Inspection·September 22, 2023

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, interviews, 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 kitchen sanitation, in that: The inside lip of the ice machine was soiled with a white chalk-like substance, boxes of dry goods were stored on the floor of the pantry, crumbs were found in a refrigerator, and a blood-like substance was found in a refrigerator. These deficient practices could place residents at risk for food borne illness. The findings were: Observation on 09/19/2023 at 10:48 a.m. revealed the presence of a white chalk-like substance on the inside lip of the ice machine. During an interview with Dietary Aide E on 09/19/2023 at 10:49 a.m., Dietary Aide E confirmed the presence of a white chalk-like substance on the inside lip of the ice machine and stated she would clean it. Observation on 09/22/2023 at 12:52 p.m., revealed three cases of thickening powder were stacked, one on top of the other, with one box placed on the floor of the pantry connected to the kitchen. Further observation at the same time revealed the refrigerator in the pantry was marked #4 and contained a five-gallon bucket of pickles with numerous crumbs on the lid of the bucket. Refrigerator #4 also contained an empty plastic rectangular tub with a substance that appeared to be dried blood in the bottom of the tub. During an interview with the Dietary Supervisor on 09/22/2023 at 1:12 p.m., the Dietary Supervisor confirmed a case of thickening powder was on the floor of the pantry, stated it had been recently received from the supplier and should have been stored on a shelf. The Dietary Manager additionally confirmed the presence of crumbs on the lid of the bucket of pickles and a substance that appeared to be dried blood in the bottom of the tub. The Dietary Supervisor stated the tub had been used to hold thawing meat and stated she would have both the bucket and the tub cleaned. The Dietary Supervisor confirmed she was responsible for cleanliness in the kitchen and that the errors were oversights. Record review of facility policy General Kitchen Sanitation, revised 05/10/2018, read All food preparation areas, food-contact surfaces, dining facilities and equipment are cleaned and sanitized after each use, including all tableware, kitchenware and food-contact surfaces of equipment. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. [ .] (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 2 of 5 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 09/22/2023 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 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 and to help prevent the development and transmission of communicable disease and infection for 4 of 10 residents (Residents #5, #20, #21 and, #57) reviewed for infection control, in that: Residents Affected - Some 1. Medication Aide B did not sanitize the blood pressure cuff between resident #5 and resident #20 2. While providing incontinent care for resident #21, CNA A did not wash her hands after touching the bed remote and, CNA D did not change her gloves or wash her hands before touching a pair of clean briefs 3. During incontinent care CNA A allowed Resident #57's cleaned genitals and catheter tubing to come into contact with the resident's soiled adult brief. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #5's face sheet, dated 09/21/2023, revealed an admission date of 12/21/2020 and, a readmission date of 08/15/2011, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 Diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure) . Record review of Resident #5's physician orders for September 2023 revealed an order for Prinivil Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD FOR Systolic blood pressure LESS THAN 100 AND diastolic blood pressure LESS THAN 60 NOTIFY NURSE Record review of Resident #20's face sheet, dated 09/22/2023, revealed an admission date of 01/18/2021 and, a readmission date of 06/22/2023, with diagnoses which included: Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Type 2 diabetes mellitus(high level of sugar in the blood), Chronic kidney disease(gradual loss of kidney function), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension(High blood pressure) Record review of Resident #20's physician orders for September 2023 revealed an order for Digoxin Tablet 250 MCG Give 1 tablet by mouth one time a day related to UNSPECIFIED ATRIAL FIBRILLATION (I48.91) HOLD IF PULSE IS LESS THAN 60 (250mcg=0.25mg) Observation on 09/21/23 at 08:30 a.m. revealed, while administering medications, Medication Aide B took the blood pressure and pulse of Resident #20. Further observation at 8:50 a.m. revealed, Medication Aide B took the blood pressure and pulse of Resident #5 with the same blood pressure/pulse cuff than the one used for Resident #20. Medication aide B did not sanitize the blood pressure/pulse cuff between the two residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 3 of 5 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 09/22/2023 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 During an interview with Medication aide B on 09/21/2023 at 9:00 a.m. revealed the the medication aide forgot to use a wipe to clean the blood pressure/pulse cuff between use. She revealed it was causing a risk of cross contamination. She received infection control training within the year. During an interview on 09/22/2023 at 9:58 a.m., the DON confirmed the medication aide should have sanitized the blood pressure/pulse cuff in between resident to avoid cross contamination. She revealed infection control training was provided to the staff multiple times a year. She revealed the staff's skills were checked annually. She also stated the ADON and herself would do spot check of the staff for skills and infection control knowledge. Further interview revealed the facility used the CDC guidelines as infection control policy. 2. Record review of Resident #21's face sheet, dated 09/22/2023, revealed an admission date of 03/17/2015 and, a readmission date of 10/27/2022, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Pain in right hip, Hypertension (high blood pressure). Record review of Resident #21's MDS quarterly assessment, dated 07/05/2023, revealed the resident had memory problem and was severely cognitively impaired. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Record review of Resident #21's care plan revealed a care plan initiated 07/07/2023 with a problem of has bowel incontinence r/t (related to) immobility and an intervention of Provide pericare(incontinent) after each incontinent episode Observation on 09/21/23 at 09:40 a.m., revealed while providing incontinent care for Resident # 21 CNA A touched the bed remote control with her gloved hands and after washing her hands. She picked up the bed remote from the floor to put it back on the foot of the bed. She did not change her gloves or wash her hands, then, opened a plastic bag containing gloves and, took a pair of gloves to give to CNA D, contaminating the gloves that CNA D was going to wear. CNA D put the contaminated gloves on and started providing care. Further observation revealed, after cleaning Resident #21's buttocks, CNA D did not change her gloves and wash her hands before touching a clean pair of briefs. The resident had a large bowel movement. During an Interview on 09/21/2023 at 9:58 a.m., CNA A confirmed she touched the bed remote after washing her hands and putting her gloves one. She did not realize the remote was considered contaminated and that she should have changed her gloves and clean her hands. She confirmed receiving infection control training within the year. During an interview on 09/21/2023 at 10:00 a.m., CNA D confirmed not changing her gloves and cleaning her hands after cleaning the resident's buttocks. She confirmed she needed to clean her hands and change gloves, but she forgot. She confirmed receiving infection control training within the year. 3. Record review of Resident #57's face sheet, dated 09/22/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Moderate Protein Calorie Malnutrition, Unspecified Dementia, and Muscle Wasting and Atrophy. Record review of Resident #57's Significant Change MDS, dated [DATE], revealed a BIMS score of 2 which indicated severe cognitive deficit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 4 of 5 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 09/22/2023 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 Record review of Resident #57's care plan, revised 06/08/2023, revealed, [Resident #57] has an ADL self-care performance deficit [related to] Confusion, Dementia, Impaired balance. Observation on 09/21/2023 at 10:03 a.m. revealed CNA A cleaned Resident #57's perineal area, genitals, and foley catheter, then allowed the resident's genitals and catheter tubing to fall into the resident's soiled adult brief. During an interview with CNA A on 09/21/2023 at 10:03 a.m., CNA A confirmed she had allowed Resident #57's genitals and catheter tubing to fall into the resident's soiled adult brief, stated she had done so mistakenly, and confirmed the resident's genitals and catheter tubing had been re-contaminated. During an interview on 09/22/2023 at 9:58 a.m., the DON confirmed the environment around the residents is considered contaminated and the staff should have changed gloves and wash their hands prior to start the care to prevent the risk for infection for the resident. She confirmed staff should change gloves and wash their hands after cleaning during incontinent care and prior to touching clean briefs so to not re contaminate the resident. She revealed infection control training was provided to the staff multiple times a year. She revealed the staff's skills were checked annually. She also stated the ADON and herself would spot check the staff for skills and infection control knowledge. Review of the facility policy, titled hand hygiene in healthcare settings, dated 01/08/2021, revealed use an alcohol-based hand sanitizer after touching the patient's environment, after contact with blood, body fluids or contaminated surface. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 5 of 5