Health inspection·September 9, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 9/9/2025 at 1:45 PM, the ADON said the nurses were responsible for checking the medication room daily for expired medications. She said medications should have an open date when they were opened such as vaccines or insulin. She said if there were not any open dates on medications, residents could get sick from taking medications that could be ineffective. She said insulin pens were good for 28 or 29 days and then should be discarded depending on the brand once opened. She said TB was good for 30 days once it was opened and should have an open date when accessed. During an interview on 9/9/2025 at 1:49 PM, the DON said the nurses were responsible for checking the medication room daily. She said medications should have open dates such as insulin and vaccines. She said insulin was good for 28 days once opened and TB was good for 30 days and then should be discarded. She said if residents took medications that were given past their dates, they could be ineffective. She said she planned to in-service the nursing staff on medication storage with vaccines and insulins. She said she would monitor to make sure medications were dated and removed it they were supposed to be. During an interview on 9/9/2025 at 1:54 PM, the Administrator said the nurses were responsible for checking the medication rooms. She said if residents were given medications that were not labeled with an open date, the medications given might not be effective. She said she expected her staff to check the medications and label them with open dates to make sure the medications were not expired.Record review of a package insert for aplisol (tuberculin) undated indicated, .aplisol vials in use more than 30 days should be discarded .Record review of a package insert for insulin lispro undated indicated, .16.2 Storage and Handling-In-use insulin lispro and insulin lispro Kwik pens must be used within 28 days or be discarded, even if they still contain insulin lispro.Record review of a facility policy titled Storage of Medications revised 8/2020 indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 3. Expiration Dating (Beyond-Use Dating) 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. b. If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility-specific policy . Event ID: Facility ID: 676172 If continuation sheet Page 2 of 5 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 09/09/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements.The facility did not ensure the arbitration agreement granted the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing.This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included:Record review of an Arbitration Agreement dated November 2024 indicated the agreement did not grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing.During an interview on 9/9/25 at 9:17 am Administrator said she was responsible for the arbitration agreements, and she had not had anyone enter into a binding agreement. She said it was something new for her since the facility was under new ownership since December of last year. She said she was not aware of the requirements of the arbitration agreement. She said the agreement was supplied by corporate office and she would have it corrected. She said the facility did not have a policy regarding arbitration agreements. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676172 If continuation sheet Page 3 of 5 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 09/09/2025 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 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 reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident's #14) and 2 of 4 staff (CNA A and NA B) reviewed for infection control. The facility failed to ensure CNA A and NA B performed hand hygiene and observed EBP by not following the instructions on the posted signage on Resident #14's door requiring the use of gown and gloves when providing care to Resident #14 on 9/08/25 and did not clarify with nursing staff when there was no PPE bin. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: Record review of Resident #14's facility face sheet dated 09/09/25 revealed Resident #14 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of diabetes.Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 15 indicating intact cognition and was always incontinent and was dependent on staff for toileting. Record review of Resident #14's comprehensive care plan dated 9/9/2024 revealed Resident #14 had an ADL Self Care Performance Deficit and required staff times two for toileting assistance.During an observation on 09/08/25 at 9:50 AM Resident #14 had a sign on her door for EBP indicating gloves and a gown were required for care.During an observation on 09/08/25 at 2:07 PM CNA A and NA B performed incontinent care to Resident #14. Neither performed hand hygiene before applying gloves nor placed PPE for EBP. CNA A opened Resident #14's brief and cleaned front to back using wipes. NA B assisted resident to right side and Resident #14's buttocks, and peri area were cleaned with wipes front to back by CNA A. The soiled brief was removed by CNA A. Using the same soiled gloves a clean brief was applied by CNA A, and Resident #14 was rolled back to her left side and brief secured. The linen and bed were repositioned by CNA A wearing the same soiled gloves. Both removed their gloves, placed them in a bag and left the room without performing hand hygiene. During an interview on 09/08/25 at 2:12 pm CNA A said she had started at the facility a week ago but had been a CNA for many years. She said she should have performed hand hygiene when she entered the room, between soiled and clean task and before leaving the room. She said she was nervous. She said she did not see the sign on the door and there was no cart by the door, so she was not aware the resident required EBP. She said when a resident required EBP you were to wear gloves and a gown with care. She said by not following infection control infections could spread. During an interview on 09/08/25 at 2:18 pm NA B said she saw the sign for EBP but there was not a PPE cart outside the door, so she proceeded without asking. She said she should have applied PPE and performed hand hygiene when she entered the room and before leaving the room. She said not following the infection control procedures infections could spread. During an interview on 09/08/25 at 2:44 PM LVN C said that Resident #14 was no longer on EBP, and the PPE was removed but not the sign. She said the staff should still recognize the sign and follow the guideline or ask before providing care. She said not following EBP could cause infections to spread. During an interview on 09/09/25 at 1:45 pm the DON said she was the infection prevention nurse and responsible for the oversight of the infection control program. She said all staff were trained on infection control measures including hand hygiene and EBP on hire and annually and she monitors randomly as needed to ensure the staff were following the program. She said that not following the infection control program could possibly cause transmission of infections. During an interview on 09/09/25 at 1:50 pm the Administrator said the DON was responsible for the infection control program. She said the staff were monitored randomly but trained on hire and annually. She said she expected all staff to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676172 If continuation sheet Page 4 of 5 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 09/09/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete follow the infection control protocols to prevent the spread of infections in the facility. Record review of CNA proficiency Audit dated 4/28/25 indicated NA B successfully completed skills for infection control for hand hygiene, incontinent care and infection control practices. Record review of CNA proficiency Audit dated 9/02/25 indicated CNA A successfully completed skills for infection control for hand hygiene, incontinent care and infection control practices. Record review an undated facility policy titled Perineal Care indicated, .1. place equipment on the bedside table, 2. wash and dry hands, 7. put on gloves, 10. remove gloves, 11. wash and dry hands .Record review of a facility policy titled Handwashing/Hand Hygiene dated October 2023 indicated, .hand hygiene is the primary means to prevent the spread of infections. Indications for Hand Hygiene: 1. a. immediately before touching a resident, d. after touching a resident, immediately after glove removal .Record review of a facility policy titled Enhanced Barrier Precautions dated 4/1/24 indicated, .1. Prompt recognition of need: a. all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. c. the facility will have discretion on how to communicate which residents require EBP as long as the staff are aware of which residents require EBP . Event ID: Facility ID: 676172 If continuation sheet Page 5 of 5