Inspection·November 2, 2023

F 0552 effective coping skills through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #38's medication profile dated 05/29/23 indicated in part: Residents Affected - Some Ativan 1 milligram, give 1 tablet by mouth 2 times a day related to anxiety. Record review of Resident #38's Medication Administration record shows that Ativan tablet 1mg was administered by mouth two times a day at 1200 and 2000 starting 05/29/2023. Record review of Resident #38's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Ativan with start date of 05/29/23. Record review of Record review of Resident #41's face sheet revealed admission date of 03/01/23 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). She was [AGE] years of age. Record review of Resident #41's admission MDS, dated [DATE], indicated he had a BIMS score of 04, which indicated she was severely cognitively impaired. The MDS also indicated Resident #41 had diagnosis of non-Alzheimer's dementia and depression. Record review of Resident #41's care plan indicated, in part: Focus: resident has an ADL self-care performance deficit related to Alzheimer's, Dementia. Goal: The resident will continue to participate in at least 3 out of room activities a week through next review date. Intervention: Monitor, document, and report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of Resident #41's medication profile dated 05/22/23 indicated in part: Mirtazapine 15 milligram, give 1 tablet by mouth at bedtime. Record review of Resident #41's Medication Administration record shows that Mirtazapine oral tablet 15mg was administered once a day at 2100 starting 05/22/2023. Record review of Resident #41's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Mirtazapine with start date of 05/22/23. Record review of Record review of Resident #63's face sheet revealed admission date of 04/29/22 with diagnoses of dementia (progressive loss of intellectual functioning, memory, and abstract thinking), anxiety disorder (ongoing anxiety that interferes with daily activities), Alzheimer's (a progressive disease that destroys memory and other important mental functions). She was [AGE] years of age. Record review of Resident #63's quarterly MDS, dated [DATE], indicated he had a BIMS score of 01, which indicated he was severely cognitively impaired. The MDS also indicated Resident #63 was diagnosed with mood disorder, Alzheimer's, dementia, and anxiety. Record review of Resident #63's care plan indicated, in part: Focus: has potential to be physically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 2 of 7 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 11/02/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm aggressive related to Dementia. Goal: The resident will demonstrate effective coping skills through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #63's medication profile dated 08/15/23 indicated in part: Residents Affected - Some Mirtazapine 15 milligram, give 1 tablet by mouth at bedtime. Record review of Resident #63's Medication Administration record shows that Mirtazapine oral tablet 15mg was administered by mouth once a day at 2100 starting 08/15/2023. Record review of Resident #63's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Mirtazapine with start date of 08/15/23. Interview on 11/01/2023 at 1:00pm, RN C stated that when a new order is received, the nurse who takes the order is responsible for calling the residents representative to obtain consent, prior to administering the medication. The consent is then scanned in by medical records. RN C stated that if the consent is not in chart, then it could be in medical records. Interview on 11/01/2023 at 1:30 pm, Medical records staff stated that she scanned in all consents that nurses have turned in to her. She stated that she kept hard copies of all consents that she received. She stated that the missing consents were not in her possession. Interview on 11/01/2023 at 1:45 pm, the DON stated that all residents receiving psychiatric medications should have a written consent signed and scanned into their chart. When the nurse gets the order, they should immediately contact the family representative and get consent. I could not find those consents, which means we failed to get those consents prior to administration of medications. We need to tighten ship on that, we currently have no one checking behind the nurses to ensure they obtained consent. Record review of the facility's policy revised 08/15/22, titled Psychotropic Medications indicated, in part: Upon noting an order for psychoactive medication on admission or initiation of therapy: Complete the Consent for Use of Psychoactive Medication therapy with the resident and/ or the resident representative at the initiation of psychoactive medication and educate on the benefits, potential negative outcomes, alternatives, and outcomes of psychoactive medication use. Consent prior to the use of initiating medication. Consent prior to the use of initiating medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 3 of 7 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 11/02/2023 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** [NAME], [NAME] Residents Affected - Some 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 diseases and infections for 2 (Resident #7 and #48) of 5 residents reviewed for infection control. CNA A failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #7. CNA D and NA G failed to wash their hands and change their gloves after they became contaminated during incontinent care while assisting Resident #48. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT #7 Record review of Resident #7's admission record dated 11/02/2023 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #7's care plan dated 08/06/23 indicated in part: Problem: Skin integrity: The resident is at risk for impaired skin integrity related to: bladder incontinence, bowel incontinence, contractures. Goal: The resident will remain free from alterations in skin integrity. Interventions: Provide timely incontinent care; provide and/or encourage good skin care (keeping skin clean, conditioned, and reducing excess moisture). Avoid massage over boney prominences during provision of care. Record review of Resident #7's MDS dated [DATE] indicated in part: BIMS = 09 indicating resident was moderately impaired. Urinary continence = Always incontinent. Bowel continence = Always incontinent. During an observation on 10/31/23 at 10:02 AM, CNA A performed incontinent care for Resident #7. CNA A washed her hands and then put on some clean gloves. CNA A then undid the resident's brief and took some wet wipes and wiped the resident vaginal and rectal area. CNA A then applied a clean brief, changed the bed sheets, adjusted the resident's pillow and then covered her, while still wearing the same gloves she used to wipe the residents vaginal and rectal area. During an interview on 11/01/23 at 10:54 AM, CNA A said she should have changed her gloves after she wiped Resident #7's vaginal and rectal area. CNA A said not changing her gloves could lead to cross contamination as she had also touched the bed sheets and other items with the same gloves that possibly came in contact with the resident's urine and other areas. CNA A said she had received training on when to change her gloves once they were contaminated. CNA A said the failure occurred because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 4 of 7 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 11/02/2023 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 she got nervous and forgot to change her gloves once they became contaminated. Level of Harm - Minimal harm or potential for actual harm RESIDENT #48 Residents Affected - Some Review of Resident #48's admission Record dated 11/2/23 revealed he was an [AGE] year-old male admitted to the facility 3/31/22 with diagnoses which included Alzheimer's Disease, hypertension (high blood pressure), chronic kidney disease stage 2, and muscle wasting and atrophy. Review of Resident #48's Annual MDS assessment dated [DATE] revealed: He scored a 3 on his mental status exam indicating severe cognitive impairment. He required extensive assistance with ADLs except for eating which only required supervision. He was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #48's Care Plan, revision date 7/26/23, revealed: Problem - Skin Integrity : Resident #48 is at risk for impaired skin integrity related to anemia, bladder incontinence, impaired circulation o sensation, impaired cognition, peripheral vascular disease. Goal - The resident will remain free from alterations in skin integrity (i.e., pressure ulcers) by/through next review date. Interventions - Provide timely incontinent care; provide and/or encourage good skin care (keeping skin clean, conditioned, and reducing excess moisture); avoid massage over boney prominences during provision of care. During observation on 10/31/23 on 12:21 PM, CNA D and NA G entered Resident #48's room and informed him they were there to do incontinent care and get him dressed for lunch. NA G and CNA D both washed their hands and donned gloves. CNA D stated that Resident #48's sheets and clothing were saturated with urine and that all the bedding would need to be removed. CNA D unfastened the soiled brief and then CNA D used wipes to clean resident front to back using each wipe only once then discarding into trash bag placed at bedside. NA G assisted resident to turn to his left side and held him in place while CNA D cleaned the resident's left buttock and tucked soiled brief and bedding under resident. CNA D placed clean brief under the resident and NA G and CNA D then rolled resident to his right side and NA G pulled the soiled bedding and soiled brief the rest of the way out from under him, placing them in a trash bag, pulled the clean brief further under him and used wipes to clean his right buttock. Resident #48 was rolled onto his back and the clean brief was repositioned and fastened. CNA D and NA G then assisted the resident in dressing. Neither CNA D nor NA G changed their gloves or performed hand hygiene after coming into contact with the soiled linens and soiled brief, or after performing incontinent care. In an interview on 11/2/23 at 2:48 PM, CNA D stated that the proper procedure for incontinent care was to knock, introduce herself, explain what she was going to do, make sure she had supplies (wipes, clothes, brief, trash bag for dirty stuff), close curtain before she undressed the resident and make sure door is closed for privacy. She stated that she would wash her hands for 20 seconds to a minute, washing under nails, palms of hands, between fingers and thumb, then rinse, and get paper towels to dry hands and turn off faucet - never used clean hands to turn off faucet. After her washing hands then she would put on gloves and tell the resident again, what she was about to do. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 5 of 7 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 11/02/2023 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 then she would remove the resident's pants or dirty clothing and place them in dirty laundry bag. CNA D stated after removing the resident's clothes, she unfastened the soiled brief. She stated that to clean the resident, she would use a wipe and clean the groin from front to back once, then throw the wipe away and repeat that process until the area was clean. Then she would tell the resident that she was going to turn them and turn them to the side and repeat cleaning with wipes using only once then throwing away until resident is clean. Then she would tuck the soiled brief under resident. CNA D stated that after removing the soiled brief she would remove her dirty gloves, use hand sanitizer, or wash her hands and put on clean gloves. She stated she would tuck a clean brief under resident and make sure it was positioned correctly and then tell the resident to roll back over towards her and then roll them back onto the other side and remove the soiled brief then roll them back to flat on their back and pull the clean brief out and adjust it to fasten. She stated she would throw soiled brief away after she had gotten the clean brief on the resident. She stated that after the incontinent care was done, she would continue assisting the resident with whatever else they needed at that time. CNA D stated that the care with Resident #48 did not go great because they did not have hand sanitizer and they did not wash their hands after they finished. CNA D acknowledged that she and NA G did not change their gloves during the incontinent care. She stated she just forgot to change her gloves because it was a very busy time of day and that she was frustrated with herself because she knew better. CNA D stated that the importance of changing gloves during resident care was to prevent cross contamination from dirty areas to clean areas, and to help stop the spread of infections in the facility whether it was from resident to staff or staff to resident. During an interview on 11/02/23 at 03:20 PM, the DON said it was her expectation that staff used good infection control practices during resident personal care such as if they touched a dirty surface then they had to use hand sanitize or wash their hands. The DON said staff were expected to remove their gloves after the gloves were soiled or became contaminated and wash their hands. The DON was made aware of the observations of incontinent care. The DON said the infection control nurse who is ADON E did audits such and check-offed staff for infection control on a monthly basis. During an interview on 11/02/23 at 03:25 PM, ADON E said she monitored staff when they performed incontinent care as part of her weekly audit and would sample at least 4 staff per week and all staff annually. ADON E said it was expected for staff to wash their hands prior to performing personal care and after they removed their gloves. ADON E was made aware of the observations of incontinent care. ADON E said staff were expected to change their gloves once they became contaminated to prevent contamination of the clean items. ADON E said the failure probably occurred because the staff got nervous and forgot to change their gloves once they became contaminated. During an interview on 11/02/23 at 03:47 PM, the Administrator said it was his expectation for residents to be free from cross contamination or infection. The Administrator said it was his expectation for the staff to follow the policy regarding hand hygiene in order to prevent health issues. The Administrator said the DON, ADON, infection control preventionist and himself were responsible to monitor the infection prevention procedures. The Administrator was made aware of the observations of incontinent care. The Administrator said if the staff used contaminated gloves to perform resident care that could lead to the spread of infections. The Administrator said the failure occurred due to missed steps and staff could have forgotten some of the steps. Record review of the facility's policy titled Infection control - purpose and policy dated 04/15 indicated in part: The infection control program is the umbrella program that encompasses both policy and procedures that fall under the purview of infection control. Periodic changes should be published under the direction of the infection control committee. The purpose of the infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 6 of 7 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 11/02/2023 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 program is to investigate, control and prevent infections in our facilities; decide which procedures such as isolation should be applied to an individual resident; maintain a record of incidents and corrective actions related to infections. The following general policy to prevent the spread of infection applies - Employees should wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Residents Affected - Some Record review of the facility's policy titled Gloves dated 04/15 indicated in part: Gloves should be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. All employees should wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. When gloves are indicated they should be used only once and discarded into the appropriate receptacle. Handwashing and/or hand disinfectant is necessary when gloves are removed. Record review of the facility's policy titled Incontinence Care (Male/Female, Catheters) dated 04/15 indicated in part: The purpose of this procedure is to provide guidelines that should aid in preventing the resident's exposure and spread of infections. Soiled disposable items should be handled so as to prevent contamination of the environment. Wash your hands thoroughly at the following intervals - before the procedures; anytime they become soiled with blood or body fluids; whenever in doubt; and upon completion of your task or procedure. Wash your hands thoroughly or use hand sanitizer at the following intervals: before resuming the procedure after an interruption; and when changing/removing gloves or any personal protective equipment. Use a washcloth with warm water and soap or incontinent product to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke, wipe from front to back, cleanse around the urethral area, move outward towards thighs and avoid rectum, finish with a clean moist cloth to remove soap and other incontinent product that may require rinsing. Remove gloves sanitize hands and apply clean gloves. Remove soiled items, replace with clean dry briefs or under pad as indicated, place disposable brief or under pad into waste container, discard disposable equipment and supplies in designated containers. Remove gloves and discard into designated container, wash and dry your hands, reposition the bed covers, make resident comfortable. Wash and dry your hands thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455974 If continuation sheet Page 7 of 7