Health inspection·May 24, 2024

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings were: Record Review of the Employee Service List, undated, revealed the Dietary Manager with a hire date of 11/20/2015 and a re-hire date of 12/2/2016 During an interview on 05/23/24 at 1:20 p.m., with the Dietary Director he revealed he had not completed the certified Dietary Manager course which was started in 11/23 but he hoped to have it completed in the next three months. The Dietary Director stated he had been working in the facility's kitchen as a cook prior to becoming the Dietary Manager in 09/23. The Dietary Manager stated he felt completion of the dietary manager course would help him to better manage the kitchen, work with Resident menus, and better understand the recommended resident diets. During an interview on 05/23/24 from 1:45p.m., to 2:00p.m., with the Human Resource Director and the Administrator, the Administrator stated she felt having the Dietary Director enrolled in the certified dietary manager course had met the facility's requirement. The Administrator stated she felt the Dietary Director finishing the certified manager's course would help him to better manage the kitchen. The Human Resource Director stated the facility did not have a policy on employees maintaining their licenses or certifications. The Human Resource Director stated the Dietary Director's completion of the certified manager's course would help him to teach the kitchen manager role to others if there was a need. Record review of the Dietary Food Service Supervisor Job Description dated 8/1/23 revealed the Food Service Supervisor was responsible for the daily operations of the dietary department, according to facility policy and procedures and federal/state regulations. The Job Description revealed an additional discussion section dated 9/1/24 which authorized the payment for the Certified Dietary Manager Course. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675815 If continuation sheet Page 2 of 6 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 675815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingsville Nursing and Rehabilitation Center 3130 S Brahma Blvd Kingsville, TX 78363 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, 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, in that: Residents Affected - Some 1. The Dietary Manager was observed in the kitchen not wearing a beard hair restraint. 2. There were two 6.5 lb bags of sliced strawberries in the freezer that were not dated. 3. There was a bag of tostada chips in the kitchen store- room that was not labeled or dated. 4. There was an electrical outlet in the kitchen that did not have an attached cover on the outlet. 5. There was a ceiling vent in the dish-room that had rust on the sprinkler head and dirt on the ceiling around the vent. 6. There was a ceiling vent in the dish-room that had dirt particles and grease on the vent slats. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 05/21/24 from 9:05 a.m. to 9:50 a.m. during the kitchen tour with the Dietary Manager revealed the following: a. The Dietary Manager was observed in the kitchen not wearing a beard hair restraint. b. There were two 6.5 bags of sliced strawberries in the freezer that were not dated. c. There was a bag of tostada chips in the kitchen store- room that was not labeled or dated. d. There was an electrical outlet in the kitchen that did not have an attached cover on the outlet. e. There was a ceiling vent in the dish-room which measured approximately one foot in diameter that had rust on the attached sprinkler head. There was also dirt on the ceiling surface around the parameter of the ceiling vent. f. There was a ceiling vent in the dish machine room which measured approximately 1x1.5 foot that had dirt particles and grease on the vent slats. During an interview with the Dietary Manager on 05/21/24 at 9:55 a.m., the Dietary Manager stated wearing a hair and beard restraint was important to keep hair from falling onto the floor or food. The Dietary Manager stated it was important for food to be labeled and dated to know when it was out of date. He stated having an attached electrical outlet cover was important for employee safety. The Dietary Manager stated having clean ceiling vents in the dish-room was important to maintain kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675815 If continuation sheet Page 3 of 6 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 675815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingsville Nursing and Rehabilitation Center 3130 S Brahma Blvd Kingsville, TX 78363 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 0812 sanitation. Level of Harm - Minimal harm or potential for actual harm During an interview with the Maintenance Director on 05/21/24 at 1:50 p.m., he stated having the outlet cover on the electrical outlet would be important for employee safety. The Maintenance Director stated having the ceiling vents cleaned in the kitchen was important to maintain kitchen sanitation. Residents Affected - Some During an interview with the Administrator on 05/22/24 at 4:40pm she stated kitchen employees wearing hair restraints would help keep hair from falling onto the floor or into the food. The Administrator stated dating food items in the kitchen helped to establish when the food item should be discarded. The Administrator stated keeping the ceiling vents clean from dirt would have promoted kitchen sanitation. Record review of facility's policy on Employee Sanitation, Policy Number 04.001 dated 2018 stated that hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Record review of the facility's policy on Food Storage, Policy Number 03.003, dated 2018 stated that food items in dry storage rooms and refrigerators should be dated and labeled. Record review of the facility's policy on Fire Containment, Policy Number 05.008 dated 2018 stated electrical outlets were to be checked to make sure they were intact. 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, Non-food-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (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: 675815 If continuation sheet Page 4 of 6 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 675815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingsville Nursing and Rehabilitation Center 3130 S Brahma Blvd Kingsville, TX 78363 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 Based on observation, interview, and record review, the facility failed to establish and 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 diseases and infection for 1 of 5 residents (Resident #51) reviewed for infection control, in that: Residents Affected - Few 1. CNA A and B failed to wash or sanitize their hands or change their gloves after touching items in close proximity of Resident #51 before starting incontinent care. 2. CNA B did not clean between her fingers with hand sanitizer while providing incontinent care. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #51's face sheet, dated 05/23/2024, revealed an admission date of 09/19/2019, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Dementia(decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Parkinsonism (Group of neurological conditions that cause difficulty with movement), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Delusional disorder (A person has one or more fixed and persistent beliefs that are not based on reality). Record review of Resident #51's quarterly MDS assessment, dated 04/15/2024, revealed Resident #18 had memory problem, and was severely cognitively impaired. Resident #51 required total care and, was frequently incontinent of bowel and bladder. Record review of Resident #51's care plan, dated 09/19/2029, revealed a problem of is at risk for skin breakdown as evidence by bladder incontinence, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. 1. Observation on 05/23/24 at 11:30 a.m. revealed while providing incontinent care for Resident #51, CNA A after putting gloves on, touched the bed remote and the call light that were on Resident #51's bed and then without changing her gloves or sanitizing her hands touched the wet wipes that were going to be use on the resident to provide care. CNA A touched the bed remote again to lower the head of the bed. Both CNA A and CNA B touched the pillow under Resident #51's feet to remove it from under his feet. Both CNAs started the incontinent care for the resident without changing their gloves or sanitizing their hands. During an interview on 05/23/2024 at 12:00 p.m. with CNA A and CNA B confirmed the environment around the resident was considered dirty and they should have changed their gloves and sanitized their hands prior to providing care. They confirmed they received infection control training within the year. During an interview with the DON on 05/23/2024 at 3:50 p.m., she confirmed the environment around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675815 If continuation sheet Page 5 of 6 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 675815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingsville Nursing and Rehabilitation Center 3130 S Brahma Blvd Kingsville, TX 78363 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 the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Residents Affected - Few Record review of the annual skills check for CNA A revealed CNA A passed competency for infection control on 02/16/2024. Record review of the annual skills check for CNA B revealed CNA B passed competency for infection control on 01/29/2024. Record review of the facility policy, titled Infection prevention and control program , dated 05/13/2023, revealed All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. 2. Observation on 05/23/24 at 11:30 a.m. revealed while providing incontinent care for Resident #51, CNA B used hand sanitizer 3 times between change of gloves. For 2 of the 3 times, CNA B did not rub the sanitizer between her fingers. During an interview on 05/23/2024 at 12:00 p.m. with CNA B confirmed she should have rubbed between her fingers every time she used the hand sanitizer. She confirmed she received training in hand washing within the year. During an interview with the DON on 05/23/2024 at 3:50 p.m., she confirmed the CNA should have rubbed the sanitizer between her fingers to completely sanitize her hands and that it could be a cause for infection to the resident. She confirmed the staff were in-serviced in infection control and hand washing and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Record review of the annual skills check for CNA B revealed CNA B passed competency hand washing on 01/29/2024. Record review of the facility policy, titled hand Hygiene , dated 10/24/2022, revealed Hand hygiene technique when using an alcohol based hand rub [ .] rub hand together, covering all surfaces of hands and fingers until hands feel dry FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675815 If continuation sheet Page 6 of 6