Inspection·August 7, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm UA revealed quite significant pyuria with urine cultures growing out an ESBL producing E. coli. ad .Assessment and Plan of Treatment: UTI with an ESBL producing gram-negative rod Record review of Resident #5's electronic medical record dashboard on 8/6/24 indicated that she had enhanced barrier precautions. Residents Affected - Few Record review of an undated list of residents on enhanced barrier precautions provided by the DON indicated that Resident #5 was not on the list. During an observation on 8/5/24 at 9:23 a.m., a clear plastic trash bag was noted on the floor in Resident #5's room. It contained what appeared to be a used brief. Residents room did not have signage indicating that she was on enhanced barrier precautions. During an interview on 8/5/24 at 9:26 a.m., LVN B said the trash bag should not have been left in Resident #5's room on the floor. She said residents could be at risk of infection if proper infection control measures were not followed. During an interview on 08/06/24 at 02:15 p.m., CNA A said she had taken care of Resident #5 yesterday morning. She said she had changed her and went to get the barrel and got distracted. She said she had left the trash bag in there and she was upset about it. She said she'd been trained on infection control. She said she would do better in the future. She said she was unaware that resident was to be on EBP until today. She said Resident #5 did not have the sign or PPE there until earlier today. She said it was not there during incontinent care this morning. She said residents could be at risk of developing infections if proper infection control measures were not followed. During an observation on 08/06/24 at 10:05 a.m., CNA A and CNA C were both present in Resident #5's room to provide incontinent care. Both washed their hands in the bathroom and applied gloves. Had supplies set up on an overbed table in the room. CNA C pulled the covers down and opened the resident's brief and placed it between her legs. CNA A rolled the resident onto her right side and CNA C removed the brief and placed it in the trash. CNA C removed her gloves and placed them in the trash and washed her hands. CNA C placed gloves on both hands, placed a towel underneath the resident's buttocks. CNA A placed a towel over the resident to cover her. Both CNAs removed their gloves and placed them in the trash, sanitized their hands and applied gloves. CNA C removed a wipe from the plastic bag and wiped across the lower abdomen and placed the wipe in the trash. CNA C removed another wipe and wiped down the middle of the vagina from front to back and placed the wipe in the trash. CNA C removed another wipe from the plastic bag and wiped both inner thighs and placed the wipe in the trash. CNA C removed her gloves and placed them in the trash, washed her hands and applied gloves. CNA A rolled the resident onto her right side and CNA C removed a wipe from the plastic bag and wiped the resident's rectal area from front to back. CNA C removed the towel that was underneath the resident's buttocks and removed her gloves. CNA C sanitized her hands and put on gloves. CNA C placed a brief and secured it in place. Both repositioned the resident in bed, removed their gloves and washed their hands. During an interview on 8/6/24 at 3:40 p.m., CNA C said they had an in-service some months ago by the Administrator on EBP. She said they were told which residents were on EBP and they also had notes on the resident doors along with PPE in drawers outside of their rooms in the hallways. She said when a resident was on EBP that meant the staff had to wear a gown and gloves while providing incontinent care. She said the residents that were on EBP included Resident #5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676172 If continuation sheet Page 2 of 4 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 676172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groveton Nursing Home 1020 W 1st St Groveton, TX 75845 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 - Few During an interview on 8/6/24 at 3:45 p.m., LVN B said the residents that were on EBP included Resident #5,who was placed on EBP earlier that day. She said anyone with a history of ESBL colonization, anyone with wounds, foley catheters, have MRSA or any opening to the body that could cause infection would be placed on EBP. During a joint interview on 08/07/24 at 11:47 a.m., the DON said that going forward they would review all hospital records when residents come back from hospital and take appropriate actions with MDROs. DON and Administrator said they would be providing education to all the staff, and they would be doing a PIP and QAPI. DON said they would be reviewing CMS guidelines to ensure they follow the appropriate infection control practices. DON said residents could be at risk of an outbreak of proper procedures were not followed. Record review of a CNA Proficiency Audit for CNA A dated 4/16/24 indicated she had been trained on infection control awareness, including universal precautions, with perineal care. Record review of a facility policy titled Enhanced Barrier Precautions undated read: 1. .EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3) .; 2. .Resident status: Colonized with a CDC-targeted MDRO without a chronic wound, indwelling medical device or secretions that are unable to be covered or contained. Use EBP: Yes .; 3. .Donning PPE for Residents on EBP Based on activity provided / assistance while in resident room: providing hygiene .Don gloves and gown: yes .; 4. (from page 3, referenced above) .List of colonized MDRO to utilize EBP: .ESBL-producing Enterobacterales .; 5. .Communication to staff: The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP . Record review of a facility policy titled Perineal Care Female dated 2003, with a revision date of December 8, 2009, read .Closing steps .discard disposables per facility policy . Record review of CMS Memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH read .The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676172 If continuation sheet Page 3 of 4 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 676172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groveton Nursing Home 1020 W 1st St Groveton, TX 75845 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 other epidemiologically important MDRO when contact precautions do not apply . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676172 If continuation sheet Page 4 of 4