Health inspection·August 17, 2022

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented on 08/13/22 that tracheostomy care and tie changes had been completed on 08/13/22 (Saturday). In an observation and interview with Resident #42 on 08/14/22 at 10:10 a.m. revealed the resident had a single lumen trach (no inner canula) that was uncapped. The tracheostomy stoma dressing was curled up, initially the date could not be seen. Resident #42 stated the staff was supposed to be changing the dressing every day but that was not happening, and it was causing her neck to itch. She also stated she was supposed to have a cap on the end of the trach tube, but it kept popping off and no one had [NAME] her a replacement cap. Resident #42 reached up and uncurled the dressing, revealing a date of 08/12/22. She stated she was waiting for the facility to get her scheduled to have the trach removed. She stated she was not having any difficulty in breathing, eating, or speaking. An observation on 08/14/22 at 1:15 p.m. revealed LVN E entered Resident #42's room. He washed his hands and put on gloves and lifted the edges of the tracheostomy dressing. Resident #42 told him it was supposed to be changed every day and stated it had not been changed. LVN E removed his gloves and told the resident he would be back and left the room. An observation on 08/14/22 at 1:30 p.m. revealed LVN E and RN D entered Resident #42's room to provide tracheostomy care. LVN E placed the unopened tracheostomy kit on the resident's bedside table without cleaning the table. Both staff washed their hands and put on clean gloves. LVNE E opened the tracheostomy care kit (holds sterile supplies for cleaning tracheostomy) and removed the sterile drape (used to create a sterile field for tracheostomy cleaning supplies) and placed it on the resident's chest. LVN E then removed the sterile gauze (while wearing non-sterile gloves) and placed them on the sterile drape, along with the package containing the stoma drainage pad and the package containing a pair of sterile gloves. LVN E then removed the bottle of sterile normal saline and poured it into the container in the tracheostomy kit and picked up the sterile gauze and placed it in the basin with the normal saline. LVN E then removed the old tracheostomy drainage pad from the around the resident's tracheostomy revealing a small amount of brownish colored drainage. LVN E discarded the draining pad in the trash can and removed his gloves and washed his hands. LVN E then put on clean gloves and reached back into the tracheostomy kit and opened the package of hydrogen peroxide and poured it on the saline soaked gauze in the tracheostomy kit tray. LVN E then removed his gloves and without performing hand hygiene opened the package containing the sterile gloves and put them on. LVN E then picked up the peroxide/normal saline soaked gauze and cleaned around the stoma area. LVN E then opened the package of trach ties and proceeded to remove the old trach ties. LVN E removed the old trach ties with the assistance of RN D. Both staff replaced the trach ties. LVN E then picked up the stoma drainage sponge and placed it around the tracheostomy tube while wearing the same gloves. LVN E them removed his gloves and dated the dressing for 08/14/22. In an interview with LVN E on 08/14/22 at 1:50 p.m. he stated he worked double weekends. He stated he did not normally change the tracheostomy dressing; he just assessed the tracheostomy site on 08/13/22. When asked what tracheostomy care meant to him, he stated he thought he was just supposed to assess the site and that the dressing was changed by the wound care nurse or the Respiratory Therapist. He stated he found out today, he was responsible for the tracheostomy dressing changes. He stated it had been over 4 months since he had tracheostomy care training. He stated he thought he had done everything right and stated he knew it was supposed to be as sterile a procedure as possible to prevent infections. In an interview with RN D on 08/14/22 at 1:55 p.m. revealed she was in orientation and had been assigned with LVN E. She stated it was her understanding that any tracheostomy dressing change was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 2 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few considered a sterile procedure. She stated they did not have enough sterile gloves for the procedure and the sterile field was not maintained. She stated it was not appropriate to place a sterile field on top of the resident. She stated the stoma site was only to be cleaned with normal saline. She stated the peroxide in the kit was for cleaning an inner cannula, which Resident #42 did not have. Review of LVN E's Competency checks for tracheostomy care reflected he was skills checked on 05/09/22 by RN C and deemed competent in trach care. In an interview with RT F on 08/14/22 at 2:20 p.m. revealed he worked on as needed basis for the facility. He stated he comes once or twice a week depending on how many trach patients the facility had. He stated he also does tracheostomy care training for the facility but stated it had been over 5 months since he had done any training with the staff. He stated Resident #42 had a single lumen (channel) trach. He stated the only care needed with this type of trach would be the stoma site care and cleaning the exterior of the trach with normal saline and changing the trach ties once a week unless they got soiled and needed to be changed more often. He stated any trach care needed to be with as much sterile technique as possible due to the risk of infections. He stated peroxide would not be used for cleaning the stoma site. He stated it was only used to clean an inner cannula and then it would be rinsed with normal saline before re-instilling into the trach. In an interview with ADON B, acting interim DON on 08/16/22 at 10:45 a.m. revealed staff are to assess residents before providing trach care and look for any signs and symptoms of infection. He stated it is the responsibility of the nurse assigned to the resident to perform the trach care, not the wound care nurse. He stated trach care is considered a sterile technique due to the risk of introducing containments into the trachea. He stated the sterile drape is not to be placed on the chest but on the table to create a sterile field and the table should be cleaned prior to placing the supplies on it. He stated only normal saline is used to clean the stoma site and outside of the trach tube. He stated using peroxide to clean the stoma site could cause skin irritation. He stated the nurse should have changed his gloves and performed hand hygiene after replacing the trach ties and before replacing the trach drainage sponge. He stated failure to follow the correct procedures could lead to infections. In an interview with the Corporate Nurse on 08/16/22 at 11:00 a.m. he stated corporate had reviewed the order options in the electronic records and had added more descriptive selections that were more patient specific related to the types of tracheostomy care a patient required. He stated they had also begun in servicing nursing staff on trach care procedures and going forward the ADON/Unit managers would be doing regular skills checks. He stated the ADON would be responsible for monitoring all new trach orders going forward. Review of the facility's policy, Trach Care Skills Checklist dated October 2021, reflected, .Check MD order .Gather Supplies .Assemble equipment and prepare dressing tray per procedure, placing trach sponge, Q-Tips, and trach brush on sterile/clean filed .Put on clean gloves .remove inner cannula .Immerse cannula in hydrogen peroxide. If single use discard and replace with new cannula .Remove used trach sponge and assess site. Discard sponge appropriately .Clean trach site with sterile/clean Q tips and normal saline. Use single swipe and move from stoma outward .Dry stoma with sterile/clean 2x2 or 4x4 .Change trach ties according to policy .Remove clean gloves and discard appropriately .Use Sterile technique: Use trach brush to clean the inside of the inner cannula and remove secretions .Apply new trach sponge .Document care given including assessment of secretions, dressing and stoma, as well as patient response FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 3 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the physician prescribed therapeutic diet for 1 of 15 residents (Resident #4) whose diets were reviewed for therapeutic diets, in that: The facility failed to provide Resident #4 a therapeutic diet as ordered by the physician. This failure could place residents on a therapeutic diet at risk for not having their nutritional needs met. Findings included: Record review of the undated face sheet for Resident #4 revealed a [AGE] year-old woman with an admission date of 06/07/21 and diagnoses to include: heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), end stage renal disease (the kidney's cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on renal dialysis (purifying the blood of a person whose kidneys are not working normally), anemia in chronic kidney disease (condition marked by a deficiency of red blood cells or of hemoglobin in the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), vitamin deficiency (a deficiency of one or more essential vitamins), and moderate protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of the MDS for Resident #4, dated 06/01/22, revealed a BIMS of 13 which indicated she was cognitively intact. The MDS also revealed a triggered care area of nutritional status. Record review of the undated care plan for Resident #4 revealed a problem of, [Resident #4] is at risk for unintended weight loss related to ESRD/Dialysis, therapeutic diet, vitamin deficiencies, history of skin integrity impairment and complex morbidities, with a goal of, [Resident #4] will be without s/sx malnutrition through review period, and an intervention of, diet as ordered. Record review of the Physician's Order for Resident #4, dated 06/16/21, revealed a diet order of regular, low concentrated sweets, no salt on tray, cut meat into bite-sized pieces, and large portions. Record review of the Nutrition Assessment Update by the Registered Dietitian for Resident #4, dated 05/24/22, revealed a diet prescription of regular, low concentrated sweets, no salt on tray, large portions and cut meat into bite-sized pieces with a daily bedtime snack. Record review of the undated meal tray ticket for Resident #4 revealed it did not specify large portions. Interview on 08/14/22 at 10:45 a.m., Resident #4 stated she did not get enough to eat at the facility. She stated she often felt hungry and requested more food from the staff which she sometimes got. Resident #4 stated she previously spoke with someone in the dietary department and was under the impression she was going to get large portions, but she had not been. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 4 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/15/22 at 12:17 p.m. revealed in the kitchen during meal service Resident #4's tray ticket did not specify large portions. The resident's lunch tray was prepared with a regular portion size of the menu items which consisted of 4 oz. beef, ½ cup rice, ½ cup vegetables and ½ cup dessert. Interview on 08/15/22 at 12:28 p.m., the Registered Dietitian stated Resident #4's meal tray ticket used to specify large portions and she was not sure why it no longer did. The Registered Dietitian stated it was possible when Resident #4 readmitted in May 2022 after being in the hospital, the diet order may have fallen through the cracks. The Registered Dietitian stated she was going to specify large portions on the meal tray ticket immediately. She stated the risk to Resident #4 was potential weight loss. Interview on 08/15/22 at 1:02 p.m., LVN A stated Resident #4 would ask for seconds, sometimes sandwiches, or extra cereal. LVN A stated when Resident #4 requested more food, they got something for her. Record review of the facility's Physician Orders Policy, dated February 2010, revealed, Orders to be carried out as stated by physician. Record review of [NAME] Y, [NAME] Q. Protein Nutrition and Malnutrition in CKD and ESRD. Nutrients. 2017 [DATE];9(3):208 revealed, Multiple studies have shown that in patients with CKD (chronic kidney disease) and ESRD (end stage renal disease), their resting energy expenditure is increased compared to non-CKD individuals. Inflammatory state and co-morbidities associated with CKD and ESRD such as cardiovascular disease, poorly controlled diabetes, and hyperparathyroidism can all contribute to the increased resting energy expenditure. Resting energy expenditure is shown to increase from 12% to 20% during dialysis. Thus, patients with renal failure require a higher amount of energy intake than healthy individuals. CKD and ESRD patients are, thus, susceptible to insufficient energy intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 5 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 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 for three (Resident #42, Resident # 11, and Resident #27) of five residents observed for infection control. Residents Affected - Some 1. LVN E failed to follow the procedure for tracheostomy care for Resident #42 on 08/14/22 when he failed to maintain a sterile/clean field for the supplies needed to provide trach care and failed to change his gloves and perform hand hygiene before applying a clean trach drainage sponge. 2. LVN E failed to prevent cross contamination of the bottle of testing strips used to obtain a fingerstick blood sugar on Resident's #27, failed to adequately sanitize the bottle of testing strips and failed to perform hand hygiene prior to administration of insulin. 3. LVN F failed to prevent cross contamination of the bottle of testing strips used to obtain a fingerstick blood sugar on Resident's #11 and failed to adequately sanitize the two contaminated glucometer and bottle of testing strips used to obtain a FSBS. Theses failure placed residents at risk for infection and cross contamination. Findings included: 1. Review of Resident #42's quarterly MDS assessment, dated 07/12/22, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. She was moderately cognitively impaired with a BIMS of 7. Her active diagnoses included chronic respiratory failure with hypoxia (absence of oxygen), tracheostomy status and traumatic brain injury. In Section O-Special Treatments, Procedures, and Programs it revealed that she required tracheostomy (trach) care during the 14 days look back period. Review of Resident #42's Consolidated Physician orders dated August 2022, reflected, .Tracheostomy care every shift and as needed .Tracheostomy Tie changes daily . Stoma (surgical opening) Care check stoma site every shift for signs and symptoms of infection .Cleanse Stoma and surrounding area with normal saline and apply dry dressing .with a start date of 11/10/21. In an observation and interview with Resident #42 on 08/14/22 at 10:10 a.m. revealed Resident had a single lumen trach (no inner canula) that was uncapped. The tracheostomy stoma dressing was curled up initially the date could not be seen. Resident #42 stated the staff was supposed to be changing the dressing every day but stated that was not happening and it was causing her neck to itch. She also stated she was supposed to have a cap on the end of the trach tube, but it kept popping off and no one had [NAME] her a replacement cap. Resident #42 reached up and uncurled the dressing, revealing a date of 08/12/22. She stated she is waiting for the facility to get her scheduled to have the trach removed. She stated she was not having any difficulty in breathing, eating, or speaking. An observation on 08/14/22 at 1:15 a.m. revealed LVN E entered Resident #42's room. He washed his hands and put on gloves and lifted the edges of the tracheostomy dressing. Resident #42 told him it was supposed to be changed every day and stated it had not been changed. LVN E removed his gloves and told the resident he would be back and left the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 6 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 An observation on 08/14/22 at 1:30 p.m. revealed LVN E and RN D entered Resident #42''s room to provide tracheostomy care. LVN E placed the unopened tracheostomy kit on the resident's bedside table without cleaning the table. Both staff washed their hands put on clean gloves. LVNE E opened the tracheostomy care kit (holds sterile supplies for cleaning tracheostomy) and removed the sterile drape (used to create a sterile field for tracheostomy cleaning supplies) and placed it on the resident's chest. LVN E then removed the sterile gauze (with non-sterile gloves) and placed them on the sterile drape, along with the package containing the stoma drainage pad and the package containing a pair of sterile gloves. LVN E then removed the bottle of sterile normal saline and poured it into the container in the tracheostomy kit and picked up the sterile gauze and placed it in the basin with the normal saline. LVN E then removed the old tracheostomy drainage pad from around the resident's tracheostomy revealing a small amount of brownish colored draining. LVN E discarded the draining pad in the trash can and removed his gloves and washed his hands. LVN E then put on clean gloves and reached back into the tracheostomy kit and opened the package of hydrogen peroxide and poured it on the saline soaked gauze in the tracheostomy kit tray. LVN E then removed his gloves and without performing hand hygiene, opened the package containing the sterile gloves and put them on. LVN E then picked up the peroxide/normal saline soaked gauze and cleaned around the stoma area. LVN E then opened the package of trach ties and proceeded to remove the old trach ties. The stoma site remained uncovered. RN D and LVN E replaced the trach ties. LVN E then picked up the stoma drainage sponge and placed it around the tracheostomy tube while wearing contaminated gloves. LVN E them removed his gloves and dated the dressing for 08/14/22. In an interview with LVN E on 08/14/22 at 1:50 p.m. he stated he works double weekends. He stated he does not normally change the tracheostomy dressing; he just assessed the tracheostomy site on 08/13/22. When asked what tracheostomy care meant to him, he stated he thought he was just supposed to assess the site and that the dressing was changed by the wound care nurse or the Respiratory therapist. He stated he found out today, he was responsible for the tracheostomy dressing changes. He stated it had been over 4 months since he had tracheostomy care training. He stated he thought he had done everything right and stated he knew it was supposed to be as sterile a procedure as possible to prevent infections. In an interview with RN D on 08/14/22 at 1:55 p.m. revealed she was in orientation and had been assigned with LVN E. She stated it was her understanding that any tracheostomy dressing change was considered a sterile procedure. She stated they did not have enough sterile gloves for the procedure and the sterile field was not maintained. She stated it was not appropriate to place your sterile filed on top of the resident. She stated the stoma site was only to be cleaned with normal saline. She stated the peroxide in the kit was for cleaning an inner cannula, which Resident #42 does not have. Review of LVN E Competency checks for tracheostomy care reflected he was skills checked on 05/09/22 by RN C and deemed competent in trach care. Interview with RT F on 08/14/22 at 2:20 p.m. He stated Resident #42 had a single lumen trach. He stated the only care needed with this type of trach would be the stoma site care and cleaning the exterior of the trach with normal saline and changing the trach ties once a week unless they got soiled and needed to be changed more often. He stated any trach care needed to be as sterile technique as possible due to the risk of infections. He stated peroxide would not be used for cleaning the stoma site due to irritating the skin. Interview with the ADON B acting interim DON on 08/16/22 at 10:45 a.m. revealed staff are to assess residents before providing trach care and look for any signs and symptoms of infection. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 7 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 trach care is considered a sterile technique due to the risk of introducing containments into the trachea. He stated the sterile drape is not to be placed on the chest but on the table to create a sterile field and the table should be cleaned prior to placing the supplies on it. He stated only normal saline is used to clean the stoma site and outside of the trach tube. He stated using peroxide to clean the stoma site could cause skin irritation. He stated the nurse should have changed his gloves and performed hand hygiene after replacing the trach ties and before replacing the trach drainage sponge. He stated failure to follow the correct procedures could lead to infections. Review of the facility's, Trach Care Skills Checklist dated October 2021, reflected, .Check MD order .Gather Supplies .Assemble equipment and prepare dressing tray per procedure, placing trach sponge, Q-Tips, and trach brush on sterile/clean filed .Put on clean gloves .remove inner cannula .Immerse cannula in hydrogen peroxide. If single use discard and replace with new cannula .Remove used trach sponge and assess site. Discard sponge appropriately .Clean trach site with sterile/clean Q tips and normal saline. Use single swipe and move from stoma outward .Dry stoma with sterile/clean 2x2 or 4x4 .Change trach ties according to policy .Remove clean gloves and discards appropriately .Use Sterile technique: Use trach brush to clean the inside of the inner cannula and remove secretions .Apply new trach sponge .Document care given including assessment of secretions, dressing and stoma, as well as patient response . 2. Record review of Resident #27's Face Sheet dated 08/15/22, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus and chronic kidney disease, stage 4. An observation on 08/14/22 at 11:30 a.m. revealed Agency LVN E at the medication cart preparing to perform Resident #27's fingers stick blood sugar (FSBS). Agency LVN E removed the glucometer and bottle of testing strips from the medication cart and wiped down the glucometer with a 3x3 germicidal wipe. Agency LVN E performed hand hygiene, donned gloves and entered the resident's room to perform the FSBS, carrying the glucometer, an alcohol wipe, a lancet, and the bottle of testing strips. Agency LVN E opened the bottle of testing strips, pulled one strip out of the bottle and placed the strip into the glucometer. Agency LVN E then pricked Resident #27's finger and obtained a blood sample for FSBS. Agency LVN E returned to the medication cart, removed the test strip from the glucometer, and disposed of it and the lancet and placed the glucometer and the bottle of testing strips on top of the medication cart. LVN E removed his gloves, performed hand hygiene and opened a single package of germicidal wipe which contained a 3x3 pre-moistened wipe and wiped the edges of the glucometer and swiped one time down one side of the bottle with the same wipe and laid them both back down on the uncleaned top of the medication cart. The bottle of strips was not completely wiped down with the germicidal wipe. LVN E then reached into the medication cart, retrieved a bottle of insulin, and drew up the required amount of insulin to be administered, re-gloved, entered the resident's room and administered the insulin. LVN E then removed his gloves and washed his hands. In an interview with LVN E 08/14/22 at 12:35 p.m. he stated she should not have carried the full bottle of test strips into the room and that by doing so he had contaminated the bottle of strips. He stated he thought he had washed his hands prior to drawing up the insulin. 3. Record review of Resident #11's Face Sheet dated 08/15/22, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus, Crohn's disease (inflammation in the digestive tract) and epilepsy (disorder of the nerve cell activity in the brain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 8 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 An observation on 08/14/22 at 11:55 a.m. revealed Agency LVN F at the medication cart preparing to perform Resident #11's fingers stick blood sugar (FSBS). Agency LVN F removed two glucometers and a bottle of testing strips from the medication cart and wiped down the glucometers with a 3x3 germicidal wipe. Agency LVN E performed hand hygiene, donned gloves and entered the resident's room to perform the FSBS, carrying the glucometers, an alcohol wipe, a lancet, and the bottle of testing strips. Agency LVN F opened the bottle of testing strips, pulled one strip out of the bottle and placed the strip into the glucometer. Agency LVN F then pricked Resident #11's finger and obtained a blood sample for FSBS. Agency LVN F returned to the medication cart, removed the test strip, disposed of it and the lancet, and placed the glucometers and the bottle of testing strips on a paper towel on top of the medication cart. LVN E removed her gloves and performed hand hygiene and opened a single package of a germicidal wipe which contained a 3x3 pre-moistened wipe and wiped the edges of both glucometers and the bottom of the bottle test strips with the same wipe and laid them both back down on top of a paper towel. The bottle of strips was not completely wiped down with the germicidal wipe. In an interview with LVN F 08/14/22 at 12:05 p.m. she stated she should not have carried the full bottle of test strips into the room and that by doing so she had contaminated the bottle of strips. She stated she does not normally do that and realized after she got in the room, she had carried the bottle of strips in with her. She stated she should have used a separate wipe for each glucometer and the bottle of strips, and by not doing that she had just spread germs from one item to the other. She stated she knew this failure could have the potential for cross contamination from one resident to the next. Interview with the ADON B acting interim DON on 08/16/22 at 10:50 a.m. revealed staff are not to carry in the full bottle of test strips into a resident's room for FSBS. He stated by doing so, they had contaminated the entire bottle of test strips since it is used for multiple patients. He stated staff should be using one germicidal wipe per item to be cleaned. He stated it may take multiple wipes to effectively clean the glucometer since the individual wipes are so small. He stated they should never use the same wipe for multiple devices or items to be sanitized. He stated staff were to always perform and hygiene before and after donning and doffing gloves. He stated failure to follow the correct procedures could lead to infections and cross contamination. Review of the CDC guidelines obtained on 08/18/22 https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, reflected, .The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose ( blood sugar) monitoring and insulin administration .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put person at risk for infection include .Failing to change gloves and perform hand hygiene between fingerstick procedures .A simple rule for safe care .Blood glucose Meters .disinfected after every use .General .unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Do not carry supplies and medications in pockets .Hand hygiene .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other person's Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, reflected, .Place the equipment on the bedside stand or overbed table .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .Wear gloves .Obtain a blood sample .dispose of the lancet in the sharps disposal container .discard disposable supplies .Clean and disinfect reusable equipment between uses .remove gloves .wash hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 9 of 10 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 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006 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 Review of the facility's policy titled, Cleaning Multi Use Medical Equipment, dated March 2019, reflected, .Multi use medical equipment such as glucometers .that goes in and out of Patients' rooms will be disinfected before and after using the equipment with an antiviral wipe or approved disinfectant solution .Prior to entering the Patient's room clean any medical equipment you will be using on the Patient with the appropriate antiviral wipe. Allow to dry .Immediately after exiting the Patient's rooms clean the medical equipment you used with the appropriate antiviral wipe. Allow to dry .This must be done again prior to entering another Patient's room to use the same equipment Event ID: Facility ID: 676128 If continuation sheet Page 10 of 10