Health inspection·October 19, 2023

F 0607 nursing facilities. Level of Harm - Minimal harm or potential for actual harm Observation and Interview on 10/17/23 at 11:10 AM with Resident # 5 revealed she was lying in her bed. She stated the night before last (Sunday night) about 1 am or 2 am a female CNA who worked night shift was rough and grabbed on her right arm and leg when providing incontinent care. She reported yesterday to charge nurse who worked yesterday and today (LVN D) about how aide was rough with her. She could not recall the name of the CNA. She stated when female CNA was rough with her it hurt and caused her arthritis to bother her more. She stated she wanted to talk to the DON about it and asked for DON. She stated previous to this incident she did not like the CNA's attitude but denied any previous abuse allegations. She stated when female CNA was in her room to provide incontinent care, she was rude and nasty to her. She stated she told the CNA she did not want to be changed and wanted her to leave. Resident #5 stated she would rather be wet than be changed by her. She stated she fought back to female CNA who was rough with her to defend herself. Residents Affected - Few Interview on 10/17/23 at 11:28 AM LVN D revealed he was aware of Resident #5 telling him yesterday at the end of shift change (2 pm) of an aide over the weekend being rough with her. He stated Resident #5 was not specific about who the aide was and when it occurred specifically. He stated he did not report it since it was around the end of his shift and was on his way out of the facility. He stated he did not report it to anyone even today about Resident #5's allegation of aide being rough. He stated he did not report it since he knew how Resident #5 was and her history of accusations in past. He stated he had not reported the allegation and did not tell his supervisor or the Administrator. Interview on 10/17/23 at 11:35 AM with the Administrator and DON revealed both were unaware of Resident #5's allegation of abuse. Surveyor reported the allegation of physical and verbal abuse to Administrator. The Administrator stated LVN D should have reported Resident #5's allegation of abuse. The Administrator and DON stated they would immediately investigate and look into this allegation of abuse. Interview on 10/17/23 at 11:55 AM with the Regional Director of Operations revealed the facility would self-report the abuse allegation to the state and initiate investigation into the alleged abuse allegation for Resident #5. He stated LVN D had been in-serviced recently on abuse protocol policy and reporting requirements. He stated LVN D would be suspended pending investigation. Surveyor attempted to contact CNA E on 10/19/23 at 10:28 AM but was unable to reach CNA E. Review of CNA E's statement dated 10/17/23 reflected On 10/15/23 I went in [Resident #5's] room and asked was she ready to be changed and she said yes. I gathered my supplies and laid her bed back. She said she can't use wipes so I went to get towels and wet them with warm water. She asked if there was soap on them I told her no. I then asked her to roll on left side so I could clean her and she asked for a towel so I provided her with one. She then rolled back on her left and I started cleaning her and she started kicking and swinging at me and said stop so I stopped and reported to the Charge Nurse. Interview on 10/19/23 at 2:00 PM with Administrator stated she had in-serviced LVN D prior with LVN just a day or two before about reporting any abuse/neglect allegations to Admin. She stated LVN D should have reported the allegation of abuse immediately to her. She stated it was important for her to be informed as the abuse coordinator of any allegations of abuse to ensure residents safety and to prevent any further abuse/neglect. She stated she had initiated an in-service now specifically to report to her as the abuse coordinator and let her decide what was reportable and what needs to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few done as the abuse coordinator. She stated LVN D was terminated yesterday for failing to report allegation to Administrator as in-serviced. Review of No Excuse for Resident Abuse facility In-service dated 10/13/23 reflected all staff including LVN D were in-serviced on abuse protocol policy to call Administrator first, then DON immediately and failure to report could end in termination. Review of Tulip reflected facility self-reported intake #458368 to HHSC on 10/17/23 at 12:34 PM for Resident #5's allegation of abuse with alleged perpetrator CNA E. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately to the Administrator (Abuse Coordinator), but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #5) of 24 residents reviewed for abuse in that: LVN D failed to report Resident #5's allegation of physical abuse to the Administrator (Abuse Coordinator) on 10/16/23. This failure could place residents at risk of continued and unrecognized abuse which could result in emotional distress and diminished quality of life. Findings included: Review of Resident #5's face sheet dated 10/18/23 reflected Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction, arthritis, chronic obstructive pulmonary disease, contractures of left and right hand, pain, bipolar disorder, and schizophrenia. She was her own responsible party. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 had a BIMS of 15 indicating she was cognitively intact. She required substantial to maximal assistance with toileting. Resident #5 was always incontinent of bladder and bowel. Review of Resident #5's comprehensive care plan last updated 10/02/23 reflected Resident #5 has history of refusing basic direct care from staff including incontinent care. Resident #5 has a well-known prior and current history of calling the state with accusations/complaints about staff and nursing facilities. Observation and Interview on 10/17/23 at 11:10 AM with Resident # 5 revealed she was lying in her bed. She stated the night before last (Sunday night) about 1 am or 2 am a female CNA who worked night shift was rough and grabbed on her right arm and leg when providing incontinent care. She reported yesterday to charge nurse who worked yesterday and today (LVN D) about how aide was rough with her. She could not recall the name of the CNA. She stated when female CNA was rough with her it hurt and caused her arthritis to bother her more. She stated she wanted to talk to the DON about it and asked for DON. She stated previous to this incident she did not like the CNA's attitude but denied any previous abuse allegations. She stated when female CNA was in her room to provide incontinent care, she was rude and nasty to her. She stated she told the CNA she did not want to be changed and wanted her to leave. Resident #5 stated she would rather be wet than be changed by her. She stated she fought back to female CNA who was rough with her to defend herself. Interview on 10/17/23 at 11:28 AM LVN D revealed he was aware of Resident #5 telling him yesterday at the end of shift change (2 pm) of an aide over the weekend being rough with her. He stated Resident #5 was not specific about who the aide was and when it occurred specifically. He stated he did not report it since it was around the end of his shift and was on his way out of the facility. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated he did not report it to anyone even today about Resident #5's allegation of aide being rough. He stated he did not report it since he knew how Resident #5 was and her history of accusations in past. He stated he had not reported the allegation and did not tell his supervisor or the Administrator. Interview on 10/17/23 at 11:35 AM with the Administrator and DON revealed both were unaware of Resident #5's allegation of abuse. Surveyor reported the allegation of physical and verbal abuse to Administrator. The Administrator stated LVN D should have reported Resident #5's allegation of abuse. The Administrator and DON stated they would immediately investigate and look into this allegation of abuse. Interview on 10/17/23 at 11:55 AM with the Regional Director of Operations revealed the facility would self-report the abuse allegation to the state and initiate investigation into the alleged abuse allegation for Resident #5. He stated LVN D had been in-serviced recently on abuse protocol policy and reporting requirements. He stated LVN D would be suspended pending investigation. Surveyor attempted to contact CNA E on 10/19/23 at 10:28 AM but was unable to reach CNA E. Review of CNA E's statement dated 10/17/23 reflected On 10/15/23 I went in [Resident #5's] room and asked was she ready to be changed and she said yes. I gathered my supplies and laid her bed back. She said she can't use wipes so I went to get towels and wet them with warm water. She asked if there was soap on them I told her no. I then asked her to roll on left side so I could clean her and she asked for a towel so I provided her with one. She then rolled back on her left and I started cleaning her and she started kicking and swinging at me and said stop so I stopped and reported to the Charge Nurse. Interview on 10/19/23 at 2:00 PM with Administrator stated she had in-serviced LVN D prior with LVN just a day or two before about reporting any abuse/neglect allegations to Admin. She stated LVN D should have reported the allegation of abuse immediately to her. She stated it was important for her to be informed as the abuse coordinator of any allegations of abuse to ensure residents safety and to prevent any further abuse/neglect. She stated she had initiated an in-service now specifically to report to her as the abuse coordinator and let her decide what was reportable and what needs to be done as the abuse coordinator. She stated LVN D was terminated yesterday for failing to report allegation to Administrator as in-serviced. Review of No Excuse for Resident Abuse facility In-service dated 10/13/23 reflected all staff including LVN D were in-serviced on abuse protocol policy to call Administrator first, then DON immediately and failure to report could end in termination. Review of Tulip reflected facility self-reported intake #458368 to HHSC on 10/17/23 at 12:34 PM for Resident #5's allegation of abuse with alleged perpetrator CNA E. Review of facility's policy Abuse Protocol dated April 2019 reflected 1. The Patient has the right to be free from abuse .The Executive Director (Administrator), and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm receiving reports of mental, physical or sexual abuse. Findings of the examination will be record in the patient's medical record. (Protection) 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incident of Patient Abuse as required under applicable regulations and regulatory guidance. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record, and the resident received behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs for 1 (Resident #33) of 6 residents reviewed for unnecessary medications. The facility failed to have a documented clinical rationale by physician to disagree with Gradual Dose Reduction for Resident #33's Depakote (antipsychotic) and Lamictal (antipsychotic) medications. The facility failed to have specific behavior monitoring and side effect monitoring for Resident #33s Depakote and Lamictal medications. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #33's Quarterly MDS assessment dated [DATE] reflected Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease, arthritis, osteoporosis, Parkinson's disease, anxiety disorder, depression, and schizoaffective disorder. Resident #1 had a BIMS of 1 indicating she was severely cognitively impaired. Resident #33 had no behaviors. Resident #1 received antianxiety, antidepressant and antipsychotic medications. Resident #33 was on hospice services. Review of Resident #33's Comprehensive Care Plan effective 06/02/20 reflected the following: Resident #33has altered thought processes r/t (related to) diagnosis of Alzheimer's/dementia .She displays consistent episodes of disorganized thinking throughout the day related to advanced disease processes and requires frequent redirection from staff. Resident #33 was currently taking psychotropic medications as evidenced by anxiety, cognitive impairment (Depakote) and Schizoaffective disorder - bipolar type (Depakote/Lamictal). Intervention included Monitor and record any displayed behavior or mood changes, Monitor effectiveness of psychotropic meds, and Psych consult as needed. She is currently followed by .Psych services, GDR's to be completed timely (at least annually and quarterly as [Resident #33] can tolerate. Review of Resident #33's physician orders dated 10/18/23 reflected Resident #33 was on the following antipsychotic medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0758 Dated 01/19/23 Lamictal 25 mg tablet - 2 tablets one time daily for schizoaffective disorder, bipolar type. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few Dated 03/13/23 Depakote 125 mg - 1 tablet delayed release for Schizophrenia, generalized anxiety disorder, major depression disorder, bipolar disorder. Review of Resident #33's September and October 2023 Treatments reflected the following: Resident #33 received Depakote 125 mg tablet at 8:00 AM and Lamictal 25 mg tablet daily at 9 AM. Anti-depressant/Psychotropic [Side effect] monitoring each shift with start date of 05/18/22 No target behaviors required side effect monitoring only medication = Depakote It reflected none by charge nurses for September and October. Anti-depressant/Psychotropic [Side effect] monitoring each shift with start date of 05/18/22 No target behaviors required side effect monitoring only medication = Lamictal It reflected none by charge nurses for September and October. Review of Resident #33's pharmacy recommendation dated 07/07/23 reflected Lamictal 25 mg 2 qd is due for GDR. NO recent behaviors documented. Please consider reducing dose to Lamictal25 mg qd and monitor behavior. It reflected disagree and signed by physician with no date. There was no clinical rationale documented for GDR disagreeing. Review of Resident #33's pharmacy recommendation dated 09/11/23 reflected Depakote 125 mg qd is due for GDR. NO recent behaviors. Please consider reducing dose to discontinuation and monitor behavior. It reflected disagree and signed by physician with no date. There was no clinical rationale documented for GDR disagreeing. Review of Resident #33's nurse notes reflected on 09/14/23 by LVN F Pharmacy recommendation qd due to GDR suggesting reduction of Depakote 125 mg was not agreed to by the Attending Physician. No changes were made to the orders It did not reflect clinical rationale. Review of Nurses notes from August to October 2023 reflected no behaviors noted for Resident #33. Review of Psychiatric assessment dated [DATE] for Resident #33 reflected Resident #33 had diagnoses of schizoaffective disorder bipolar type, generalized anxiety disorder and dementia. Resident #33 was very confused currently .Her confusion is baseline for her. It did not indicate any behaviors for Resident #33. Observation on 10/17/23 at 10:25 AM revealed Resident #33 was sleeping in her bed with low bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/19/23 at 10:39 AM with LVN G reflected Resident #33 had confusion, was a fall risk and would try to get up on her own. She stated when Resident #33 was more confused she would refuse care and start fighting staff and push her bedside table out of the way. She stated usually when residents on psychotropic medications, the behavioral monitoring for each shift would have which specific behaviors and side effects to monitor the resident each shift. She stated when resident was on Lamictal medications she would monitor hallucinations, look for targeted behaviors of agitation and anxiety. She stated for Resident #33 on Depakote medication she would look for targeted behaviors of confusion, refusing care and wandering. She stated she would document resident behaviors in the nurse notes. She stated behavioral monitoring was on Treatment Administration Record and was to be monitored each shift by the nurse. Interview on 10/19/23 at 11:40 AM with LVN H revealed Resident #33 had behaviors of confusion, push things out of her way and getting up on her own. She stated side effects to Depakote medications could be mood swings, agitation, and anxiety. She stated side effects for Lamictal medications she was not certain about and would have to look up. LVN H stated medication side effects and behavioral monitoring were usually specific on the treatment record to monitor for each shift but Resident #33 did not have any target behavior or specific side effects monitoring. Interview on 10/19/23 on 10:58 AM with Consultant Pharmacist revealed residents on Depakote and Lamictal medications should have targeted behaviors to be monitored for side effects based on diagnosis and centered to the specific resident. She stated she would expect staff to monitor Resident #33 for hallucinations as a side effect to psychotropic medications. She stated she did make pharmacy recommendations of gradual dose reduction for Resident #33 but the facility followed up with the physician about the recommendations. Interview on 10/19/23 at 11:40 AM with Resident #33's physician revealed Resident #33 had multiple falls and gradual dose reduction was not indicated for Lamictal and Depakote medications. He stated Resident #33 was stable on both medications and was on Hospice services. He stated Resident #33 was resistive to care and aggressive towards staff. He stated his clinical rationale for disagreeing with GDR were stable on medications and for medical necessity. Interview on 10/19/23 at 12:10 PM with the DON revealed Resident #33 had hallucinations of auditory and visual. She stated Resident #33 had behaviors of acting up, pushing staff and was a fall risk . She stated hospice nurse reported to her about resident's hallucinations. She stated in the past she had been told of Resident #33's heightened behaviors and was stable at this time. She stated the psych notes had the clinical rationale to continue psychotropic medications and not attempt gradual dose reduction. She stated Resident #33 should be monitored for behaviors and side effects of agitation and restlessness for Depakote. The DON stated residents on Lamictal medication need to be monitored for hallucinations. Interview on 10/19/23 at 12:52 PM with CNA I revealed Resident #33 was difficult to change and aggressive towards staff by fighting in the morning but once she was given her morning medications Resident #33 was cooperative with care and calmer. She stated in the morning Resident #33 was more confused. She stated Resident #33 had behaviors of getting up on her own and moving items in her room around. She stated when Resident #33 was more confused she was more aggressive and fighting with staff. She stated Resident #33 did have hallucinations of seeing people not in the room. Interview on 10/19/23 at 1:10 PM with Regional Clinical Director of Operations reflected nurses should be documenting Resident #33's behaviors and monitoring residents for side effects/behaviors for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents on psychotropic medications specific to the resident each shift. He stated if nurses were unaware of specific behaviors and side effects to monitor for residents on psychotropic medications there was a potential for nurses to not know which resident specific behaviors and side effects to monitor each shift. Review of facility's policy Medications dated November 2017 reflected Patients who use psychotropic medications must receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these medications .8. Behaviors and side effects of the use of medication must be monitored and documented for Patient/Residents receiving psychotropic medication . Event ID: Facility ID: 676128 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates for 1 of 4 medication carts (Medication cart #1) reviewed for medication storage. The facility failed to have Medication Cart #1 free of expired medications. This failure could place residents at risk for increased or decreased potency of medication. Findings included: Observation on 10/17/23 at 09:55 AM of medication cart #1 revealed, one bottle of Lanthanum Carbonate chewable tablet: 1000 mg with an expiration date of 9/2023. Interview on 10/17/23 at 10:08 AM, MA A stated, she checks her medication cart every 30 days for expired medications. MA A stated the expiration was 9/2023 and that she would pull the medication out now. MA A stated that giving expired medications could possibly hurt them (the resident). Interview on 10/19/23 at 10:30 AM with the DON revealed, that the nurses and medication aides were expected to check the carts weekly for expired medications. The DON stated the expired medications should be removed due to clutter of cart and that it might alter the effectiveness of medication. Record review of the facility's policy titled Storage of Medications revised November 2020, discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 one (Residents #28) of three residents reviewed for infection control in that: Residents Affected - Few CNA C failed to perform hand hygiene when going from dirty to clean during Resident #28's incontinent care. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #28's quarterly MDS assessment, no dated given, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #28's BIM score was an 12 which reveals a moderately impaired cognition. Her active diagnoses included anemia, high blood pressure, and stroke. MDS section, bladder and bowel, reflects that Resident #28 is always incontinent of urine and bowel. Review of Resident #28's care plan dated 10/18/23, reflected, .[NAME] is incontinent of bowel and bladder and is at risk for skin break down and infection Check for incontinence every two hours and prn; clean and dry skin if wet or soiled. Observation on 10/17/23 at 10:34 a.m. revealed CNA C and CNA B entered Resident #28's room, and both did hand hygiene and placed gloves on. CNA C cleaned between the labia front to back. CNA C with same gloves, pulled on draw sheet to help with transfer then CNA B helped roll her. CNA C cleaned both buttocks and in between the buttocks. CNA C pulled out brief and put it directly into the trashcan. CNA C removed gloves and placed new gloves without performing hand hygiene. CNA C placed clean brief under Resident #28. CNA C placed powder into folds and on Resident #28's buttocks and clasped the brief closed. CNA C and CNA B covered her up with her sheet and pulled her up in bed. CNA C and B removed gloves after care was completed and did perform hand hygiene. In an interview on 10/17/23 at 10:45 a.m. CNA C stated that she has been taught to change gloves when going from dirty to clean, but not to do hand hygiene. She stated not doing hand hygiene from dirty to clean can cause infection . In an interview on 10/17/23 at 11:37 a.m. CNA B stated that he has been taught to change gloves and do hand hygiene when going from dirty to clean, to do hand hygiene anytime he changes his gloves, and before and after patient care. He stated not doing hand hygiene from dirty to clean can cause infection. In an interview on 10/19/23 at 10:30 a.m. the DON stated she expected staff to perform hand hygiene when entering a resident's room, anytime they change their gloves, anytime going from contaminated to clean, and before they leave the resident's room. The DON stated she is in charge of training for infection control and the DON does quarterly hand hygiene audits. The DON stated that doing hand hygiene was to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 Review of the facility's policy titled Infection Control, dated November 2017, reflected, .a system for preventing, identifying, reporting, investigating, and controlling infections . Review of the facility's policy titled Handwashing, revised March 2019, reflect, .handwashing is the single most important means of preventing the spread of infection . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676128 If continuation sheet Page 13 of 13