Health inspection·October 8, 2021

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few female admitted to the facility 08/30/2021 with a diagnoses of urinary tract infection, hypertension, Type II Diabetes Mellitus, abnormalities of gait and mobility, osteoporosis, acute post hemorrhagic anemia, cerebrovascular disease and history of fall with hip fracture. Review of Resident #52's care plan dated 09/20/2021 revealed Resident #52 to require an indwelling catheter, history of surgery for left hip fracture with healing incision, history of fall at home, stage IV pressure ulcer, dependence on staff for mobility and activities and on antibiotics for a urinary tract infection. Review of resident #52's admission MDS assessment dated [DATE] revealed Resident #52 had a BIMS score of 15 which indicated resident was cognitively intact, required two-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and had a stage II pressure ulcer. Review of hospital history and physical dated 08/30/2021 revealed Resident #52 had surgery for a broken hip from a fall she experienced at home. There was no indication on the discharge paperwork to indicate Resident #52 had a pressure ulcer upon leaving the hospital. Review SNF rehabilitation discharge summary indicated Resident #52 was at the facility from 08/16/21 to 08/30/21. There was no indication on the discharge summary Resident #52 had a pressure ulcer or other skin issue. Review of Resident #52's initial skin assessment dated [DATE] revealed no issues noted except blanchable redness on coccyx. Review of Resident #52's care plan dated 09/05/2021 revealed Resident #52 to be a risk for development of a pressure ulcer with the following interventions Follow facility policies/ protocols for the prevention/ treatment of skin breakdown .Notify nurse immediately of any new areas of skin breakdown: Open area, redness, blisters .the resident needs assist to turn/ reposition at least every 2 hours . Review of Resident #52's nursing progress note dated 09/08/21 revealed Resident #52 to have a stage II pressure ulcer to left and right buttocks. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks (no measurements or pressure ulcer description was documented). Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 3 pressure ulcer on coccyx with measurements of 1.8 cm in length, 0.8 cm in width and the depth was unable to be determined. The ulcer assessment revealed the pressure ulcer had slough, yellow or white tissue adhered to the wound, approximately 50% of necrotic tissue, no exudate present, and the edges had maceration with the surrounding skin color noted to be bright red. The pressure ulcer was not noted to have an odor or signs/symptoms of infection. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's nursing progress note dated 09/16/21 revealed Resident #52 to have a stage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 2 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 III pressure ulcer on coccyx. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Residents Affected - Few Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage IV pressure on coccyx with measurements of 2.4 cm in length, 1.2 cm in width and 0.2 cm in depth. The ulcer was ntoed to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 75% of the wound and granulation was 25% of wound. The exudate was noted to light, bloody and clear with no undermining or tunneling present. There was no bone, tendon, or hardware visible or directly palpable in the wound. The wound deges were noted to have had maceration with the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's physician progress note dated 09/24/21 revealed Resident #52 to have the pressure ulcer debrided by physician and the pressure ulcer noted as a stage IV. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 4 ulcer noted to coccyx. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 4 pressure ulcer on coccyx with measurements of 1.5 cm in length, 0.5 cm in width and 0.75 cm in depth. The ulcer was noted to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 25% of the wound and granulation was 75% of wound. The was no exudate present and no undermining or tunneling. The wound deges were noted to not have any issues and the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's Braden scaled for assessment of pressure ulcer risk revealed assessments completed weekly between 08/30/21 - 09/23/21 noted Resident #52 to be at low risk of pressure ulcer development. In an interview on 10/03/21 at 11:20 AM CNA E stated it was difficult to respond to call lights when there are only 2-3 aides working the whole facility. She said they have been short staffed for several months, but it is improving. She said they try to get to everyone as fast as they can but when you were showering a resident, you could not leave and if there is not someone else available on your hallway, residents had to wait. In an interview on 10/04/21 at 3:30 PM DON stated Resident #52's pressure ulcer was facility acquired. DON stated she spoke with Wound Care Physician and did not believe the pressure ulcer had declined to a stage IV pressure ulcer. DON stated the Treatment Nurse does the initial skin assessment upon admission and if the Treatment Nurse was not available, the charge nurse would complete it. DON said weekly skin assessments were completed by the charge nurse on the day the assessment was due. DON said she did not know of any issues Resident #52 had with being able to turn and reposition herself in bed. She said Resident #52 was weak upon admission and may have needed some help but could assist in turning herself. She said the Treatment Nurse was involved with pressure ulcers usually at stage II and floor staff complete treatment for all other skin issues like skin tears. She stated wounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 3 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety Residents Affected - Few are referred to Treatment Nurse the same day or next day for treatment. She confirmed the wound confirmed in progress notes as stage II for Resident #52 on 09/08/21 should have been referred to the Treatment Nurse that day or the next day. She said the Treatment Nurse was out with COVID in September and that is probably why the first weekly ulcer assessment and treatment was not completed until 09/16/21. DON did not know how Resident #52 had a stage II ulcer on 09/08/21, a stage 3 ulcer on 09/16/21 and a stage IV ulcer on 09/24/21. DON said incontinence might be an issue, but Resident #52 was confirmed to have a catheter for urinary incontinence. She said the incontinence with the Braden scale of pressure ulcer risk and resident having a current pressure ulcer should not be there. If a resident has a stage III-IV pressure and it was facility acquired, it would make them more than a low risk for pressure ulcers. She said a low air mattress is ordered for a stage III or greater pressure ulcer. All residents have a pressure relieving mattress upon admission. Observation on 10/05/2021 at 8:41 AM of wound care for Resident # 52's coccyx pressure ulcer revealed the Treatment Nurse used her clean gloved hand to move the resident's adult brief out of the way, then cleaned the ulcer with gauze using the same gloved hand. She then pushed calcium alginate into the wound with the same gloved hand that touched the brief. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. She stated I don't remember touching the brief on (Resident # 52.) In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated he had only seen Resident #52 once on 09/24/2021 and debrided her pressure ulcer. He confirmed Resident #52 had no prior history of a stage III or IV pressure ulcer that he knew of or had treated. He was not sure why it was documented that she had a previous pressure ulcer. He said the pressure ulcer was a stage IV after debridement and with the resident being so new to the facility, he assumed she was admitted with the pressure ulcer. When informed she was admitted with no pressure ulcer, he confirmed the pressure ulcer did form quickly and declined quickly. When asked if he thought this was avoidable for the resident, he could not say without reviewing her record. He confirmed the resident did not have any condition that would make her more likely to form a pressure ulcer. In an interview on 10/06/21 at 12:11 PM, Resident #52's Primary Care Physician stated Resident #52 was essentially bed bound upon admission and therefore spent a lot of time sitting or lying in bed which resulted in the pressure ulcer. When asked if the pressure ulcer could have been avoided if Resident #52 was turned frequently as ordered every two hours, she said yes. She said turning and repositioning would have likely reduced the likelihood of a pressure ulcer. She said now Resident #52 was stronger and able to reposition herself but at admission to the facility she would have required staff assistance. In an interview on 10/05/21 at 2:10 PM Resident #52 stated she required assistance from staff to reposition and move in bed or to transfer from the bed to a chair. She said she was better at turning herself now, but when she was first admitted she was weak and needed help. She said she does not remember them turning and repositioning her frequently or even once per day when she was first admitted . She said she did not know she was supposed to turn or reposition in bed or in her wheelchair to prevent the pressure ulcer from forming or declining. She stated her daughter bought her a wedge pillow so she could shift her weight while she was lying in bed. She said sometimes the call light response was slow if the staff were busy. In an interview on 10/05/21 at 2:35 PM the Treatment Nurse stated she returned from leave on 09/16/21 and assessed Resident #52. She said it was the first time she saw the pressure ulcer and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 4 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety Residents Affected - Few identified it as a stage III pressure ulcer. She stated Resident #52 did not have an underlying reason for the fast development and decline of the pressure ulcer. When asked what could have caused the fast development and decline of Resident #52's pressure ulcer, she stated it was likely caused from lack of repositioning or turning Resident #52 in bed as ordered every two hours. She confirmed the facility was short staffed and aides did not always have the time to reposition residents every two hours. Review of Resident #52's point of contact documentation of repositioning/turning dated September 2021 revealed Resident #52 to not have reposition/turning documentation for 24 out of 30 days on at least one shift per day. In an interview on 10/05/2021 at 3:00 PM the DON stated the facility was short staffed over the last month. She stated normally five aides were scheduled during the daytime shift and they frequently worked with only two to three aides. She confirmed it would have been difficult for the aides to turn and reposition residents as required every two hours. B) Review of Resident #46's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, sepsis, muscle weakness, dysphagia (difficulty swallowing) and difficulty in walking. Review of Resident #46's Quarterly MDS dated [DATE] reflected she was rarely or never understood and was totally dependent on two-person physical assist for bed mobility (moving to and from a lying position, turning side to side and positioning body) and transfers. Review of Resident #46's Care plan dated 04/14/21 reflected The resident has potential for pressure ulcer development. Interventions: The resident needs assistance to turn/reposition at least every two hours. Review of a weekly skin assessment for Resident #46 completed on 07/16/21 reflected she did not have any pressure, venous, arterial or diabetic ulcers. Review of a weekly skin assessment for Resident #46 completed by the facility's Treatment nurse on 08/16/21 reflected she had a pressure ulcer. Review for weekly skin assessments for Resident #46 reflected no skin assessment were completed between 07/16/21 and 08/16/21. Review of a Weekly Ulcer Assessment for Resident #46 completed on 8/16/21 by the facility Treatment Nurse reflected discovery of a new Stage III pressure ulcer to her coccyx with slough (yellow or white tissue adhered to the wound) and 25% necrotic (dead) tissue. Stage III pressure ulcer involves the full thickness of the skin and may extend into the fatty tissue layer. The pressure injury was not present on admission. The Stage III pressure ulcer to her coccyx measured 2.5 cm length, 0.5 cm width and <0.1 cm deapth. Review of a Weekly Ulcer Assessment for Resident #46 completed on 09/30/21 reflected her coccyx ulcer had progressed to a Stage IV pressure ulcer. According to the National Institutes of Health website (nih.gov) in an article dated January 2015, a stage IV pressure ulcer is the is the most severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 5 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety Residents Affected - Few type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The characteristics are: full thickness skin loss with extensive destruction, tissue necrosis (death) or damage to muscle, bone or supporting structures. Observation on 10/05/2021 at 8:14 AM for wound care on Resident # 46's coccyx revealed the Treatment Nurse touched the resident's unclean bedding with her clean gloved hand and did not sanitize her hands or change gloves before she cleaned the wound. She used gauze to clean across the wound and dried all over, working from potentially contaminated areas of skin outside of the open wound. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. I didn't realize I touched bedding before touching the wound on (Resident # 46.) In an interview on 10/05/2021 at 11:45 AM the DON stated the skin assessment shower sheets which had areas for staff to note alterations in skin integrity, was a new assessment she just initiated and did not have any for Resident #46 for 07/16/21 through 08/16/21. In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated the first time he examined Resident #46 was on 09/24/2021. The Wound Care Physician stated he did not know why the resident was not referred to him sooner. He stated the facility should be assessing the resident's skin frequently. In an interview on 10/05/21 at 1:13 PM Resident #46's PCP was asked his expectations for repositioning residents to prevent skin breakdown stated, he stated With folks who are confined to bed, they need to be more vigilant in moving and turning them. They need to check their vulnerable areas and keep them clean. In an interview on 10/05/2021 at 1:54 PM with the Treatment Nurse who stated When I returned from leave, someone told me Resident #46 had not been assessed in a while. The CNAs are supposed to come to me or the charge nurse with any skin issues. I found (Resident # 46's) pressure ulcer. In an interview on 10/05/21 at 3:35 PM with a CNA who chose to remain anonymous and was asked about having enough staff to turn and change residents stated, We were definitely understaffed in July, August and September. It makes everything harder and the wait times longer for residents. In an interview on 10/05/21 at 4:00 PM the ADON stated she and LVN B were Charge Nurses on Resident #46's hall during July and August 2021 when her weekly skin assessments were not completed from 07/16/2021 until 08/16/2021. On 08/16/2021 a stage three pressure ulcer was discovered on her coccyx. The facility ADON stated the charge nurses were responsible for doing the weekly skin assessments and there should always be a weekly skin assessment. In an interview on 10/06/21 at 8:40 AM LVN M, who worked at the facility and quit in September 2021, stated she did not remember if she was scheduled to do Resident #46's weekly skin assessments. She stated if it popped up on her schedule, she would do it. She stated if she did not do it the ADON (who is the current DON) would let her know the next morning. LVN M stated she did not recall any skin problems with Resident #46. In an interview on 10/06/21 at 11:39 AM the DON who stated she had been the DON for three weeks stated she was the ADON previously. When asked if it was her responsibility to ensure weekly skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 6 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety assessments were completed, she stated, Yes, If I saw that it (skin assessment) was flagged on my computer and I had time to look at the computer, I would. I was working 12-hour shifts on the floor and always doing patient care. There was no opportunity to do the ADON job or ensure staff were completing the skin assessments. The DON further stated regarding issues on staffing We hire them, and they never show up or they show up and then stay for two days and quit. The pay is not competitive. We've lost four aides to (another facility in town.) Residents Affected - Few In an interview on 10/06/21 at 4:00 PM CNA F stated We try to get to the residents as soon as we can. We saw redness on some of their skin, (Resident's #46). She stated Resident #46 could not turn herself. The residents need more attention which means we need more staff. Last night was the first time I've seen six staff. I've never seen that before. In an interview on 10/07/21 at 10:49 AM CNA N stated when she saw Resident # 46's coccyx area on a Thursday (08/12/2021) it was red with a white dot in the middle and she applied barrier cream. I told a nurse but I'm not sure who. She stated she was gone for a three-day weekend and when she returned on Monday, 08/16/2021, there was a hole in Resident # 46's coccyx. She stated, We were short staffed. In an interview on 10/07/21 at 10:52 AM with LVN B who stated, We were understaffed when Resident #46 got her pressure ulcer, so I don't know if she was turned or kept clean. She stated RN A mainly did the wounds during that time on the weekends and sometimes during the week. During the nighttime we don't have enough staff. There's only 2 or 3 for the whole place. C) Review of Resident #2's face sheet dated 10/04/2021 revealed resident #2 was a [AGE] year-old male admitted to the facility 04/27/20 with a diagnosis of paraplegia, left above the knee leg amputation, anemia, non-pressure chronic ulcer of back, neuropathic bladder and osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of Resident #2's comprehensive care plan dated 08/09/21 revealed resident #2 to require care for an ostomy, treatment with an anticoagulant, wound care for stage 4 pressure ulcer to sacrum, require pain medication, an indwelling catheter and history of major infection. Review of resident #2's Quarterly MDS assessment dated [DATE] revealed resident #2 to have a BIMS score of 14, required two-person assist with bed mobility and transfer from bed to chair, had an indwelling catheter and colostomy, Stage IV pressure ulcer and required a prevention plan for reducing risk of pressure ulcers. Observation and interview on 10/04/21 at 11:00 AM revealed RN A in Resident #2's room to preform wound care. RN A already had the treatment field set up in room when surveyor arrived. RN A donned gloves outside at the treatment cart and entered the room. RN A did not perform hand hygiene prior to donning his gloves. RN A then removed the dressing from residents left inside knee. RN A stated the wound was from hardware from his knee replacement penetrating the skin and causing it to open. After removing the dressing RN A pushed around on the wound with his gloved hands and reached for the gauze from the table. With the same gloves' RN A cleaned around the area, cleaning across the wound. RN A then reached for a spray bottle (skin prep spray) on his field and sprayed it on the gloves and applied it to the wound with his gloves. RN A then retrieved a dressing from the field and applied it to the wound. RN A with same gloves felt up and down Resident #2's leg then repositioned Resident #2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 7 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety Residents Affected - Few and removed his brief and turned him over (still wearing the same gloves) and removed the coccyx dressings to reveal a large Stage IV pressure ulcer to the coccyx and Stage IV pressure ulcers to his right and left ischial tuberosity. In an interview with Resident #2 he stated he was admitted with the pressure ulcers. RN A without hand hygiene or a glove change cleaned the coccyx wound cleaning across the wound which was approximately 12 cm x 12 cm with .3 depth. RN A touched the wound all over with his gloves and cleaning with the gauze only certain areas of the wound. RN A then with same gloves began cleaning Resident #2's left and right ischial Stage IV pressure ulcers cleaning across the wounds and touching the wounds with is gloves (he did get a new gauze for each wound) he then applied hydrogel to the wounds with his gloves going from one wound to another. RN A then applied the collagen powder with his gloves patting it into the pressure ulcers going from one pressure ulcer to another. RN A without changing gloves or performing hand hygiene applied clean dressings to coccyx wound with the dressing reaching only to middle of pressure ulcer and with the tape being applied directly on the open pressure ulcer. RN A then applied a foam dressing to right ischial with the tape being on the coccyx pressure ulcer. RN A did the same with the left ischial pressure ulcer. RN A then stated he needed to get another brief, so he took off his gloves and without hand hygiene left room he came back in room with gloves on applied the brief to the resident. RN A then with the same gloves he took the spray bottle he used during treatment and put it in his left chest pocket of his scrubs, and he put the scissors that were on the overbed table with the treatment supplies in the side pants pocket of his scrubs without cleaning them. RN A then gathered the left-over treatment supplies and took them back to the treatment cart. In an interview on 10/04/21 at 3:21 PM RN A sated he was not trained in wound care and stated his training at the facility consisted of making rounds with treatment nurse. RN A stated he did not change his gloves or wash his hands throughout the procedure and did not clean his scissors before or after the procedure. RN A stated I should know better than that he stated he was not aware of the no touch technique for applying medication to wounds (the use of a sterile applicator). RN A stated he was not aware you could not remove treatment supplies from the room or that they were considered contaminated. RN A agreed he had touched the supplies with the gloves that he did not change during the entire wound care procedure. In an interview on 10/07/21 at 1:23 PM the RNC stated he expected staff to clean hands before donning gloves and before they start a treatment and when going from clean to dirty. When he was asked about going from wound to wound, he stated they should not do that. He stated no supplies should be removed from the room that cannot be sanitized and they should be sanitized. The RNC stated the remaining dressing supplies should have been disposed of. He stated there was no corporate policy regarding training staff for wound care other than the policy that was provided to surveyors. Review of the facility's policy Skin and wound management dated 2021 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in the Procedure Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 8 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 - Immediate jeopardy to resident health or safety Residents Affected - Few ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water .16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Review of the facility's policy Skin Integrity Management dated 10/05/16 reflected .4. Reposition residents at risk for pressure sores or with pressure sores at least every two (2) hours, if unable to turn themselves. 5. Use pillows or foam wedges to keep bony prominences from direct contact .8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every 2 hours .12. The presence of a pressure reducing device/ specialty bed does not negate the need to turn/ reposition the resident at least every two (2) hours .15. Skin should be cleansed at the time of soiling and at routine intervals .19. Use aseptic techniques for all topical treatments . Review of the facility's policy Pressure Injury: Prevention, Assessment, and Treatment dated 08/12/16 reflected .2. Early prevention and/or treatment is essential upon initial nursing assessments of the condition of skin .9. Assess for early signs of skin breakdown and report any findings. Early signs of skin breakdown and report any abnormal findings . The Interim Administrator was notified of the Immediate Jeopardy on 10/06/21 at 5:00 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 10/08/21 at 1:04 PM and included the following: Problem: Treatment/Services to Prevent/Heal Pressure Ulcers. Interventions: o 100% skin rounds to be completed (10/7/2021) by DON, Patient Care Coordinator, and Treatment Nurse, with Regional Compliance Nurse [RCN] oversight. o Skin assessment for resident #46 and resident #52 current. Update on current wound condition provided to resident #46's primary care physician on 10/6/21 with review of current treatment order to ensure appropriate treatment in place. Weekly ulcer assessment in place with current measurements for resident # (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 9 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 46 and resident #52. Care plans for resident #46 and resident #52 were reviewed and revised on 10/6/21. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Few Pressure Ulcer Prevention and Treatment (Licensed Staff), including notification and documentation of The following in-services were initiated by the Director of Nursing on 10/6/2021: pressure ulcers (Certified Nurse Aid/Non-certified Nurse Aid) Notification of Physician with change of condition (Licensed staff) Completing Weekly Skin Assessments and Weekly Ulcer Assessments in the absence of the Treatment Nurse (Licensed staff) Ongoing in-services will be completed by DON/ADON/TREATMENT NURSE, until all nursing staff have completed the in-services. The Director of Nursing/Designee will in-service licensed staff on the proper process for wound care beginning 10/7/21. Ongoing in-services will be completed by DON/Treatment Nurse/Designee until all licensed staff has completed the in-service. <[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 10 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure a registered nurse served as the Director of Nursing on a full-time basis for one of one facility reviewed for registered nurse coverage in that: Residents Affected - Many The facility failed to ensure the Director of Nursing did not serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents preventing her from providing supervision and oversight of the staff for 6 of 30 days in September 2021. These failures placed residents at risk for not having their nursing and medical needs met. Finding include: Review of the average daily census of the facility from 07/14/21 to 10/03/21 reflected the average census of the facility was 65. Review of the facility's staff schedule dated September 2021 revealed the DON worked as a charge nurse for six out of 30 days. The average daily census for the facility during September was 65. In an interview on 10/06/21 at 9:30 AM the RNC stated he had been in his position for 3 years. The RNC stated the old DON would cover shifts on the floor if they were short. The RNC stated they started a recruiting and retention plan on 08/20/2021 that included HR posting positions on hiring sites and face book. The plan included the administrative nurses (ADON and DON) filling in and working the floor. The RNC stated that PCC would give the alerts to the administrative nurses when assessments were not being done. In an interview on 10/06/21 at 9:33 AM the DON stated she had been in her position for 3 weeks. She stated the facility has reached out to agencies and the facility has two contracts with staffing agencies, but they are never able to get anyone. She stated they were able to get a staff member once but then they called in. The DON stated she is aware of the staff storages but was not aware the skin assessments were not being done. She stated the ADON assist her with oversight on this, but she is working the floor most days. She stated PCC will give her clinical alerts when things are not being done but she has worked on the floor almost every day except for this week even working night shift and has not had time to do audits or check that assessments are being done. She stated she was absolutely not able to give 40 hours a week to the DON position or DON responsibilities. Review of the facility's Job Description for the Director of Nursing dated 2014 reflected .Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with the Company, local, state and federal regulations .Mange nursing staff through appropriate hiring, training, evaluation, assignment and delegation of duties .Augment floor staffing if needed . Review and ensure proper resident charting and procedure documentation .Train and develop nursing staff to achieve positive resident outcome . The facility did not provide a policy regarding the DON working the floor when the census was over 60 residents prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 11 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates for two of three medication carts reviewed and one of one wound care carts reviewed and failed to ensure potential contaminants were kept off of the medication carts for 2 of 3 medication carts reviewed. The facility failed to ensure expired medications were removed from the carts and failed to ensure potential contaminants including loose pills, debris, and personal items were not on the carts. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications A) Observation on 10/03/2021 at 2:33 PM of the Nurses' med cart located on Hall A revealed Pro-Stat Sugar-free liquid supplement with no date on the bottle to indicate when it was opened. The bottle instructions state Discard 3 months after opening, Record date opened on bottom of container. Interview on 10/03/2021 at 2:42 PM with LVN Q who stated (Pro Stat Sugar-free) is supposed to be dated when it's opened. Potentially it could lose potency and effectiveness. It could spoil and be contaminated. Observation on 10/03/2021 at 2:48 PM of the Nurses wound care cart on Hall B revealed Hibiclens with an expiration date of 9/2021 and Clotrimazole Cream 1% for a resident no longer in the facility. Interview on 10/03/2021 at 2:50 PM with LVN R who stated the Clotrimazole should be off the cart. That resident had her funeral last week. Observation on 10/03/2021 at 2:59 PM of the med cart for Hall B revealed four packets of Vitamin A and D ointment with expiration dates of 6/2021 and Trolamine Salicylate 10% with an expiration date of 01/03/2021. Interview on 10/03/2021 at 3:05 PM with LVN R who was asked if the Vitamin A and D ointment and Trolamine Salicylate with the expired dates should be discarded, she stated Oh yes. Interview on 10/04/2021 at 10:00 AM with the RNC who when asked if outdated meds should be on the cart stated, No, there shouldn't be any. Those should be pulled off. The Pro Stat is supposed to be dated. We should be following manufacturer's instructions. Interview on 10/04/2021 at 4:13 PM with the DON who stated I expect anything outdated not to be on the carts. The ADON goes through the med carts and does med audits. In an interview on 10/06/21 at 9:33 AM the DON stated she had been in her position for 3 weeks. She stated the ADON assists her with oversight on this. She has worked on the floor almost every day except for this week even working night shift and has not had time to do audits. She stated she was not able to give 40 hours a week to the DON position or DON responsibilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 12 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/04/2021 at 10:12 AM with the ADON who stated The expired meds could lose potency and not be effective. There could be an adverse reaction from expired medications. B) Observation and interview on 10/03/2021 at 2:36 PM of the Nurses' med cart for A Hall revealed four white pills and other debris in the bottom left drawer. LVN Q could not identify the pills and stated, they shouldn't be there. Observation on 10/03/2021 at 3:19 PM of the Med Cart for Hall C revealed a cup of ice in a Styrofoam cup, four pieces of candy and a hairbrush inside the cart. Interview on 10/03/2021 at 3:22 PM with LVN S who when asked if the cup of ice, candies and hairbrush should be in the med cart, stated Not with the meds. Interview on 10/04/2021 at 10:12 AM with the ADON who when asked about the four white pills and debris found in the bottom of the med cart on Hall A, stated The nurses sometimes pop pills and lose them. They drop into the bottom of the cart. They're supposed to clean the carts. There should be no loose medications. Interview on 10/04/2021 at 4:13 PM with the DON indicated there should be no food on the carts, no personal drinks and nothing hygiene related should be on there either. Interview on 10/04/2021 at 4:20 PM with the RNC who was asked for any policies regarding protocol for keeping the medication carts free of contaminants but none was provided. Review of the facility Recommended Medication Storage policy from the Pharmacy Policy and Procedure Manual revised 7/2021 and provided by the facility ADON reflected Medications that require an open date as directed by the manufacturer should be dated when opened, in a manner that is clear when the medication was opened. The document included a list of medications that require a date when opened and stated, the list is not all inclusive and the manufacturers recommendations will supersede this list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 13 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for three of six Residents (Resident #2, #52 and #46) reviewed for pressure ulcers wound care. Residents Affected - Some A) The facility failed to ensure RN A followed standard precautions during wound care for Resident #2's Stage IV coccyx pressure ulcer and Stage IV's right and left ischial pressure ulcers when he failed to perform hand hygiene, gloves changes or proper wound cleansing. B) The facility failed to ensure the Treatment Nurse followed standard precautions during wound care for Resident #52 when she failed to perform proper wound cleansing and failed to perform hand hygiene after contamination of her gloves. C) The facility failed to ensure the Treatment Nurse followed standard precautions during wound care for Resident #46 when she failed to perform proper wound cleansing. These failures could place residents at risk for developing wound infections. Findings included: A) Review of Resident #2's face sheet dated 10/04/2021 revealed resident #2 was a [AGE] year-old male admitted to the facility 04/27/20 with a diagnosis of paraplegia, left above the knee leg amputation, anemia, non-pressure chronic ulcer of back, neuropathic bladder and osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of Resident #2's comprehensive care plan dated 08/09/21 revealed resident #2 to required care for an ostomy, treatment with an anticoagulant, wound care for stage 4 pressure ulcer to sacrum, require pain medication, an indwelling catheter and history of major infection. Review of resident #2's Quarterly MDS assessment dated [DATE] revealed resident #2 to have a BIMS score of 14, required two-person assist with bed mobility and transfer from bed to chair, had an indwelling catheter and colostomy, stage IV pressure ulcer and required a prevention plan for reducing risk of pressure ulcers. Observationand interview on 10/04/21 at 11:00 AM revealed RN A in Resident #2's room to preform wound care. RN A already had the treatment field set up in room when surveyor arrived. RN A donned gloves outside at the treatment cart and entered the room. RN A did not perform hand hygiene prior to donning his gloves. RN A then removed the dressing from residents left inside knee Resident #2 stated the wound was from hardware from his knee replacement penetrating the skin and causing it to open. After removing the dressing RN A pushed around on the wound with his gloved hands and reached for the gauze from the table. With the same gloves RN A cleaned around the area, cleaning across the wound. RN A then reached for a spray bottle (skin prep spray) on his field and sprayed it on the gloves and applied it to the wound with his gloves. RN A then retrieved a dressing from the field and applied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 14 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it to the wound. RN A with same gloves felt up and down Resident #2's leg then repositioned Resident #2 and removed his brief and turned him over (still wearing the same gloves) and removed the coccyx dressings to reveal a large Stage IV pressure ulcer to the coccyx and Stage IV pressure ulcers to his right and left ischial tuberosity. RN A without hand hygiene or a glove change cleaned the coccyx wound cleaning across the wound which was approximately 12 cm x 12 cm with .3 depth. RN A touched the wound all over with his gloves and cleaning with the gauze only certain areas of the wound. RN A then with same gloves began cleaning Resident #2's left and right ischial Stage IV pressure ulcers cleaning across the wounds and touching the wounds with is gloves (he did get a new gauze for each wound) he then applied hydrogel to the wounds with his gloves going from one wound to another. RN A then applied the collagen powder with his gloves patting it into the pressure ulcers going from one pressure ulcer to another. RN A with changing gloves or performing hand hygiene applied clean dressings to coccyx wound with the dressing reaching only to middle of pressure ulcer and with the tape being applied directly on the open pressure ulcer. RN A then applied a foam dressing to right ischial with the tape being on the coccyx pressure ulcer. RN A did the same with the left ischial pressure ulcer. RN A then stated he needed to get another brief, so he took off his gloves and without hand hygiene left room he came back in room with gloves on applied the brief to the resident. RN A then with the same gloves he took the spray bottle he used during treatment and put it in his left chest pocket of his scrubs, and he put the scissors that were on the overbed table with the treatment supplies in the side pants pocket of his scrubs without cleaning them. RN A then gathered the left-over treatment supplies and took them back to the treatment cart. In an interview on 10/04/21 at 3:21 PM RN A sated he was not trained in wound care and stated his training at the facility consisted of making rounds with treatment nurse. RN A stated he did not change his gloves or wash his hands throughout the procedure and did not clean his scissors before or after the procedure. RN A stated I should know better than that he stated he was not aware of the no touch technique for applying medication to wounds (the use of a sterile applicator). RN A stated he was not aware you could not remove treatment supplies from the room or that they were considered contaminated. RN A agreed he had touched the supplies with the gloves that he did not change during the entire wound care procedure. B) Review of Resident #52's face sheet dated 10/04/2021 revealed resident #52 was an [AGE] year-old female admitted to the facility 08/30/2021 with a diagnosis of urinary tract infection, hypertension, Type II Diabetes Mellitus, abnormalities of gait and mobility, osteoporosis, acute post hemorrhagic anemia, cerebrovascular disease and history of fall with hip fracture. Review of Resident #52's care plan dated 09/20/2021 revealed resident #52 to require an indwelling catheter, history of surgery for left hip fracture with healing incision, history of fall at home, stage IV pressure ulcer, dependence on staff for mobility and activities and on antibiotics for a urinary tract infection. Review of Resident #52's MDS assessment dated [DATE] revealed resident #52 had a BIMS score of 15, required two-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and had a stage II pressure ulcer. Observation on 10/05/2021 at 8:41 AM of wound care for Resident # 52's coccyx pressure ulcer revealed the Treatment Nurse used her clean gloved hand to move the resident's adult brief out of the way, then cleaned the ulcer with gauze using the same gloved hand. She then pushed calcium alginate into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 15 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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 the wound with the same gloved hand that touched the brief. Level of Harm - Minimal harm or potential for actual harm Interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. She stated I don't remember touching the brief on (Resident # 52.) Residents Affected - Some C) Review of Resident #46's Face Sheet reflected she is an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, sepsis, muscle weakness, dysphagia (difficulty swallowing) and difficulty in walking. Review of Resident #46's Quarterly MDS dated [DATE] reflected she is rarely or never understood and was totally dependent on two-person physical assist for bed mobility (moving to and from a lying position, turning side to side and positioning body) and transfers. Review of Resident #46's Care plan dated 04/14/21 reflected The resident has potential for pressure ulcer development. Interventions: The resident needs assistance to turn/reposition at least every two hours. Observation on 10/05/2021 at 8:14 AM for wound care on Resident # 46's coccyx revealed the Treatment Nurse touched the resident's unclean bedding with her clean gloved hand and did not sanitize her hands or change gloves before she cleaned the wound. She used gauze to clean across the wound and dried all over, working from potentially contaminated areas of skin to the open wound. Interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. I didn't realize I touched bedding before touching the wound on (Resident # 46.) In an interview on 10/07/21 at 1:23 PM the RNC stated he expected staff to clean hands before donning gloves and before they start a treatment and when going from clean to dirty. When he was asked about going from wound to wound, he stated they should not do that. He stated no supplies should be removed from the room that cannot be sanitized and they should be sanitized. The RNC stated the remaining dressing supplies should have been disposed of. He stated there was no corporate policy regarding training staff for wound care other than the policy that was provided to surveyors. Review of the facility's policy Infection control Plan: Overview dated 2019 reflected The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Review of the facility's policy Skin and wound management dated 2021 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in the Procedure Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675821 If continuation sheet Page 16 of 17 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water .16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Event ID: Facility ID: 675821 If continuation sheet Page 17 of 17