Inspection·November 8, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some station was dirty with food crumbs near clean dishes/utensils, an open bottle of lemon juice undated, and the storage under the prep area has a black greasy substance where the clean pots and lids were kept. 6. Warmer #1 had trays inside with a dried leftover substance, and under the warmer was a piece of chicken. Behind the stove was a drinking cup, a fryer basket, food container, some plastic wrap and a bottle of lemon juice with no date covered in a greasy substance. In an observation and interview on 11/5/24 at 9:28 AM Dietary Aide A was washing and removing dishes from dish machine then putting them up in the clean part of the kitchen storage. He stated that he or his coworkers check the dish machine several times a day and document on the log . He was unable to voice what proper chlorine sanitization level should read when using test strips. In an observation and interview on 11/5/24 at 9:31 AM Dietary Manager tested the chlorine sanitizer level in the low temperature dish machine which read at a level of 25 parts per million. The Dietary Manger stated this level was not the correct level and should read between 50-100 parts per million when tested. She further stated that lack of proper chlorine sanitization level could lead to sickness. She also stated that she and her staff would review the dishes that were washed at this level and re-wash them. In an interview on 11/7/24 at 7:18pm the Dietary Manager stated the following regarding kitchen cleanliness and sanitation, We have already started cleaning. I told them(kitchen staff) we need a schedule and have put one in place for housekeeping to do the floors once a month. We do have a cleaning schedule, but they are so new that they just do at it if you know what I mean. I told my Assistant Dietary Manager that we must hold them accountable. She stated that an adverse outcome of unclean kitchen could cause bugs or sickness.Facility policies and procedures for food storage and cleaning schedules were requested on 11/7/24 at 7:18 PM from Dietary Manager, but not provided. Record review of the policy Equipment Cleaning Procedures revised 1/2013 revealed the following [in-part]: Policy: It is the policy of this facility that all dietary equipment and environment are cleaned and sanitized in a manner that meets local(if applicable), state, and federal regulations. Fundamental Information: Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning is the practice of removing soil and dirt with an approved cleaning agent . Cleaning Frequency: Daily: Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily. Record review of the policy Ware Washing revised 5/2012 revealed the following [in-part]: Policy: The purpose of ware washing is to clean and sanitize utensils and equipment used during the preparation and service of food from the dietary department. Proper ware washing is an essential component m the prevention of food borne illnesses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455849 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 455849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230 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 Procedure: Level of Harm - Minimal harm or potential for actual harm The following temperature and sanitizer strength will be followed: 2. Low temperature Dish Machines Residents Affected - Some b. chemical: Chlorine sanitizer= 50ppm (parts per million) Quat sanitizer= 200ppm (or according to manufacturer's instructions) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455849 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 455849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230 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 to help prevent the development and transmission of communicable disease and infections for one (Resident #10) of three residents reviewed for infection control practices. Residents Affected - Few CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #10's face sheet dated 11/08/23, revealed an 82- year- old female admitted to the facility on [DATE] with diagnoses including personal history of Covid-19, cutaneous abscess of perineum, constipation, reduced mobility, and Alzheimer's disease. Review of Resident #10's MDS assessment dated [DATE] revealed Resident #10 required substantial/maximal assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #10 was always incontinent of bowel and bladder. Review of Resident #10's Care Plan dated 03/26/23 revealed Resident #10 is incontinent of bowel and bladder related to loss of control/muscle tone, impaired mobility. Observation of incontinence care for Resident #10 on 11/06/24 at 2:30 p.m. revealed CNA A did not wash her hands prior to donning gloves. She retrieved the resident's clean brief and placed it near the soiled brief. Resident #10's brief was soiled with fecal matter. CNA A wiped the resident from front to back. She made 5 strokes of clean with the same soiled wipes. CNA A did not change her gloves and continued to clean Resident #10. She used the same soiled gloves to apply skin protector on Resident #10. CNA A's gloves were visibly soiled with fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before putting Resident #10's clean brief and placing it underneath the resident. She removed the soiled gloves and fastened the clean brief on Resident #10. CNA A retrieved the trash and walked out of Resident #10's room without washing her hands. In an interview on 11/06/24 at 2:41 p.m. with CNA A, she said she should have washed her hands before starting care and changed her gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #10. CNA A stated she has been in the facility since August 2024 and had infection control training last month. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. CNA A added she did not follow standard precautions and good infection practice because she was nervous. During an interview with the DON on 11/08/24 at 10:17 a.m., she stated she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility's protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. The DON explained she was the infection preventionist responsible for training staff and monitoring infection control practices. She stated she monitors the staff by conducting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455849 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 455849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230 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 in-services. The DON added the staff receive infection control training annually and in-services at least once a month. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Hand hygiene policy revised 02/11/22 reflected: Residents Affected - Few Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455849 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 455849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230 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 f. Use clean towel to turn off the faucet. 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: 455849 If continuation sheet Page 6 of 6