admission Assessment/Baseline Care Plan Summary indicated the effective date was 12/09/22 and the created date was on 12/12/2022 at 3:26 p.m. by the ADON. The admission Assessment/Baseline Care Plan Summary indicated Resident #84 was totally dependent for personal hygiene, toileting, eating, dressing, transfers, and required extensive assistance with bed mobility. The Assessment indicated Resident #84's skin turgor, skin color, were normal and the temperature was warm and dry. The admission Assessment/Baseline Care plan Summary narrative did not mention his pressure injury to his coccyx (tailbone). During an interview on 12/13/2022 at 1:45 p.m., the ADON indicated she had completed Resident #84's assessment and assessed his skin on 12/12/2022. The ADON indicated Resident #84's sacral(lower back above the tailbone) wound measured 1.5 x 3.0 and was a stage 2 wound. The ADON said the receiving nurse should input the physician's orders including wound care orders, and initial assessment. The ADON indicated then she would sign off on the baseline care plan generated from the initial admission assessment. The ADON indicated the reason the admission assessment and baseline care plan were not completed until 12/12/2022 was a mystery to her. During an interview on 12/14/2022 at 10:10 a.m., LVN A indicated she received Resident #84 during the start of the evening meal service time. LVN A indicated she opened the Resident #84's admission assessment and completed the areas down to the skin assessment. LVN A indicated she did not complete the skin assessment nor the remaining assessments with the baseline care plan. LVN A indicated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 3 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few passed the task off to LVN B for him to resume and complete Resident #84's assessment and baseline care plan. LVN A indicated Resident #84's wound could worsen without the baseline care plan and admission assessment completion. LVN A indicated she made LVN B aware of the need to complete Resident #84's assessment and baseline care plan. LVN B did not return the phone call for an interview. During an interview on 12/14/22 at 2:30 p.m., the DON indicated the ADON finished Resident #84's admission assessment, including the skin assessment, and baseline care plan on 12/12/2022. The DON indicated the admission assessment generates the baseline care plan. The DON indicated since the admission assessment was not completed for Resident #84 the baseline care plan was not generated until 12/12/2022. The DON indicated the baseline care plan then did reflect the stage 2 to his coccyx. The DON indicated normally after an admission the ADON and DON review the assessment on the next day. The DON indicated Resident #84 admitted late on a Friday 12/09/2022 when she was off and his follow up did not occur until Monday 12/12/2022. The DON indicated LVN A or LVN B could have informed the weekend RN of the need to review the new admission and the baseline care plan including the initiation of wound care. The DON indicated there was no process in place for the weekend RN to complete the baseline care plan until now. During an interview on 12/14/2022 at 2:48 p.m., the Administrator indicated he trusted the DON and ADON to ensure the admission assessments and baseline care plans were completed timely. The Administrator indicated the DON and ADON were responsible for ensuring the baseline care plan was completed within the 48 hour timeframe. The Administrator indicated every morning there was a nurse meeting, then after the nurse meeting there was a morning meeting. The Administrator indicated during the morning meeting he learns of the new admission and the needs of the resident at that time. The Administrator indicated he was ill last week and was not present in the facility. The Administrator indicated not completing the assessments and baseline care plans could have negative outcomes for the resident. The Administrator in this case indicated Resident #84's wound could get worse. Record review of the Care Planning policy and procedure dated March 2022 indicated the interdisciplinary team was responsible for the development of resident care plans. 1. Resident care plans were developed according to the timeframes and criteria established by Regulatory reference number 483.21 (a) Baseline Care Plans, which states baseline care plans must be developed within 48 hours of a resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 4 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 4 residents reviewed for pressure ulcers. (Resident #84) Residents Affected - Few The facility failed to ensure Resident #84 had a wound care treatment for the stage 2 wound to his coccyx from when he admitted to the facility on [DATE] until 12/12/2022. The facility failed to prevent Resident #84 from acquiring two more pressure injury wounds. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings include: Record review of a face sheet dated 12/13/2022 indicated Resident #84 was [AGE] years old, admitted on [DATE] with the diagnosis of Covid-19, pneumonia, heart attack, and respiratory failure. Record review of a Braden Scale for Predicting Pressure Sore Risk indicated on 12/09/22 Resident #84's score was a 16 indicating Resident #84 was at risk for pressure injuries. Record review of Resident #84's Admission/re-admission Evaluation assessment indicated the assessment was opened by LVN A on 12/09/2022 at 4:45 p.m., and completed and closed by the ADON on 12/12/2022 at 3:26 p.m. The assessment indicated Resident #84 had a wound to his sacrum (low back above the tailbone) measuring 1.5 cm long x 3.0 cm wide x 0.1 cm deep and was a stage 2. Record review of Resident #84's comprehensive care plan dated 12/12/2022 indicated Resident #84 had potential/actual impairment to the skin integrity of the coccyx related to pressure. The goal of the care plan indicated Resident #84 would not have complications related to the stage 2 of the coccyx. The interventions included follow the facility protocol for the treatment of injury, monitor and document location, size, and treatment of skin injury, and weekly treatment documentation to include measurements of each area of skin breakdown, width, length depth type of tissue and exudate and any other notable changes or observation. Record review of Resident #84's skilled nurse note documented on 12/11/2022 at 1:44 a.m., did not reveal any skin conditions such as pressure ulcers, or a dressing change was needed. The entire section of Skin Integrity was left blank. Record review of Resident #84's consolidated physician orders dated 12/13/2022 indicated an order was obtained on 12/12/2022 for a coccyx wound. The physician's order was to cleanse the coccyx with normal saline/wound cleanser, pat dry, apply collagen flakes and secure with a dry dressing daily and as needed for soiling and displacement. The physician's orders did not indicate an order for wound care was provided or initiated prior to 12/12/2022. During an observation on 12/12/2022 at 10:05 a.m., Resident #84 was lying in bed positioned on his back. Resident #84's bed surface was an inflatable waffle mattress over the top of his pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 5 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few redistributing mattress. The waffle type mattress was firm and not alternating pressure relief. Resident #84 was not resting on a low air loss mattress. During an observation and interview on 12/13/2022 at 1:25 p.m., LVN C indicated she oversaw Resident #84's care for the last two days. LVN C indicated this was the first time she had seen Resident #84's wound. Resident #84 was lying on his left side facing the wall. Resident #84 did not have a dressing covering his coccyx wound. Resident #84's wound had an area of eschar (black, dead tissue) appearing to the center of the wound bed and the remaining surface of the wound bed was a maroon color according LVN C's verbal assessment. The tissue surrounding the wound was red in color and extending into the intergluteal cleft (between the buttocks). The wound was located on the coccyx not the sacrum. Resident #84 had two open areas one on the right buttock and one on the left buttock. LVN C indicated she was unaware of the two new areas. LVN C indicated she was unaware Resident #84 had a wound prior to 12/13/2022. The Sacrum and Coccyx (spineuniverse.com) accessed on 12/20/2022: The sacrum and coccyx are unlike other bones in your spinal column. The sacrum, sometimes called the sacral vertebra or sacral spine (S1), is a large, flat triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra (L5). The coccyx, commonly known as the tailbone, is below the sacrum. Individually, the sacrum and coccyx are composed of smaller bones that fuse (grow into a solid bone mass) together by age [AGE]. The sacrum is made up of 5 fused vertebrae (S1-S5) and 3 to 5 small bones fuse creating the coccyx. Both structures are weight-bearing and integral to functions such as walking, standing and sitting. During an interview on 12/13/2022 at 1:45 p.m., the ADON indicated Resident #84's admission assessment was not completed by the admitting nurses. The ADON indicated she measured the wound on 12/12/2022 because the admission assessment was not completed including the skin assessment. The ADON indicated Resident #84's coccyx wound measured 1.5 x 3.0 and was a stage 2. The ADON indicated the two new buttock wounds were not present on 12/12/2022 when she completed the assessment. Record review of a progress note created by the ADON dated 12/13/22 at 3:34 p.m., indicated the right buttock wound measured 0.5 cm x 0.5 cm x less than 0.1 cm and the left buttock wound measured 1.0 x 1.0 x less than 0.1. The note did not mention a measurement for the coccyx wound. Record review of Resident #84's physician orders indicated on 12/14/2022 had new orders initiated for the left buttock and right buttock wounds. The orders included to cleanse with normal saline/wound cleanser, pat dry, apply collagen flakes and secure with a dry dressing daily and as needed if soiled or displaced. During an interview on 12/14/22 at 2:30 p.m., the DON indicated the admission assessment was completed by the ADON, including the wound measurements on 12/12/2022. The DON indicated the ADON obtained wound orders on 12/12/2022 for Resident #84's pressure ulcer to his coccyx. The DON said normally the new admissions would have been reviewed by the DON and ADON on the next day to ensure the assessment was completed, and the wound had treatment orders. The DON indicated Resident #84 admitted on a Friday 12/09/2022 in the evening, therefore the assessment was not reviewed until Monday 12/12/2022. The DON indicated the weekend nurse was unaware of the new admission. The DON stated she was aware Resident #84 had no wound care orders or the assessment until Monday 12/12/2022. The DON indicated she was not aware of the waffle mattress overlay on Resident #84's bed. The DON indicated this type of a mattress was not used for pressure reduction or prevention in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 6 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a Pressure Ulcer/Skin Breakdown-Clinical Protocol policy dated April 2018 revealed: 1. The nursing team member and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss and a history of pressure ulcer. 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, b. pain assessment c. Resident's mobility status d. Current treatments, including support surfaces; and all active diagnoses. 3. The team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Treatment and Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Pressure Injury - StatPearls - NCBI Bookshelf (nih.gov) accessed 12/15/2022: Pressure injuries are formed when pressure causes localized damage to underling skin and soft tissue. These skin and soft tissue injuries remain a significant problem within hospitals and long-term care facilities and results in decreased quality of life and high costs for both the patient and our health care system. To avoid the high morbidity and mortality associated with these pressure injuries, they must be promptly diagnosed and treated Pressure injuries are defined as localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices. Pressure injuries of the skin and soft tissue are formed when the pressure above a certain threshold causes prolonged tissue ischemia, eventually leading to necrosis. Injury from reperfusion is also a contributing factor, as the return of blood supply after a period of ischemia can cause the formation of reactive oxygen species triggering an inflammatory response. In patients positioned at an incline, internal structures such as bone and muscle are displaced downward due to gravity, which can lead to tissue hypoxia as blood vessels are distorted or flattened.[1] A staging system should be used to assess all pressure injuries. At this time, there is a lack of a universal classification system for pressure injuries, but the National Pressure Injury Advisory Panel staging system is widely used as listed below [1][2]: stage 1: non-blanchable erythema of intact skin and erythema remains for greater than one hour after relief of pressure stage 2: partial-thickness loss of skin with exposed dermis stage 3: full-thickness loss of skin tissue; subcutaneous skin and muscle may be visible stage 4: full-thickness loss of skin tissue; tendons, bone, and joints may be visible unstageable: full-thickness loss of skin tissue that is obscured by eschar or slough deep tissue: skin that is persistently non-blanchable, with maroon or purple discoloration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 7 of 8 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, and interview, and record review, the facility failed to ensure adequate monitoring of oxygen storage to prevent accidents or hazards with 1 of 1 oxygen storage room. Residents Affected - Few The facility failed to ensure 4 oxygen cylinders were secured in the oxygen storage closet. This failure could place residents at risk for injury. Findings included: During an observation on 12/12/2022 at 10:23 a.m., the oxygen storage closet had 4 oxygen cylinders free-standing without being stored in the oxygen holding rack. The oxygen holding rack had ample room to store the free-standing oxygen cylinders. During an observation, and interview on 12/14/2022 at 10:05 a.m., the ADON indicated there were 4 free-standing oxygen tanks in the oxygen storage room. The ADON indicated the oxygen cylinders should be stored in the available rack. During an interview on 12/14/2022 at 2:30 p.m., the DON indicated the oxygen cylinders should be stored in the oxygen storage rack for safety. The DON indicated the oxygen could be knocked over, explode, and become a fire hazard. The DON indicated nursing and maintenance were responsible for oxygen storage. During an interview on 12/14/2022 at 2:48 p.m., the Administrator indicated all staff who entered the oxygen storage room was responsible for the appropriate storage of the oxygen. The Administrator indicated the oxygen cylinders could fall over and explode but he believed this was highly unlikely. Record review of Oxygen Safety policy and procedure dated May 2011 indicated all personnel must learn methods of oxygen safety and must report conditions that could result in a potential hazard. 1. Oxygen safety was the responsibility of all personnel, residents, visitors, and the general public. 2. Whoever identifies a hazard, or other conditions that could develop into a hazard, must report the situation to the department director or Maintenance Director as soon as practical. The following safety precautions must be followed in the facility at all times: f. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. 5. The facility will train personnel on oxygen safety methods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 8 of 8