Inspection·August 31, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaned and stored in a plastic bag with the resident's name on it. The MS stated there were multiple used towels on the floor that staff should put in a plastic bag and stored in the linen barrels located in the laundry room. There were pieces of trash on the floor and the shower room needed sweeping and mopping. The MS stated she had alerted nursing staff of her findings before but was not sure about the outcome. Observation and interview on 8/31/23 at 3:35 PM with Housekeeping Staff A in the 100/200 shower room revealed she had worked at the facility about 4 months. Housekeeping Staff A stated she was not sure what her exact duties were when cleaning the shower rooms. Housekeeping Staff A stated she had picked up the dirty towels off the floor, swept the floor and removed the used brush. Observation and interview on 8/31/23 at 3:45 PM with LVN B, the DON and the ADM, in the 100/200 shower room revealed LVN B stated the aides were responsible for cleaning up the shower room after showering each resident and housekeeping staff would deep clean the shower room at the end of the day. LVN B stated the aides should place all used towels in a plastic bag and put them in a linen barrel located in the laundry room. They should gather up all resident items and return them to the resident room; clean and disinfect all resident equipment along with the shower stall, sweep and mop the floor as needed. LVN B stated the brown smudge on the toilet top of the shower chair looked like fecal matter including the brown spot on the wall. LVN B stated there were multiple dried urine stains on the bottom of the toilet seat of the shower chair located in the vanity area. LVN B stated the residents who were showered could be infected or become sick related to cross contamination. LVN B stated it was important to clean and disinfect the shower stall and all resident equipment. 2. Observation and interview on 8/31/23 at 3:30 PM during environmental rounds of the 500/600 shower room with the MS revealed multiple used towels on the floor outside one of the stalls; there were clean towels in the sink; the sink had a layer of dust in it; there was a roll on detergent stick opened and left on top the shower bed positioned perpendicular along the back wall; there was another shower bed located crossways at the foot of the first shower bed blocking the shower area. There was a large white area on top of the mattress, attempts to wipe the area down with a paper towel were unsuccessful. The white residue was dried on the mattress top. The MS confirmed the stated findings and stated the white area looked like baby powder. The MS stated the used towels should not be left on the floor, the clean towels in the sink could not be used because the sink was dirty and staff should not use the roll on deodorant on multiple residents and should secure it in a plastic bag with the resident's name on it. Observation and interview on 8/31/23 at 4:00 PM with LVN B, the DON and the ADM, in shower room [ROOM NUMBER]/500 revealed the sink had a layer of dust in it; there was a white piece of deodorant on top of the shower bed positioned perpendicular to the back wall; there was another shower bed located crossways at the foot of the first shower bed. There was a large white area on top of the mattress, attempts to wipe the area down with a paper towel were unsuccessful. The white residue was dried on the mattress top. Interview with LVN B confirmed these stated findings. LVN B stated it looked like the sink had not been cleaned and again stated the resident equipment had not been cleaned and disinfected per facility policy to prevent the spread of diseases and infections. 3. Observation on 8/31/23 at 3:45 PM with LVN B, the DON and the ADM, revealed there was a linen cart with towels and bed sheets exposed on the 400 hall. The cloth flap was left open. On the top of the linen cart was a black purse. On the inside of the cart there was a soft drink cup, a Yeti cup, a blanket and another bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 2 of 3 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 675159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957 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 Interview on 8/31/23 at 7:19 PM with LVN B revealed she closed the linen cart because there was a soft drink cup, a Yeti cup, a personal blanket and a personal bag mixed in with the clean linens. LVN B stated there was also a black purse on the top of the linen cart. LVN B stated this was a risk for cross contamination; the spread of diseases and infections to residents. LVN B stated she spoke with the CNA who was working the 300/400 halls and confirmed that all of the belongings mentioned belonged to the CNA. Interview on 8/31/23 at 7:07 PM with CNA C revealed the shower room and resident equipment should be cleaned and disinfected after showering every resident. CNA C stated the dirty linens should be bagged and the floor should be swept and mopped. CNA C stated resident supplies should only be used on the resident the supplies belong to and not on any other residents. CNA C stated the concern would be cross contamination and the spread of infections. Interview on 8/31/23 at 7:27 PM with CNA D revealed shower rooms should be cleaned from top to bottom after each resident shower to prevent the spread of infections. CNA D stated personal supplies should only be used on the resident who belonged to the resident. CNA D stated personal supplies should either be bagged with the resident name and kept in the cabinet in the shower or taken to the resident room. Review of a facility policy, Infection Prevention and Control Program, dated 5/13/23 read: This facility has established a maintains 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 as per accepted national standards and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. e. Environmental cleaning and disinfection shall be performed according to the facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department. 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen should always be separated from soiled linen. c. Clean linen shall be delivered to resident care units on covered carts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 3 of 3