Inspection·August 6, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who had a foley catheter bag touching the floor had a potential for infection. Record review of a facility document titled, Infection Prevention and Control Program, date implemented 05/13/2023, revealed, Policy: This facility has established and 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. 2. Record review of Resident #5's admission record dated 08/06/2025 reflected a [AGE] year-old male with an admission date of 07/25/2025. Record review of Resident #5's Medical Diagnosis sheet dated 08/06/2025, reflected diagnoses which included nodular prostate with lower urinary tract symptoms, retention of urine, unspecified, and pressure ulcer of sacral region, stage I. Record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 15 out of 15, which suggested no cognitive impairment (no problems making decisions about care or things that affected daily life). Further review reflected Resident #5 had a urinary catheter. Record review of Resident #5's Care Plan, documented the following focus areas: The resident has an ADL self-care performance deficit r/t general weakness level of function through the bathing but requires staff to bathe lower extremities, dated 07/28/2025, With interventions including requiring extensive to total assistance by two staff to move between surfaces. Resident has the need for Enhanced Barrier Precautions due to: foley catheter and ileostomy, dated 08/06/2025, with interventions including assess for signs and symptoms of infection. Record review of Resident #5's Order Summary Report, dated 08/06/2025, reflected doctor's orders, including the following: Check Foley catheter every shift Use leg strap to secure Foley in place. Dated 07/28/2025. Foley cath [catheter] care q shift and PRN every shift. Dated 07/28/2025. Foley catheter 16Fr 10ml. Dated 07/28/2025. During an observation on 08/05/2025 at 3:00 p.m. outside Resident #5's room, there was an EBP sign to indicate to staff that the resident required staff to wear extra PPE (gown in addition to gloves) for high-contact care activities, including transferring and during device care or use. PPE was observed in the hall and readily available. Further observation revealed Resident #5 had a urinary catheter bag inside a privacy bag underneath his wheelchair. During an observation on 08/05/2025 at 3:35 p.m., CNA D and CNA F did not put on a gown before assisting Resident #5 with a transfer and emptying his urinary catheter bag. During an observation on 08/05/2025 at 3:36 p.m., CNA D and CNA F assisted Resident #5 into bed with a transfer board, and CNA D emptied the urinary catheter bag. During an interview on 08/06/2025 at 3:42 p.m., CNA D stated she did not wear a gown to transfer Resident #5 or empty his foley catheter bag. When asked why they did not put on a gown in addition to gloves, CNA D she did not see the sign, so she did not put on a gown in addition to gloves. CNA D further stated that she knew the expectation and had been trained on EBP. When asked what the risks to the resident were if they did not follow EBP precautions, CNA D said it was important to follow the precautions to decrease the risk of infection to the resident. During an interview on 08/06/2025 at 3:43 p.m., CNA F stated that she did not wear a gown in addition to gloves before assisting with the transfer of Resident #5 from his wheelchair to the bed, and when asked they did not put on all the recommended PPE, CNA F stated, I wasn't paying attention, and did not see the sign outside the door. CNA F further stated she was aware of the use of EBP and had been trained. CNA F stated the risk of not following the precautions was possible infection to the resident. During an interview on 08/06/2025 at 5:46 p.m., when asked what EBP precautions were for, the DON stated to prevent potential infection and to protect the resident from the staff., the DON further stated, all nursing staff were expected to wear recommended EBP PPE when the sign was posted outside a resident's door. When asked what the risks to the resident were if they did not follow EBP precautions, the DON stated, risks of infection, and for Foley [catheter], a urinary tract infection. (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 08/06/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of an example of the facility's Enhanced Barrier Precautions posting (provided by the DON) marked with the CDC logo and reviewed on 08/06/2025, with no date, reflected Providers and staff must also wear gloves and a gown for the following high-contact resident care activities. transferring and during device care or use: central line, urinary catheter, feeding tube, tracheostomy. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 04/24/2024, reflected that the facility used enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Further review reflected .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. , which included transferring. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Event ID: Facility ID: 675159 If continuation sheet Page 3 of 3