Inspection·September 23, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm locked at all times, LVN D did not answer this surveyors question and stated I understand the importance of keeping the medication cart locked at all times. 09/21/22 01:11 PM Record review of the Facility's Medication Carts and Supplies for Administering Medication policy and procedure dated 10/01/19, states; Residents Affected - Some #2. The Medication cart is locked at all times when not in use. #3. Do not leave the medication cart unlocked or unattended in the resident care areas. 09/22/22 01:39 PM Interview with DON revealed, when asked about the facilities policy and procedure for medication carts, DON stated I have only been here for four days, I don't know what the policy states. This surveyor read facility's Policy and Procedure for Medication Carts and Supplies for Administering Medication to DON, line #2, which states, The medication cart is locked at all times when not in use. This surveyor asked DON what at all times meant to her and she stated, at all times when not using medication cart. This surveyor asked, if a nurse is in the medication room away from the medication cart, should it be locked? DON stated, well yeah, when not standing right in front of it and not using it, yeah. Record Review of Policy on Medication Storage dated 10/01/19 Record review of the Facility's Medication Carts and Supplies for Administering Medication Policy and Procedure dated 10/01/19 stated .#2. The Medication cart is locked at all times when not in use. #3. Do not leave the medication cart unlocked or unattended in the resident care areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 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 455974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382 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, including hand hygiene, designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for four Residents (#3, #15, 27, and #54) of 17 residents reviewed for infection control practices during personal care: Residents Affected - Some 1. Certified Medication Aide (CMA) B did not perform hand hygiene after touching various objects in the immediate vicinity, prior to putting on clean gloves, and prior to administering Resident #15 her eyedrops. 2. Licensed Vocational Nurse (LVN) C did not perform hand hygiene between glove changes and did not wash her hands for at least 20 seconds when performing wound care for Resident #3, #27, and #54. These failures could place residents that require assistance with personal care and medication administration at risk for healthcare associated cross-contamination and infections. The findings included: 1. Record review of Resident #15's Face Sheet dated 09/22/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: Unspecified visual loss, glaucoma (damaged nerve connecting the eye to the brain usually due to high eye pressure), dry eyes, and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #15's Quarterly Minimum Data Set, dated [DATE] revealed Resident #15 had severely impaired vision, had clear speech, and had a brief interview of mental status score of 9moderately impaired cognition. Record review of Resident #15's September 2022 Physician Orders documented Dorzolamide HCl Solution 2% (used to treat increased eye pressure), Instill 1 drop in both eyes two times a day for high pressure in eyes; Latanoprost Solution 0.005 % (used to treat increased eye pressure), Instill 1 drop in both eyes one time a day for pressure in eyes. Miacalcin Solution 200 Units (Calcitonin Salmon- used to treat osteporosis), 1 spray alternating nostrils one time a day for osteoarthritis. Odd days use left nare and even days use right nare (nostril). Observation of medication pass on 09/21/22 at 09:29 AM revealed CMA B locked her medication cart using her right hand, knocked on Resident #15's door with her right hand and moved the privacy curtain to the right side with her right hand. CMA B spoon fed Resident #15 her crushed medications then administered Calcitonin-Salmon 200 units nasal spray in Resident #15's left nostril. CMA B retrieved gloves from a box in the wall mount beside the sink, put them on and administered Resident #15 her Dorzolamide HCL 2% eye drops in both eyes, without performing hand hygiene. At 9:36 PM, CMA B knocked on Resident #15's door with her right hand, moved the privacy curtain to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 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 455974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382 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 - Some the side with her right hand, retrieved gloves from the wall mount, put the gloves on, and administered Resident #15's Latanoprost 0.005% to both eyes, without performing any hand hygiene. Interview with CMA B on 09/21/22 at 09:39 AM revealed she said she should have washed her hands before putting on her gloves and administering Resident #15 her eye drops but forgot. CMA B said it was important to perform hand hygiene before administering eye drops to prevent cross contamination and possibly infection. 2.) Resident #3 Record review of Resident #3's Face Sheet dated 09/23/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: Dementia, cerebral infarction (stroke), diabetes mellitus (high blood sugar), left hip replacement surgery. Record review of Resident #3's Quarterly Minimum Data Set, dated [DATE] revealed she had a brief interview of mental status score of 4- severe cognitive impairment, usually made self understood and usually understood others. Resident #3 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #3 was at risk for pressure ulcer development. No pressure ulcers documented at the time of this assessment. Record review of Resident #3's Physician Orders dated September 2022 documented Clean surgical site left hip with normal saline, pat dry with 4x4 gauze, apply Calcium Alginate (debriding treatment for wound healing) dressing, cover with optifoam dressing. Observation on 09/22/22 at 09:17 AM revealed Resident #3 was lying in bed on her right side with her eyes closed. LVN C stood outside of Resident #3's room and gathered supplies for wound care. At 9:24 AM, LVN C removed Resident #3's left hip dressing that had moderate clear drainage. LVN C removed her gloves and immediately put on clean gloves, without performing any hand hygiene. LVN C cleaned Resident #3's wound, dried the wound, removed her gloves, applied clean gloves and placed a Calcium Alginate dressing over Resident #3's wound. LVN C did not perform hand hygiene between glove changes. LVN C washed her hands, scrubbed her hands with soap and water for a total of 10 seconds then rinsed her hands with water. Resident #27 Record review of Resident #27's Face Sheet dated 09/23/22 documented an [AGE] year-old female admitted [DATE] with the diagnoses of: Dementia, cerebral infarction (stroke), pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). Record review of Resident #27's Quarterly Minimum Data Set, dated [DATE] revealed she had a brief interview of mental status score of 9- moderately impaired cognition, usually made self understood and usually understood others. Resident #27 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #27 was at risk for pressure ulcer development. No pressure ulcers documented at the time of this assessment. Record review of Resident #27's Physician's Orders dated September 2022 documented Cleanse pressure injury to coccyx (a small triangular bone at the base of the spinal column in humans) with normal saline, pat dry with 4x4 gauze, apply medihoney (wound cleanser and debrider), cover with optifoam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 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 455974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382 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 dressing, daily and PRN (as needed). Level of Harm - Minimal harm or potential for actual harm Observation of Resident #27 on 09/22/22 at 09:43 AM revealed she was lying in bed on her left side with her eyes closed. LVN C entered the room and informed Resident #27 of wound care needed to be done. LVN C washed her hands, scrubbed her hands with soap and water for a total of 13 seconds before rinsing her hands with water. LVN C removed Resident #27's coccyx dressing and threw it away in the trash. LVN C removed her gloves and put on clean gloves, without performing hand hygiene between glove changes. LVN C cleaned Resident #27's coccyx wound then removed her gloves and put on clean gloves, without performing any hand hygiene between glove change. Residents Affected - Some LVN C washed her hands, scrubbed her hands with soap and water for a total of 11 seconds then rinsed her hands with water. Resident #54 Record review of Resident #54's Face Sheet dated 09/23/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: Dementia, Alzheimer's Disease, receptive-expressive language disorder. Record review of Resident #54's Quarterly Minimum Data Set, dated [DATE] revealed she had short and long term memory problem, had severe cognitive impairment, rarely/never made self understood and sometimes understood others. Resident #54 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #54 was at risk for pressure ulcer development but did not have any pressure ulcers at the time of the assessment. Record review of Resident #54's Physician Orders dated September 2022 documented Cleanse deep tissue injury (DTI - purple or maroon localized skin discoloration due to damage of underlying soft tissue from pressure or shear) to right great toe with normal saline, pat dry, apply skin prep and leave open to air. Cleanse DTI to right bunion with normal saline, pat dry, apply skin prep, and leave open to air. Observation of Resident #54 on 09/22/22 at 10:02 AM revealed she was lying in bed on her right side with her right foot elevated on a pillow. LVN C washed her hands, scrubbed her hands with soap and water for a total of 14 seconds before rinsing her hands with water. LVN C applied clean gloves, cleaned Resident #54's right great toe wound with normal saline and gauze, pat dried with clean dry gauze, and rubbed skin prep over the wound. LVN C removed her gloves and washed her hands, scrubbed her hands with soap and water for a total of 15 seconds before rinsing her hands with water. Interview with LVN C on 09/22/22 at 01:06 PM revealed she said she forgot to perform hand hygiene between glove changes. LVN C said she Usually sing the Happy Birthday song in my head three times when washing my hands. When asked if she sang the song while performing hand washing she said I didn't. LVN C said she was trained to wash her hands with soap and water for 20 seconds before rinsing her hands with water. LVN C said she was last trained on hand hygiene approximately 3-4 months ago. LVN C said it was important to perform proper hand hygiene to prevent infection. Interview with Registered Nurse (RN) E on 09/22/22 at 11:20 AM revealed she said she was the facility's Infection Preventionist. RN E said the facility's hand hygiene policy was to wash hands with soap and water for a total of 20 seconds before rinsing. RN E said staff were expected to perform hand hygiene before and after resident contact, between glove changes, and glove removal. RN E said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 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 455974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockport Nursing and Rehabilitation Center 1902 Fm 3036 Rockport, TX 78382 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 - Some importance of hand hygiene was to prevent infection and disease. RN E said she conducted random monthly observations of personal care and hand hygiene but said she had not been able to meet her observation quota in the last couple of months due to other duties. Interview with the Director of Nurses (DON) on 09/22/22 at 01:39 PM revealed she said the facility policy was to perform and hygiene before putting on gloves, between gloves changes, and after removing gloves. The DON said she was employed just four days ago and had not had a chance to do any care observations of staff. The DON said it was important to perform hand hygiene to prevent cross contamination and wound infection. Record review of LVN C's Hand Washing competency and proficiency test dated 04/04/22 revealed competency was met. Record review of CMA B's Hand Washing competency and proficiency test dated 04/24/22 revealed competency was met. Record review of the facility's Handwashing- Hand Hygiene policy and procedure dated 01/2018 documented Use a alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; . l. After contact with objects in the immediate vicinity of the resident . The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Applying gloves: 1. Perform hand hygiene before applying non-sterile gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 6 of 6