Health inspection·April 6, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Observation on 4/5/23 at 09:39 am of Resident #1 revealed her oxygen canister rate was set at 3.5 L/mins. The DON accompanied the surveyor, she confirmed the rate, and changed the rate to 2 L/min. Interview on 04/04/2023with Resident #1, she stated her oxygen rate should be at 2 L/min. She stated she had always used oxygen and that the nurses adjusted her oxygen rate. Residents Affected - Few Interview on 04/05/2023 with the DON revealed for Resident #1, we do not want to go over three liters because of her CHF. It is important to have the oxygen rate correct because it could be harmful for the resident to get too much or not enough oxygen and make it difficult for her to breath. Interview on 4/5/2023 at 11:58 a.m. with LVN A revealed I did not check the oxygen concentrator rate this a.m. or yesterday a.m. and I realized today it was on the wrong rate. We must check the oxygen rates. I was too busy. I have been working so many hours here. I signed off that I checked it but did not actually check the rate. Resident #1 does not adjust her own rate. She has COPD, the wrong rate could make it hard for her to breath and result respiratory distress. Review of the facility policy and procedure titled Oxygen Administration dated revised 05/2007 revealed Turn the unit on to the desired flow rate .reassess oxygen flow meter for correct liter flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675766 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 675766 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901 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, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (#1) of two residents observed for infection control in that: Residents Affected - Few CNA B and CNA C failed to follow infection control requirements while performing incontinent care for Resident #1. This deficient practice could affect residents who receive incontinent care and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters). The findings were: Review of Resident #1's electronic face sheet dated 04/04/2023 revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, (a serious condition that affects the oxygen levels in the blood and can damage vital organs), chronic obstructive pulmonary disease (disease with persistent respiratory symptoms like progressive breathlessness and cough) and congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles that causes fatigue and shortness of breath). Review of Resident #1's quarterly MDS assessment with an ARD of 02/08/2023 revealed Resident #1 always incontinent of bowel and bladder. Further review of the MDS revealed Resident #1 scored an 11/15 on her BIMS which indicated she was moderately cognitively impaired. She could usually understand others. Review of Resident #1's comprehensive person-centered care plan revised date 02/16/2023 revealed Focus .has bowel/bladder incontinence r/t sphincter function .interventions .check as required for incontinence .wash, rinse and dry perineum. Interview on 04/04/2023 at 09:20 a.m. with Resident #1 revealed she was wet and that no one came to change her. She stated she put her call light on but no one came. She stated that most CNA's wear gloves when they provide her care and that others do not. Observation on 04/04/2023 at 09:30 a.m. of CNA C and CNA B perform incontinent care for Resident #1 revealed both CNAs did not sanitize their hands prior to putting on clean gloves. CNA B removed the urine soaked brief and cleaned the resident and did not sanitize her hands prior to putting on clean gloves. She then removed gloves, went out of the room to get a clean draw sheet, came back into the room, and placed the clean draw sheet on the bed under the resident with her bare hands. CNA C took off her dirty gloves and placed them onto the Resident #1's bed. CNA C did not sanitize her hands prior to donning clean gloves. CNA B then put clean gloves on without sanitizing her hands and finished Resident #1's care. Interview on 4/4/23 at 10:20 a.m. with CNA's B and CNA C revealed they had training on infection control. CNA C stated she should have sanitized her hands and not put the dirty gloves onto the resident's bed. She stated she did not know why she did not put the dirty gloves in the trash. CNA B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675766 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 675766 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901 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 stated she should have sanitized her hands before and during incontinent care when she changed her gloves. She stated she should not have managed the clean linen without sanitizing her hands and wearing gloves. She stated she did not know why she did not sanitize her hands and that it could cause cross contamination and could result in the resident getting an infection. Interview on 4/4/23 at 10:41 a.m. with the DON revealed that the CNA's needed to sanitize their hands before putting on clean gloves and between glove changes because it could cause contamination and could result in a urinary tract infection for the resident. Review of CNAs B and C's comprehensive clinical reviews dated 01/11/2023 revealed they were checked off for completing hand hygiene and perineal care. Review of the facility competency check list and procedure titled Perineal Care revealed perform hand hygiene. Apply clean gloves .remove gloves .hand hygiene, apply clean gloves. Review of the facility policy and procedure titled Hand Hygiene revision date 10/2022 revealed Procedure .use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap, (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents .after removing gloves. Review of the facility A Guide to the Usage of Gloves dated 7/2007 revealed When to use gloves .cleaning incontinent resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675766 If continuation sheet Page 4 of 4