Inspection·February 20, 2026

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility's policy Janitor's Closet, dated October 2018, reflected Mops and brooms must be stored head up. Record review of facility's policy Ice Machines, dated October 2018, reflected The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. Record review of facility's policy Food Storage, dated October 2018, did not reflect that prepared foods needed to have a discard date as was reflected in the 2022 FDA Food Code. Record review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Event ID: Facility ID: 675159 If continuation sheet Page 2 of 4 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 02/20/2026 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 2 of 4 residents (Residents #13 and #43) reviewed for the accuracy of their medical records. 1.The facility failed to ensure that documentation on Resident #43's chart accurately reflected the diagnosis of dementia (decline of mental ability).2.The facility failed to accurately document Resident #13's blood pressure for 02/16/2026 and 02/17/2026 at 1PM, 02/17/2026 at 5PM. These failures could place residents at risk of receiving improper care.Findings included: 1.Record review of Resident #43's face sheet, dated 2/17/2026, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: anxiety disorder (mental condition characterized by excessive and persistent feelings of fear that significantly interfere with daily life function), delusional disorder (mental illness characterized by holding one or more firm false beliefs), and gout(pain full form of inflammatory arthritis caused by high levels of uric acid in the blood). The face sheet and monthly physician orders for February 2026 did not reveal a diagnosis of dementia. Record review of Resident #43's BIMS assessment, completed 11/30/25, revealed a BIM score of 2, which indicated severe cognitive impairment. Record review of Resident #43's hospital discharge paperwork, dated 11/25/2024, revealed a diagnosis of dementia. Record review of Resident #43's care plan, updated 9/2/2025, revealed a care plan with a focus on resident has ADL self-care related to dementia. Interview with MDS Nurse H on 02/19/26 at 9:15 AM, MDS Nurse H stated the admission nurses responsible for entering the diagnosis for Resident #43 on 11/26/2024 and 11/30/2025 were no longer employed with the facility, and the diagnosis of dementia was not entered. MDS Nurse H stated Resident #43 may not have received proper care because the diagnosis was not present on the face sheet. During the interview on 2/19/2026 at 11:25 AM, the DON stated she had been in her role for six weeks and had not yet audited all previous admissions for accuracy. The DON shared that listing dementia only in the care plan, rather than on the face sheet, could cause confusion for other providers and may result in Resident #43 not receiving appropriate care. The DON stated MDS nurses were responsible for this task, with ADONs conducting random monitoring. 2. Record review of Resident #13's face sheet, dated 2/20/2026, revealed Resident #13 was a [AGE] year-old male initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include Hypotension (low blood pressure). Record review of Resident #13's significant change in status MDS assessment, dated 1/28/26, reflected Resident #13 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #13's order summary report, dated 02/17/2026, reflected Midodrine HCl Oral Tablet 10 MG. Give 1 tablet by mouth three times a day for Hypotension. Hold if SBP over 150 with start date 01/27/2026. Record review of Resident #13's care plan, undated, revealed [Resident #13] has hypotension r/t heart failure, revised 01/13/2026, with intervention Give medications as ordered. Monitor for side effects and effectiveness, initiated 01/13/2026. Record review of Resident #13's MAR for February 2026 reflected Midodrine HCl Oral Tablet 10 MG. Give 1 tablet by mouth three times a day for Hypotension with start date 01/27/2026. It further reflected there was no blood pressure entered in for 02/16/2026 at 1:00 PM and the medication was administered, which was signed by LVN I. There was no blood pressure entered on 02/17/2026 at 1:00 PM and the medication was administered, which was signed by LVN I. There was no blood pressure entered on 02/17/2026 at 5:00 PM and the medication was administered, which was signed by LVN I. Phone interview on 02/19/26 at 3:56 PM, LVN L stated she checked Resident #13's blood pressure and held the medications if it was out of parameters. LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 3 of 4 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 02/20/2026 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 0842 Level of Harm - Minimal harm or potential for actual harm L was not at the facility and stated she could not confirm or deny having administered specific medication times, but she followed doctor's orders. LVN L stated it was important to administer medications as prescribed for resident care and important to document blood pressure to assess how the resident was doing. Record review of the facility's policy charting and documentation in the medical record, dated 10/24/2022, revealed each resident's medical record shall contain an accurate representation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 4 of 4