Health inspection·June 30, 2023

F 0583 and Atrophy. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #50's MDS dated [DATE] documented: Resident # 50 requires Extensive assistance for Bed Mobility, Toilet use and requires limited assistance with Transfers, Dressing, Eating, and Personal Hygiene. Residents Affected - Few Observation on 6/28/2023 at 3:16PM of medication administration. MA A knocked on resident's door, introduced herself to Resident # 50, MA A then raised residents bed to appropriate height, washed hands for approximately 35 seconds, and put on gloves. MA A elevated Resident # 50's head of bed to appropriate elevation. MA A proceeded to explain to Resident # 50 about the medication being administered and administered medication to Resident # 50. MA A at no time provided privacy by drawing privacy curtain or closing Resident # 50's room door. Resident # 50's bed is located by room door and bed was visible from hallway. No interviews were able to be conducted with Resident #50 and Resident #61 due cognitive impairment and R#61 and R#50 were non-interviewable. Interview with MA A on 6/28/2023 at 3:37pm. MA A stated she has been working about 9 years with the facility as a MA. MA A stated, it is important for residents to have privacy because it was their right and she was nervous. MA A stated, she forgot to provide privacy and thought this surveyor was going to close the door. MA A stated she was In-serviced on Resident rights about a couple of months ago but could not remember exact date. Interview with DON, on 6/28/2023 at 4:02PM stated residents have the right to have privacy, so no one sees their treatments, care, or overhear the medications they are receiving. DON stated resident rights are important and is part of the facility's policy and DON ensures training is done with all staff to ensure resident privacy/rights are understood and practiced. Interview with Regional RN Consultant on 6/28/2023 at 4:05PM stated, all residents' have a right of privacy, dignity, and it is company policy that is frequently in-serviced on. Review of In-service on Resident Privacy dated 6/28/2023 and In-service on Resident Rights-Resident Has Right to Privacy dated 6/12/23 Review of Residents Rights (skills checklist) upon MA A's hire dated 8/30/2012 Review of Promoting/Maintaining Resident Dignity Policy dated 1/13/2023 states: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 2 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment, for 1 (Resident #3) of 1 resident observed for safe, comfortable, homelike environment. The facility failed to remove nail orange stick from Resident #3's bed after nail care had been attempted. These failures could place residents at risk of not being in a safe environment placing them at risk of injury. The findings were: Record review of Resident #3's face sheet dated 06/30/23, documented an [AGE] year-old male admitted [DATE], with diagnoses including cerebral infarction (stroke), gastronomy status (a tube inserted through the wall of the abdomen directly into the stomach used to give drugs and liquids, including liquid food, to the resident), colostomy status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), pressure ulcer of sacral region, stage 4 (full thickness skin loss with extensive destruction; tissue death; or damage to muscle, bone, or supporting structure - such as tendon, or joint capsule), absence of right upper limb above elbow Record review of Resident #3's Quarterly Minimum Data Set assessment, dated 06/16/23, revealed he had a BIMS score of 03, indicating he had severe cognitive impairment. Quarterly MDS revealed Resident #3 was usually able to make self-understood, usually able to understand others, required extensive assistance of two staff for bed mobility and dressing, was totally dependent on two staff for toilet use and personal hygiene, was totally dependent on one staff for eating, and transfers only occurred once or twice with the assistance of two staff. Resident #3 had a Foley catheter and a colostomy bag. Record review of Resident #3's Care Plan, dated 06/19/23, revealed Resident #3 has a Foley catheter with the goal of Resident #3 would remain free from catheter-related trauma. Interventions included checking for tubing for kinks [as needed] each shift; Monitor and document intake and output as per facility policy; Monitor for s/sx of discomfort on urination and frequency; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The date initiated was 05/16/2022. Observation on 06/29/23 at 10:44 a.m., during incontinent care when CNAs A and CNA B repositioned resident to roll onto left side, an orange nail stick was observed under resident's right shoulder on rolled towel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 3 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/29/23 at 11:10 a.m., CNA A stated she did not know who did resident's nails and left the nail stick in bed after attempting to complete nail care for Resident #3. In an interview on 06/29/23 at 11:13 a.m., CNA C stated she had been there since 3am and was with other CNAs when they turned the Resident #3 earlier. She stated she did not turn Resident #3 and did not see the nail stick when the other CNAs turned the resident. In an interview on 06/29/23 at 11:23 a.m., CNA E stated Resident #3 was turned about 10am. CNA E stated she was doing the nail care on Resident #3, and he did not want her to do the nail care. CNA E stated she forgot the nail stick. CNA E stated she was sorry, but did not state what the potential risk was. In an interview on 06/29/23 at 01:41 p.m., the Administrator stated staff should not have left a nail stick (orange stick) in a resident's bed. The Administrator stated the resident could have been poked in the head or anywhere else. In an interview on 06/29/23 at 02:34 p.m., the DON stated CNAs do nail care (cleaning) usually on Sundays, but Resident #3 must have refused care (since the CNA was attempting nail care on a Thursday). The DON stated Resident #3 could have been poked and caused injury from having the nail stick behind his right shoulder and the nail stick should have been removed from the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 4 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 (Resident #3) of 16 residents reviewed for indwelling urinary catheters. The facility failed to ensure Resident #3's urinary catheter leg strap was applied. This failure could affect resident with an indwelling urinary catheter and place them at risk of tugging or pulling out the catheter. The findings included: Record review of Resident #3's face sheet dated 06/30/23, documented an [AGE] year-old male admitted [DATE], with diagnoses including cerebral infarction (stroke), colostomy status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), pressure ulcer of sacral region, stage 4 (full thickness skin loss with extensive destruction; tissue death; or damage to muscle, bone, or supporting structure - such as tendon, or joint capsule) Record review of Resident #3's Quarterly Minimum Data Set assessment, dated 06/16/23, revealed he had a BIMS score of 03, indicating he had severe cognitive impairment. Quarterly MDS revealed Resident #3 was usually able to make self-understood, usually able to understand others, required extensive assistance of two staff for bed mobility and dressing, was totally dependent on two staff for toilet use and personal hygiene, was totally dependent on one staff for eating, and transfers only occurred once or twice with the assistance of two staff. Resident #3 had a Foley catheter and a colostomy bag. Record review of Resident #3's Care Plan, dated 06/19/23, revealed Resident #3 has a Foley catheter with the goal of Resident #3 would remain free from catheter-related trauma. Interventions included checking for tubing for kinks [as needed] each shift; Monitor for s/sx of discomfort on urination and frequency; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The date initiated was 05/16/2022. Record review of Resident #3's physician order dated 10/24/22, revealed to check Foley catheter every shift for placement may use leg anchor to secure Foley in place. Observation on 06/29/23 at 10:44 a.m., during incontinent care when CNA A tucked the brief down between Resident #3's legs, revealed the Foley catheter tubing was not attached to the resident's leg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 5 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/29/23 at 11:10 a.m., CNA B stated the nurse is responsible for placing the Foley leg band on the resident. She said if there is a leg band they (CNAs) see it is not attached, they (CNAs) will attach the Foley tubing. In an interview on 06/29/23 at 11:26 a.m., ADON F stated the nurses are responsible for placing the Foley catheter leg band. ADON F stated nurses are to check the catheter every shift including checking for the leg band. ADON F stated if there were not a leg band holding the Foley tubing, the Foley could tug and possibly be pulled out. In an interview on 06/29/23 at 11:29 a.m., LVN G for floor stated she is the nurse for Resident #3. She stated she rounded on Resident #3 this morning (06/29/23). LVN G stated she did notice Resident #3 did not have a leg band for the Foley. LVN G stated the DON told her a leg band was considered a restraint and she was going to clarify. LVN G stated there was a patch sticker (leg strap/band) holding the Foley tubing when she rounded the first time. LVN G stated she was going to check it again on her second round. She stated there was a patch sticker the first time she rounded around 6:45-6:50 a.m. (06/29/23). LVN G stated Resident #3 moves a lot (in the bed). LVN G stated with if there was nothing holding the Foley catheter tubing, the Foley could be pulled out. In an interview on 06/29/23 at 01:41 p.m., the Administrator stated there should be a leg band or something on a resident's leg to hold the catheter tubing, so it does not pull or do damage. In an interview on 06/29/23 at 02:34 p.m., the DON stated staff are supposed to use the anchors (leg bands) for Foley catheter tubing. DON stated CNAs and nurses are responsible for ensuring catheter tubing is secured with a leg band. If catheter tubing is not anchored, it can be pulled tugged or dislodge. NIH (https://www.ncbi.nlm.nih.gov/books/NBK482270/) accessed on 06/30/23. Last update May 30, 2023 indicated: Prevention of Inappropriate Self-Extraction of Foley Catheters Traumatic, unintended Foley catheter extractions, whether patient-initiated or accidental, can cause permanent urologic complications, affect hospital length of stay, decrease patient satisfaction grades, increase catheter-associated urinary tract infections (CAUTIs), and lower hospital quality scores. Interventions to Reduce Traumatic and Inappropriate Self-Extraction of Foley Catheters Identify Patients at Risk Every patient with a Foley catheter who has delirium or dementia is potentially at risk of a traumatic Foley catheter removal. This would include patients recovering from anesthesia, procedures, or sedation and particularly if the Foley catheter is new. Patients with head injuries are at particular risk. Often these patients are in the recovery room or intensive care unit (ICU) settings, but this may not always be the case. Other patients at risk include: Any patient with delirium or dementia, particularly an elderly nursing home patient with a recently placed Foley catheter or one who has a prior history of traumatic self-extraction of catheters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 6 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0690 Patients who are constantly pulling or tugging on their Foley catheters. Level of Harm - Minimal harm or potential for actual harm Patients with a history of agitation from brain injury, medications, or other illnesses. Residents Affected - Few Patients admitted for mental status changes whose degree of confusion is unclear, and their tolerance of the new Foley catheter is not yet known. Patients with newly inserted Foley catheters who are just waking from anesthesia and may become agitated. Any patient being transferred where the catheter may become caught and accidentally pulled or tugged. Patients with a history of prior Foley catheter self-extractions.[4] Use Standard Preventive Measures All patients with Foley catheters should include a properly placed Foley stabilization device as well as additional observation by staff if patients appear confused or agitated. Do not use a Foley stabilization device on suprapubic catheters. Reposition the Foley Catheter Under the Thigh, Tape and Cover it In higher-risk patients, reposition the catheter by directing it under the thigh and then taping it directly to the skin without a gap. Leave no space under the tubing or the catheter for the patient to use his fingers to grab it. Being unable to encircle the catheter and tubing makes it much harder for the patient to secure purchase on the Foley and pull it out. The catheter needs to be completely secured with tape, starting almost at the level of the meatus and continuing as the catheter is secured underneath the thigh. Record review of SOM Appendix PP revised 10/21/22 https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r8som.pdf CATHETERIZATION Additional care practices related to catheterization include: -Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter; and -Securing the catheter to facilitate flow of urine, preventing kinking of the tubing and position below the level of the bladder. (Also refer to F880 - Infection Control for policies and procedures related to care of the catheter and equipment, such as tubing, bags, etc.). Record review of CDC Center for Disease Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 7 of 8 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 675635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520 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 0690 https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html Page last reviewed November 5, 2015 Level of Harm - Minimal harm or potential for actual harm Catheter-Associated Urinary Tract Infections (CAUTI) II. Proper Techniques for Urinary Catheter Insertion Residents Affected - Few E. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Category IB) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675635 If continuation sheet Page 8 of 8