Health inspection·December 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and stated he was comfortable. During an interview on 12/11/2025 at 4:27 PM, the DON and ADON was informed of the lift observation. The ADON stated so much can happen. The DON stated staff were trained on how to use the mechanical lift on hire and annually during the skills check-off. The ADON stated the potential outcome to the residents would be skin tears and injury. The ADON stated the nurses were responsible for monitoring transfers and she also worked the floor and had not seen any issues. Interview on 12/11/25 at 5:02 PM, the Administrator was informed of the mechanical lift observation. She stated she understood the concern with the transfer. Review of the facility's policy and procedure on Safe Mechanical Lifting, undated, revealed:It is the policy of the facility to ensure resident and employee safety when transferring residents with any mechanical lift.1) Two nursing staff members who have been trained and have shown proficiency in the proper use of the mechanical lift are to be present every time a resident is transferred using a mechanical lift.2) All mechanical lifts will be operated according to manufacturer's recommendations. Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 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 - Many 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 assure drugs and biologicals were stored properly in 1 of 1 medication room reviewed for expired medications and drug storage. The medication room contained 1 opened vial of insulin that was not dated when it was opened. The medication refrigerator contained 1 opened multi-use vial of Tuberculin PPD that had expired[PH1] . (Tuberculin is a sterile liquid containing the growth products of or specific substances extracted from the tubercle bacillus and used in intradermal skin tests for the diagnosis of tuberculosis). This deficient practice could place residents and staff at risk for not getting an accurate screening for Tuberculosis and at risk of not receiving the therapeutic dose of medication. Findings included: [PH1]Include the dateFindings included: During an observation and interview on 12/10/2025 at 10:18 AM the medication room was inspected with LVN A present. In the medication room was a small basket that contained insulin supplies to include an opened insulin vial. The insulin vial nor the box it was stored in had an open date inscribed on it. The vial was about a quarter full of insulin. The LVN said she was not sure when the vial had been opened and that whenever she opened the new insulin she would always write the open date on it. LVN A said the insulin was usually good for 28 days after being opened and then had to be discarded. The LVN said she had not noticed that insulin did not have an open date till just now. LVN A said she would discard it and get a new bottle of insulin. The LVN said that if that insulin was administered it might not have the effect it was meant to do as it might have been expired by now and there was no way to tell when to discard it without an open date on it. The insulin box had directions that indicated Discard unused portion 28 days after first opening. The medication refrigerator was then inspected. Inside the refrigerator was an open box of tuberculin solution that indicated Opened: 10/31 Expires: 11/28. The tuberculin box indicated Once entered, vial should be discarded after 30 days. LVN A said the tuberculin solution should have been removed from the refrigerator as it had expired. The LVN said if the expired solution was used it could lead to an incorrect reading and that she would be replacing the solution. LVN A said it was up to each nurse that worked the floor to keep up with the removal of expired items. During an interview on 12/11/2025 at 5:28 PM the DON was made aware of the observation of the undated insulin and expired TB vial. The DON said the night shift charge nurse was supposed to check the medication room for expired medications and remove them. The DON said the charge nurse failed to do their job and she as the DON failed to make sure the charge nurse was doing their job. The DON said the TB being expired could lead to inaccurate readings and could affect several residents as it was used to test for possible positive TB. The DON said the insulin may not provide the desired effect if it was expired. During an interview on 12/11/2025 at 5:28 PM the Administrator was made aware of the observation of the undated insulin and expired TB vial. The Administrator said both of those things had the potential to lead to inaccurate readings and not be as effective as they were made to be and could affect several residents. Record review of the facility's policy and procedure titled Insulin pens and dated 09/26/2018 indicated in part: It is the policy of (facility name) to use insulin pens in order to improve the accuracy of insulin dosing and provide increased resident comfort. Insulin pens must be clearly labeled with the resident's name, physician name, date dispensed, type of insulin, amount to be given, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete frequency and expiration date. If the label is missing, the pen will not be used, a new pen must be ordered from the pharmacy. Insulin pens must be disposed of after 28 days or according to manufacturer's recommendations. Record review of the facility's policy and procedure titled Drugs and biological distribution, labeling, packaging and storage and dated 08/31/2023 indicated in part: It is the responsibility of the night shift charge nurse to do a twice a month inventory of all drugs and biologicals to check expiration dates and ensure expired drugs do not remain stored in areas where they are available for continued use. This twice a month inventory of expiration dates will be done in all med storage areas, including med storage refrigerator and all medication and treatment carts. And medications that will be expiring within the next 30 days will be marked with an orange sticker. Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The ceiling fan located above the stove, dishwasher and prep table had lint and dust build up. The Maintenance Supervisor was not wearing a beard restraint when he entered the kitchen on several occasions and while food was present and open to air. [NAME] B coughed while preparing food without covering her mouth, failed to wash her hands correctly, put her bare hands into cooked food, and did not properly sanitize the thermometer while taking temperatures of food. These failures could place the residents that consumed food prepared in the kitchen at risk of food-borne illness. Findings included: Findings included: During an observation and interview on 12/09/2025 at 11:05 AM an initial tour of the kitchen was conducted. There was a ceiling fan above the dishwasher, prep table and stove area which had a buildup of dust and lint. The DS said it needed to be cleaned as that could cause some of the lint to fall on the food and that would be unsanitary. The DS said they would get it cleaned and that they had a cleaning schedule and provided a copy of the document. During an observation on 12/10/2025 at 3:45 PM the MS was observed on a couple of occasions entering the kitchen without a beard restraint. The kitchen staff was observed cooking food on the stove top and so the food was uncovered when the MS was in the kitchen. During an observation and interview on 12/10/2025 at 3:58 PM the DS was made aware of the observations of the MS in the kitchen without a beard restraint. At this time the MS was again in the kitchen and was made aware of him having to use a beard restraint whenever he was in the kitchen. The MS said, My bad and that he would make sure to wear a restraint when in the kitchen. The DS said she would make sure the MS wore a beard restraint whenever he entered the kitchen to prevent possible contamination. During an interview on 12/11/2025 at 5:25 PM the Administrator was made aware of the observation of the ceiling fan in the kitchen and the MS in the kitchen without a beard restraint. The Administrator said both of those things had the potential to lead to contamination and the issues had been resolved. Record review of the facility policy titled Cleaning and sanitation of dining and food service areas dated 2021 indicated in part: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for department. Staff will be trained on the frequency of cleaning as necessary. Staff will be held accountable for cleaning assignments. Record review of the facility policy titled Food safety and sanitation dated 2012 indicated in part: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Employees are required to have their hair styled so that it does not touch the collar and to wear clean aprons, clothes and shoes. Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of the 2022 Food Code U.S. Food and Drug Administration indicated in part: Hair restraints. Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils , and linens ; and unwrapped single -service and single -use articles. Residents Affected - Many https://www.fda.gov/food/retail-food-protection/fda-food-code. Accessed on 12/29/2025. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 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 observations, interviews, 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 infection for two of four (Residents #1 and #26) residents reviewed for infection control, in that: The facility failed to ensure CNA E and CNA F donned PPE while performing personal care for Resident #26. The facility failed to provide PPE for residents in need of EBP for Resident #1 This failure could place residents at risk for spread of infectious diseases. Findings included:Resident #1 Review of Resident #1's admission Record, dated 12/10/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including, Hydronephrosis (swelling of the kidney due to an obstruction of the urinary tract), bladder obstruction, and bladder cancer. Review of Resident #1's admission MDS, dated [DATE], revealed:He had a BIMS score of 7 of 15 (indicating severe cognitive impairment) and showed no signs of delirium. He had an indwelling catheter. Review of Resident #1's Care Plan, revised on 11/4/25, revealed:Focus: Resident has an ADL self-care performance deficit related to Muscle Weakness (generalized) and unspecified lack of coordination due to diagnosis of urinary tract infection/ sepsis. Goal: Resident will increase strength and independence with all ADLs through the review date. Interventions included: Toilet Use - Resident had an indwelling catheter; care each shift. Empty catheter drainage bag each shift. Review of Resident #1's Care Plan, revised 11/5/25, revealed:Focus - Resident had an indwelling catheter 16 French/30 ml (size of catheter) foley catheter related to status post dilation of urethral and ureteral stent placement, prostate cancer. Goal: Resident will be/remain free from catheter-related trauma through review date Interventions included nothing regarding EBP Review of Resident #1's Physician Order Summary, dated 12/10/25, revealed no orders about EBP precautions. Observation on 12/09/25 at 2:43 PM, revealed no PPE on door or accessible in Resident #1's room. Resident #26Review of Resident #26's admission Record, dated 12/11/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included stroke, dementia with agitation, acquired absence of other part of urinary tract (colostomy), and other artificial openings or urinary tract status (colostomy). Review of Resident #26's admission MDS, dated [DATE], revealed:Review of his BIMS was 3 of 15 (indicating severe cognitive impairments) with no signs of delirium. He had range of motion impairment of the upper and lower extremity on one side, and he used a wheelchair. He needed substantial/maximum assistance with transfers. He had an ostomy. Review of Resident #26's Care Plan, updated 9/19/25 revealed:Focus: Resident has (stage 1) pressure ulcer (left heel) and potential for further pressure ulcer development related to altered mobility, and bowel incontinence due to recent stroke. Goal: Resident's pressure ulcer will show signs of healing and remain free from infection by/through altered mobility, and bowel incontinence due to recent stroke; and Resident will have intact skin, free of redness, blisters or discoloration by/through review dateInterventions included: Use lift or draw sheet to move Resident in bed. Review of Resident #26's care plan, updated 9/19/25, revealed:Focus: Resident has a urostomy related to bladder cancer.Goal: Resident will show no signs or symptoms of urinary infection through review date. Review of Resident #26's Physician Order Summary Report, dated 12/11/25 revealed no order for EBP. Observation on 12/10/2025 at 1:18 PM, revealed CNA E and CNA F did not put on PPE as they entered Resident #26's room, Resident #26's colostomy hung out of his shirt. CNA F and CNA E performed a mechanical lift transfer from the wheelchair to the bed. Observation on 12/10/2025 at 4:54 PM, CNA E stated the aides would wear PPE for any residents with sores or on isolation. CNA E stated they would need to check if there was any other situations. During an Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 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 interview on 12/11/2025 at 4:27 PM, the DON and ADON stated the expectation for staff for enhanced barrier protection was anyone with something like an open wound. The ADON stated anyone with an ostomy, a foley catheter was supposed to be on EBP. The ADON stated the staff knew there was an order for the EBP and it should be on the task sheet. The ADON stated there should be PPE on door. The DON stated Resident #1 needed PPE available. The ADON stated it happened because the facility had moved so many people around the facility it must have been missed. The ADON stated it was a lack of monitoring on her part and the outcome could be the spread of infection. Interview on 12/11/25 at 5:02 PM, the Administrator was informed of the EBP observations and stated the facility would have to retrain the staff. The Administrator stated she understood the issue with EBP. Review of the EBP Policy and Procedure, undated, revealed:Supplement enhanced barrier precautions for the prevention of transmission of multi-resistant organisms.Enhanced barrier precaution (EBP) refers to an infection control intervention designed to reduce transmission of Multi-drug Organism that employs targeted gown and gloves use during high contact resident care activities.Procedure:The Facility will ensure staff comply with enhanced barrier precautions.The enhanced barrier precautions standing order will be implemented for residents with any of the following: wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MRDO. The facility will ensure gowns and gloves are available immediately near or outside of the residence room.The facility will ensure PPE for enhanced barrier precautions is only necessary when performing high contact care areas and may not need to be donned prior to entering the resident room. High contact resident care activities include:iii transferring. Event ID: Facility ID: 676020 If continuation sheet Page 8 of 8