Inspection·October 10, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #48's order summary reflected an active order dated 10/04/24 for Low Air loss mattress with Bolster. Record review of Resident #48's most recent fall risk evaluation dated 08/20/24 reflected Resident #48 scored a 10 (High Risk). Residents Affected - Few During an observation on 10/08/24 at 9:55 AM, Resident #48's bed was not in the lowest position and no fall mats were in place at the sides of her bed. During an interview with the RP of Resident #48 on 10/08/24 at 9:55 AM, the RP stated Resident #48 had only fallen once approximately 6 months ago since she had been at the facility. The RP stated there used to be fall mats in place at Resident #48's bedside. The RP stated he was always included in care plan meetings, but that he did not remember them discussing specifics on how to keep Resident #48 safe in case of falls. During an observation on 10/10/24 at 8:42 AM, Resident #48's bed was not in the lowest position and no fall mats were in place at the sides of her bed. During an interview with LVN A on 10/10/24 at 8:53 AM, LVN A stated she was currently the nurse in charge of hall 100, the hall that Resident #48 resided on. LVN A stated she had only been working at the facility for a week. LVN A stated she was not aware Resident #48 had a fall in the past. LVN A stated a score of 7 or above on the fall risk assessment indicated a high risk. LVN A stated if a resident was high risk, she would put their bed in the lowest position and put fall mats in place at the sides of the resident's bed. LVN A stated based on Resident #48's fall risk assessment, she should have fall mats and her bed placed in the lowest position. LVN A stated Resident #48 was at a higher risk of fractures and head injuries because she did not have these precautions. During an interview with the ADON on 10/10/24 at 9:06 AM, the ADON stated a score of 10 or greater on the fall risk assessment indicated a high risk. The ADON stated they do individualized care at the facility, and just because a resident was indicated as high risk on their fall assessment, does not mean fall mats and lowering the bed to the lowest position were necessary. The ADON stated Resident #48 had an air mattress with bolsters on the sides to help prevent her from falling out of bed. The ADON stated Resident #48 had fall mats in place after her fall on 03/07/24, but that the IDT team decided they were unnecessary and removed them on 09/30/24. The ADON stated staff knew to lower Resident #48's bed if they saw it in a high position. The ADON stated Resident #48 would raise her bed on her own. The ADON stated she thought it was highly unlikely Resident #48 would fall again. During an interview with the DON on 10/10/24 at 9:10 AM, the DON stated a score of 10 or greater on the fall risk assessment indicated a high risk. The DON stated Resident #48 had bolsters on her air mattress, which helped to prevent a fall. The DON stated the fall mats were in place after Resident #48's initial fall, but they were removed on 09/30/24 after the IDT team decided they were unnecessary. The DON stated Resident #48's previous fall was an isolated incident. The DON stated staff knew to lower Resident #48's bed if it was too high. The DON stated they review and revise care plans quarterly and as needed. The DON stated they in-service as much of the nursing staff as possible after every fall. The DON stated if a nurse was not aware of an intervention implemented on behalf of a resident, it would be harder for the nurse to care for that resident. Record review of the facility policy titled Comprehensive Care Plans dated 10/24/22 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 0656 3. The comprehensive care plan will describe, at a minimum, the following: Level of Harm - Minimal harm or potential for actual harm a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to maintain the floors safely. The facility failed to ensure utensils were clean and sanitized. The facility failed to ensure dishes were clean and sanitary. The facility failed to ensure juice guns were maintained and sanitary. The facility failed to ensure ingredients were not left open to air. The facility failed to ensure food in the refrigerator was not expired. The facility failed to ensure food in the dry storage area was properly covered. The facility failed to ensure food in the freezer was properly packaged. The facility failed to ensure equipment was maintained and sanitary. These failures could place residents at risk of foodborne illnesses. Findings included: An observation of the kitchen on 08/24 at 8:52 AM revealed the following: The floors were wet and slippery. A large spatula on the puree machine had broken edges on all sides. There were 71 plastic drinking glasses with heavy white residue on the bottoms and insides. There were 13 plastic coffee cups with white residue, dark brown stains, and scratches on the insides. Two of the coffee cups were on the cart for serving residents, and the rest were on the clean racks. One of the coffee cups had a gel-like substance on the inside. There were 21 plastic bowls with residue and/or food particles on the insides and deep scratches on the bottoms. 2 of 2 juice guns were soaking in a bucket of a cloudy brown liquid. The inside of the heads had a removable black substance around them. Inside the ice machine there was a removable brownish substance on the ice chute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 There was an uncovered Styrofoam bowl on a prep table with a white powered substance. The bowl was uncovered and had discolored clumps in it and a small scoop. Level of Harm - Minimal harm or potential for actual harm A partially filled 5-liter container in the refrigerator labeled pudding had a use-by date of 10/01/24. Residents Affected - Some There were 5 bowls of dry cereal on a tray in the dry storage that were not properly covered. There was a partially filled box of sugar frozen cookie dough in the freezer open to air. There were 4, 4-oz. Individual containers labeled vanilla ice cream in the freezer with what appeared to be melted contents on the tops of the containers. The can opener was crusted with filth. The DA/DW was observed dumping dirty plastic glasses, bowls, and coffee cups from the trays on the clean racks into the rinse water of the 3-compartment sink. Observation of the kitchen on 10/10/24 at 2:05 PM revealed lids for Styrofoam cups were in the dry storage area in 4 different sizes and had lids to fit all sizes. In an interview with the DA/DW on 10/08/24 at 9:05 AM, he said he was the dishwasher today and it was his responsibility to check the dishes for cleanliness before they were used. He said the plastic cups, drinking glasses and bowls were on the clean rack, ready for use. He said he did not know what the white residue was inside the plastic drinking glasses, coffee cups, and bowls. He said the kitchen staff used the spatula with the broken edges daily in the puree, and said, It (the spatula) was fine. He said the juice guns were cleaned every day. He said he did not know what they were soaking in and he did not put them in there. He said, I would drink from the glasses. I don't know what the problem is. I don't sit there and look at everything, I just do my job. He said the FSM was out today. In an interview with the cook on 10/08/24 at 9:10 AM, she said the uncovered bowl of white powder was thickener. She said it had been open to air for about two hours. She said she did not know what the clumping came from, then placed another bowl upside down on top of it with the scoop still inside. In an interview with the FSM on 10/10/24 01:18 PM, she said the ADM told her about the juice guns. She said the guy from the juice gun company was replacing them now. She said she told the DA/DW not to soak the juice guns in water the way he was, with no sanitation. She said kitchen staff soaked the plastic dishes daily. She said she spoke with the water people about getting a water softener. She said kitchen staff would have to physically scrub the glasses to remove the residue and that would take a whole person all day. She said the scratches in the coffee cups and bowls could harbor food and bacteria and make the residents ill. She said of the scratches in the coffee cups and bowls there could be loose plastic, and the residents could ingest it. She said the facility ordered new ones. She said the brand-new spatula came with the new puree machine. She said the spatula could split and fall into the food and plastic bits could be ingested by the residents and cause illness. She said the cooks were responsible for overseeing damaged equipment to let her know so she could replace it. She said she cleaned the can opener and it should not be rusted. She said she was ordering a new one because it was rusted. She said the ice machine was supposed to be wiped down daily. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 - Some vent to the ice machine was left off by the maintenance man. It was on top, and he replaced it yesterday afternoon. She said the vent covering and filter fell off frequently and daily because it was held on by velcro, even though there were screw holes. She said the ice machine vent cover and filter had been that way for several weeks. She said the process for using thickener was to follow the manufacturer directions that were printed on the box for whatever needed to be thickened. The bowl by the prep table should not have been there. She said the use by date on the pudding had 3 days from the date on the item to use it by and it was expired. She said the bowls of cereal were not covered properly-they had the right size lids. She said the DA was responsible for fitting the proper lids to the cups and bowls. In an interview with the MS on 10/10/24 at 2:08 PM, he said the process of maintenance needs for the kitchen was that he did almost daily walk throughs and sometimes received them verbally. He said maintenance requests were normally generated by the facility electronic maintenance request system for staff to enter. He said the vent on the ice machine covered the filter for the ice machine. He said he used the Velco system for about 3 months and every couple of days, if not more, it would fall off and he would find it on top of the ice machine. He said without the cover and filter, the condenser and fan could get dirty. He said cross contamination could occur and get something in the food because someone would have to pick it up during food service and put it on top of the machine because it was right there near the stove. In an interview with the ADM on 10/10/24 at 5:14 PM, she said she was having the water company come out and look into a water softener. She said she ordered 2 cases of new plastic cups & bowls. She said she was hiring a new DM and educating and revamping the process and systems of the kitchen to make sure they were followed. She said she did not know any of this was going on in the kitchen because she expected the leadership there to do better. Record review of the daily cleaning log dated 09/01/24 - 09/30/24 revealed the following: The ice scoop and container, knife rack, other equipment, garbage, range and grill, steam table, and storeroom were not cleaned on 09/07/24. The microwave, other equipment, range and grill, refrigerator, freezer, and cooler were not cleaned on 09/17/24. Cutting boards and other equipment were not cleaned on 09/18/2024. The coffee machine, cutting boards, dish machine, garbage, ice scoop and container, juice machine, knife rack, microwave, other equipment, and sinks and faucets were not cleaned on 09/19/24. Other equipment was not cleaned on 09/20, 09/21, and 09/22/24. The coffee machine, cutting boards, knife rack, and ice scoop and container were not cleaned on 09/27, and 09/28/24. None of the 21 items listed on the daily cleaning schedule were initialed on 09/29/24. Further review revealed the initials on the daily cleaning schedule appeared to be written by the same hand. There were no other cleaning schedules provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 Record review of kitchen in-services revealed the following: Level of Harm - Minimal harm or potential for actual harm 05/04/24-sanitation; all dietary staff will complete their daily cleaning schedule before leaving their shift. All dietary staff will sign off on all daily and monthly cleaning schedule. FSM will check for completion of these duties daily. Any infractions of not doing these duties will lead to one-on-one or disciplinary actions. Labeling and dating-all dietary staff will label and date any leftover foods daily. All foods will be discarded in 2 days. Any boxes of food that have been opened and resealed has to have the date it was opened. Daily Cleaning Duties-all staff are required to sweep & mop at end of each shift. If you drop something, pick it up, make sure handwashing sink is kept clean .Infection control-On serving line, nothing that has left the kitchen such as coffee cups, water mugs, plates, silverware, etc. Will be placed with dirty equipment to be washed and replace with clean when asked for. Residents Affected - Some 06/07/24-Cleaning schedule-All dietary staff will complete cleaning schedule and initial on log that it has been done daily. Failure to do so will lead to one-on-one or interdisciplinary action. 07/02/24-Covered foods for hallways, Garbage disposal, Snack Carts. 09/16/24-Hot beverage service. 10/10/24- Juice machine and guns; juice machine will be cleaned every shift and juice guns cleaned with hot water and scrubbed with brush. Guns will not be left in water in container after cleaning. Guns will be placed in clean gun holder after cleaning, Wet Floors; all dietary staff will mop up any spills which will cause floors to be slippery. When racking all dishes they need to be racked over 3-compartment sinks to prevent spillage of any liquids. Floors are to remain dry at all times. Record review of the facility policy titled, Manual Cleaning and Sanitization of Utensils and Portable Equipment dated October, 1, 2018 revealed under Policy: The facility will follow the cleaning and sanitization requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Under Procedure: 5. Prior to washing, pre-flush or pre-scrape all equipment and multi-use utensils. When necessary, presoak to remove gross food particles and soil. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment. Record review of the FDA Food Code 2022 Ch. 4, part 4-2, subpart 4-201, Section 4-201.11 Equipment and Utensils. Equipment and utensils shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 4-202 Cleanability 4-202.11 Food contact surfaces (A) Multiuse food-contact surfaces shall be: (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections 4-602 Frequency4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. 3-6 Food Identity, Presentation, and On-Premises Labeling 3-601.11 Standards of Identity. Packaged Food shall comply with standard of identity requirements in 21 CFR 131-169 and 9 CFR 319 Definitions and standards of identity or composition, and the general requirements in 21 CFR 130 - Food Standards: General and 9 CFR 319 Subpart A- General. 3-602 Labeling (A) Food packaged in a food establishment, shall be labeled as specified in law, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 marking devices, and containers. (B) Label information shall include: (1)The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to provide the required 80 square foot per resident in 47 of 47 multiple resident rooms numbers (101, 102, 103, 104, 105, 106, 107, 108, 109, 203, 204, 205, 206, 207, 208, 209, 210, 301, 302, 303, 304, 305, 306, 307, 401, 403, 404, 405, 406, 407, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 600, 601, 602, 604, 606, 608, and 609). The facility failed to provide 80 square feet per resident in 47 shared resident rooms. This failure could affect residents who resided in the facility and could result in inadequate space for resident's activities of daily living in their rooms. Findings included: During an interview with the Administrator on 10/08/24 at 9:30 AM, the Administrator stated she wanted to apply for a room waiver again this year. The Administrator stated there had been no changes to room sizes since the last survey. The Administrator stated all their resident rooms were under 160 square feet. Review of annual surveys revealed the square footage of 20 sampled room measurements were as followed: 102 - 154.9 103 - 153.3 104 - 151.1 105 - 148.7 204 - 153.6 205 - 153.3 206 - 153.5 208 - 152.9 301 - 151.7 302 - 151.0 404 - 154.3 407 - 151.9 503 - 155.1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 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 455838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 0912 504 - 152.5 Level of Harm - Potential for minimal harm 507 - 154.6 508 - 152.8 Residents Affected - Many 602 - 154.0 604 - 153.8 608 - 154.2 609 - 153.8 Record review of the facility Bed Classification form dated 10/08/24 revealed all resident rooms were certified as rooms for 2 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455838 If continuation sheet Page 10 of 10