Inspection·July 27, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm three, 3.2 oz. packages of baby food, six, 4 oz. cups of fruit, three sleeves of round crackers, one opened and partially empty 24 oz. bottle of syrup, five, 0.7 sticks of powered orange drink, 20, 3 oz. packages of yogurt, 24, 3.2 oz. packages of applesauce-were all unlabeled and undated. The thermometer inside the nutrition room showed the temperature in the room was 78F. There was no log to record or monitor the temperature of the nutrition room. Residents Affected - Many An interview with the COOK on 07/24/23 at 10:43 am revealed the cups on the tray on the coffee maker were clean and in use. Interview with the AAD on 07/24/23 at 11:10 am revealed she used to work in the kitchen, and she was helping out today because the DS was out with Covid-19 for the last 3 days, and she did not know the dishes were not cleaned. Interview with DA A on 07/24/23 at 11:20 am revealed the residue in the juice glasses was because they were stained from the night before. The DA A stated it (the residue) doesn't come off, even with washing them by hand. The DA A stated the stained juice and milk glasses were like that because they did not have time in the mornings to make the juices and milk and pour them, so they did it the night before around 8:00 pm and the full glasses would sit in the refrigerator overnight. The DA A stated breakfast was at 7:00 am and the kitchen staff came in at 6:00 am. The DA A stated there was no cleaning schedule, and the kitchen staff just does the routine stuff, like mopping, dishes, and wiping things down. An interview with the ADM on 07/24/23 at 11:45 am stated they were now using paper cups, bowls, and glasses because the dishes in the kitchen were unusable. Interview with the DM on 07/25/23 at 10:35 am revealed her turnover was terrible and that she only had 3 employees. The DM stated she was down 2 cooks and 1 dietary aid. The DM stated she soaked the cups, bowls, and glasses with a degreaser and then ran them through the washer. The DM stated the degreaser got the residue off. The DM stated, The cleaning schedule was a check-off type, and it was on her desk when she left last Wednesday (07/19/23) because she was out sick. The DM stated she checked the cleaning schedule every morning to make sure the staff was checking it off. The DM stated the staff knows to check off their duties. The duties did not get done since she went home Wednesday (07/19/23) because she had left it on her desk. They do their daily thing-cooking, temperature logs, trash cans, sweeping, and mopping. The DM stated this morning when she returned to work, she cleaned the steam table. The DM stated she did in-services with them (kitchen staff) when she finds the staff not doing their duties. The last in-services were last month. The DM stated the RD wrote on her last visit for maintenance to take care of the air vent, but they did not. The DM stated she (herself) put it into the electronic maintenance log to get it (the air vent) cleaned last month. She stated there was no water softener at the facility. She stated the COOK knew to soak the dishes because she's the cook. She stated it was the dietary aids' job to make sure the dishes were clean. She stated the other aides trained the new aides. She stated she trained the cooks and the aides. She stated she did not have a guide to use for training. She stated she looked at the chemical and temperature logs. She stated, She looked at the logs today and found the dietary aid had not taken the temperatures of the milk, coffee, and food, so she did it herself. She stated, It was important to make sure food and milk were not in the danger zone for hot food, milk 41F, cold food 40F and under, coffee can't too hot. It should be at 151F or 152F because we don't want to run the risk of the residents burning themselves. Besides taking care of things herself, she did a lot of hands-on training that might stick (stay in their heads/remember) for a couple of days. She stated there were no posters or reminders for staff to look at for guidance when she was not there, other than the cleaning schedule. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 2 of 6 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robstown Nursing and Rehabilitation Center 603 E Ave J Robstown, TX 78380 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated if she was not there, the staff did not do the regular cleaning. The DM stated she had an in-service this morning on sanitation. She stated, For someone coming off the street, it can be overwhelming to learn. An interview with DA B on 07/25/23 at 4:50 pm revealed she had been employed at the facility for over a year and her training consisted of 3 days, where she mostly just watched, then she was shadowed for another 2 days, she had an in-service today about sanitation on the cups. An interview with the ADM on 07/26/23 at 02:24 pm revealed she knew the formula (for tube feedings) did not need to be labeled, but the residents' drinks and snacks, she thought they had the names on the boxes. The ADM stated it was required to have their (resident's) names and dates on drinks and snacks the residents kept in the nutrition room. The ADM stated staff were responsible for labeling the items in the nutrition room-whoever took in the item should have labeled it before it ever reached the nutrition room. The ADM stated labeling items was important because the items were the property of the residents and you wouldn't want to give a resident someone else's drinks or snack because that resident might get sick. The ADM stated the nutrition room should be cooler than it was because the heat could ruin the items in there. The ADM was asked to provide policies for nutrition room temperatures and storage. In an observation and interview with DA B on 07/26/23 at 04:45 pm revealed a partially full 16 oz. bottle of soda on the prep table, next to the steam table. The dishes with residue were cleaner but still had residue on the insides of them. The steam table still had scaling and redness in them. DA B stated she soaked the dishes in the sanitation side of the 3-compartment sink for 15 minutes. DA B stated she did not know what the chemical was in the 3-compartment sink. DA B stated the cups still looked bad. DA B stated the bottle of soda belonged to the COOK, who was Spanish speaking only. DA B stated the COOK knowa a little English, and they do the best they can to communicate. The only Daily Cleaning schedule provided, posted, and checked off in the kitchen was dated 07/24/23 and 07/25/23. DA B stated they don't really go by the cleaning schedule-they just clean whatever looked like needed to be cleaned-they sweep and mop and wipe down the prep tables. Interview and observation of the nutrition room with the AMS on 07/27/23 at 1:50 pm revealed The temperature in the nutrition room should be at 72F. Upon entering the nutrition room, the AMS stated, It's hot in here-there should be air conditioning in here, and stated the thermometer showed 79F. The AMS stated, It should be cooler because the cans of soda could burst or the snacks could melt and be ruined and they belong to the residents. A record review of the electronic maintenance log documented the vent in the kitchen was cleaned and the filter changed monthly on 04/28/23, 05/05/23, and 06/14/23. There was no documentation that the request for cleaning was made last month by the DM, or the RD. A record review of In-Services for kitchen staff documented: 01/04/23 Food Handling on Tray Line, 02/08/23 Temperature Logging, 03/10/23 Foods and Meat Textures, Dialysis Sack Lunch, Thicken Liquids, 03/21/23 Handling Leftovers, 04/05/23 Menu Substitution Guide, 04/06/23 Shelf-Life, 04/19/23 Communication Slips, 04/24/23 Auto-Chlor, Janitor Closet Dispenser, 05/31/23 Disposal, 06/08/23 Infection Control-Sanitizing dining room tables. There was no in-service dated 07/25/23. The facility did not provide policies for nutrition room temperatures or storage after being asked for them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 3 of 6 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robstown Nursing and Rehabilitation Center 603 E Ave J Robstown, TX 78380 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 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 one (R#200) of five residents reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure CNA A performed hand hygiene and changed gloves prior to perineal care and after touching multiple surfaces. 2. The facility failed to ensure dietary staff immediately exited the facility after testing positive for COVID-19. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: 1. Record review of Resident #200's Face Sheet, dated 07/27/2023, revealed the resident was originally admitted to the facility on [DATE]. Resident #200 was a [AGE] year-old female with diagnoses which included: Alzheimer's (degenerative cognition), muscle weakness, difficulty walking, anxiety, hypertension (high blood pressure). Record review of Resident #200's MDS assessment dated [DATE] documented a 6 out of 15 BIMS score which indicated severe cognitive impairment. The MDS also revelaed Resident #200 required extensive dependency of staff to assist in activities of daily living. Resident #200 was coded for always incontinent. Record review of Resident #200's Comprehensive Care Plan date initiated 05/09/2023 and revised 05/23/2023 stated, Focus: Resident #200 has bladder incontinence r/t Alzheimer's. Goal: Resident #200 will remain free from skin breakdown due to incontinence and brief use through review date. Interventions: brief use: Resident #200 uses disposable briefs. Change frequently. Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Incontinent: check frequently for incontinence. During an observation on 07/26/23 at 04:28 PM Resident #200 granted consent to perform perineal care. CNA A began by washing her hands for 28 seconds. CNA A continued by applying clean gloves and retrieved supplies. With the initial pair of clean gloves CNA A touched Resident #200's bed controls, call light, and removed Resident #200's pants and visibly soiled brief. CNA A continued by retrieving multiple clean wipes, and with the initial pair of gloves commenced the perineal care. CNA A proceeded to turn Resident #200 by grabbing the residents left leg, and in a pushing motion, turned the resident to the right side. CNA A continued to clean the gluteal excrement using the same initial pair of visibly soiled gloves. CNA A did perform hand hygiene for 43seconds after perineal care. During interview on 07/26/2023 at 4:42 PM with CNA A, inquired about the procedural steps taken on Resident #200's perineal care. CNA A stated she should have removed her contaminated gloves, performed hand hygiene, and applied new gloves prior to perineal care. CNA A stated she was nervous and it slipped her mind. CNA A stated once she was done cleaning the perineum area, she should have removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 4 of 6 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robstown Nursing and Rehabilitation Center 603 E Ave J Robstown, TX 78380 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 her dirty gloves, performed hand hygiene, and applied a new pair of gloves prior to turning R#200. CNA A stated by performing hand hygiene followed by applying a new set of clean gloves before performing rectum cleaning care, would be a preventative measure to promote infection control and minimize potential of cross contamination. CNA A stated by touching the bed control, call light, Resident #200's pants and soiled brief, followed then by Resident#200's perineal area, may have exposed the resident to infectious microorganisms. CNA A stated she was in serviced about infection control and hand hygiene two weeks ago but was nervous and forgot her training. During interview on 07/26/2023 at 5:12 PM with the DON, she stated prior to the commencement of perineal care, CNA A should have performed hand hygiene after touching the multiple surfaces as a preventative measure to assist in infection control. The DON stated CNA A potentially exposed Resident #200 to infectious microorganisms and the potential spread of bacteria. The DON stated if a resident contracts an infection, the infection could lead to a severe urinary tract infection or worse confusion. The DON stated the reasoning as to why these specific steps were necessitated was to minimize risk of infection. The DON stated it was standard of practice to clean from cleanest to dirtiest. The DON stated she followed CDC recommendations and it was not necessary for CNA A to change gloves from moving from the perineum area to buttock area. The DON stated she facilitated an in-service on perineal/incontinent care June 2023. The DON stated she conducted in-services and skill checkoffs upon hire, annually and as needed. The DON stated each skill check off was focused on infection control. Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, last reviewed January 8, 2021 indicated Healthcare providers should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Record Review of the facility's Hand Hygiene Policy, dated 10/24/22 indicated: .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. (Table was not presented upon request) 6. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 2. During an interview on 7/24/2023 at 1:45 PM with the Complainant #1 revealed dietary staff tested positive for COVID-19 and was required to finish preparing breakfast at the facility. During an observation and interview on 7/25/2023 at 10:45 AM, dietary staff C said she tested herself for COVID-19 on 7/19/2023 between 5:20 AM and 5:40 AM. She said she called the administrator and sent a photo of the positive test. She said it was about 7:00 AM when she talked to the administrator, and she left the facility after breakfast was served at about 8:10 AM. Dietary staff A exhibited signs of infection such as cold sweats. Dietary staff C wore a mask. During an interview with the DON on 7/25/2023 at 12:30 PM, she said she sent dietary staff C home (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 5 of 6 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robstown Nursing and Rehabilitation Center 603 E Ave J Robstown, TX 78380 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 after 10:45 AM. The DON said dietary staff C did not have a fever but had a dry cough. The DON said that Dietary staff C had tested negative for COVID-19. The DON said she could tell there was something else going on with her and did not need to assess her further based on what dietary staff C told her. During an interview with the Administrator on 7/25/2023 at 1:00 PM she said staff who didn't feel well needed to call in and let the facility know. The administrator said she would like a four-hour notice, or the earliest possible. The administrator said she could not find anyone to come in, so dietary staff C remained in the facility. The administrator said she kept dietary staff C at the facility, preparing breakfast for the residents, until a replacement was available around 8:10 AM. During an interview with the Administrator on 7/27/2023 at 2:45 PM, she said she arrived at the facility on or/about 7:20 AM - 7:30 AM on 7/19/2023. The administrator said she did not punch in. The administrator said she saw dietary staff C and told her a replacement staff was coming. The administrator said she was in a hurry and did not tell dietary staff C to leave. The administrator said dietary staff C should have known to leave. The administrator said she should have told dietary staff A to leave. During an interview with LVN B on 7/27/2023 at 3:05 PM, she said she was shown Dietary staff C's positive COVID-19 test, and told Dietary staff C she needed to leave immediately and to call the administrator from the car on the way home. LVN B said Dietary staff C needed to leave immediately because she was covid-19 positive. Dietary staff C was in her office when LVN B told her to leave. LVN B said she told dietary staff C to leave because she didn't want to be exposed to covid. LVN B said dietary staff C said she would leave but did not. During an interview with Dietary Staff C on 7/25/2023 at 10:45 AM she said she did not leave because there was no one else there. During an interview with the DON on 7/27/2023 at 3:45 PM, she said the facility did in-services in the past that would indicate staff were supposed to alert the administrator if staff showed signs or symptoms of COVID-19. The DON stated dietary staff C should have left when she tested positive. Record review of the facility's COVID-19 emergency preparedness plan reflected: CMS Centers for Clinical Standards and Quality. Safety and Oversight Group (3/20/2022) Ref: QsO-20-14-NH Page 4 of 7: Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should: Immediately stop work, put on a face mask, and self-isolate at home. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 6 of 6