Inspection·March 2, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #29's Care Plan revised 4/26/2022 revealed Resident continent of both bowel and bladder during waking hours and sleeping hours incontinent of bladder and at times bowel. The goal was to ensure the Resident #29 maintain current continent status. Observation on 03/01/2023 at 9:00 AM revealed Resident #29 was in her room brushing her hair at the sink. She was clean and well-groomed, and no offensive odor detected. She was alert and oriented and could make her needs known. Observation and Interview on 03/01/2023 at 2:20 PM, revealed Resident #29 was observed in bed. She was alert and oriented. Interview at that time Resident #29 said she was able to go to the bathroom by herself. She said she wore a brief because sometimes she dribbles but she does not go in her brief. She said she goes to the bathroom when she needs to defecate (bowel movement). She said a couple weeks ago she was really sick and was in the hospital and when she got back, she was incontinent for about two days and after that she was going to the bathroom by herself. She said she does not go on herself. Interview on 3/1/2023 at 2:30 PM with the MDS Coordinator, she said Resident #29 was not always incontinent of Bowel. She said the resident goes to the bathroom. At that time, she looked at the MDS and said that the coding was incorrect, and she was going to correct the MDS. Record review of Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy read in part . Purpose/Policy . The purpose of the MDS policy is to ensure each Resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental and psychosocial well-being . Federal regulations at 42 CFR 483.20 require that: 1. The assessment accurately reflects the resident status . , FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 2 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's physical, mental and psychosocial needs for 1 of 6 residents (Resident #9) reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan to address Resident #9's use of indwelling catheter. This deficient practice could place residents at risk of being inappropriately provided care. Findings include: Record review of Resident #9's face sheet, dated 04/19/2018, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: cerebrovascular disease (stroke), muscle weakness (generalized), assistance with personal care, behavioral disturbance, psychotic disturbance, mood, gastrostomy status, hematuria and obstructive and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney) and aphasia. Record review of Resident 9's MDS (quarterly), dated 01/26/2023, revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderately impaired cognition, and did not address indwelling catheter, (section H - bladder and bowel and was always incontinent). Record review of Resident # 9 eMAR-Administration Note, dated 02/18/2023 and 03/01/2023, revealed Foley catheter care every shift. Record review of Resident #9 hospital discharge instructions on 1/15/23 read in part . You have been discharged with an indwelling urinary catheter . Record review of Resident #9 physician's order on 2/18/23 revealed Order Summary: Foley catheter care every shift .Change Foley Catheter using 16 fr 10ml bulb as needed . Record review of Resident #9's Care Plan dated 04/20/2018 and target date for goals 03/15/2023 revealed resident was incontinent of both bowel and bladder. Read in part . Resident will be clean, dry, odor free and will be from sign and symptom of urinary tract infection through next review . There was no care plan to address the resident's catheter. Observation on 02/28/23 on 8:00 a.m. and throughout the survey, Resident #9 was lying in bed with indwelling catheter with yellow urine in bed side drainage bag. Interview on 03/02/2023 at 10:03 a.m., Resident #9 stated He had indwelling catheter when he came back from the hospital. Interview on 03/02/2023 at 10:45 AM with MDS Coordinator, she checked current Care plan and stated I drop the ball and I forgot to care plan for the F/C. I will care plan it now. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 3 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/02/2023 at 11:36 a.m., the DON stated she believed the facility would care plan for use of indwelling catheter and it was the MDS coordinators responsibility for completing the care plans. Interview on 03/02/2023 at 1:41 p.m., with the MDS coordinator who reviewed the care plan and said she should have care planned Resident #9's F/C. However, he was not able to find the care plan for catheter care in Resident #9s EMR. The MDS coordinator further said the reason for care planning F/C was to ensure interventions were effective and she was ultimately responsible for the care plan. Record review of the facility's Nursing Policy and Procedure Manual policy , titled Comprehensive Care Planning, read in part . The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs Each resident will have a person-centered care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 4 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based on 6 errors out of 54 opportunities, which involved 3 of 8 residents (Resident's #2, and #33) and 1 of 2 staff (MA A) and ADON, LVN ) observed during medication administration reviewed for medication error, in that: Residents Affected - Few -MA A did not to administer Eliquis tab (apixaban= is a direct -acting oral anticoagulant used to prevent and treat certain types of blood clots), to Resident #33 as prescribed by the physician. -ADON, LVN did not administer Acetaminophen (medication used for pain) and Docusate liquid (medication used for constipation) to Resident #2 as ordered by the physician. These failures could place residents at risk for not receiving adequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #33 Record review of Resident #33's face sheet revealed a [AGE] year old male admitted to facility on 1/20/2020 and re admitted on [DATE]. His diagnoses included multiple sclerosis (a condition that affects your brain and spinal cord) acute embolism and thrombosis (blood clot) of deep veins of right upper extremity, hyperlipidemia (high lipid/fat), dysthymic disorder, acute kidney failure, and elevation of levels of liver transaminase levels (high liver enzymes). Record review of Resident #33's quarterly MDS dated [DATE] revealed his BIMS was 10 out of 15 indicating he was moderately impaired. Record review of Resident #33's Physician order summary report on 02/28/23 had Active Orders as of: 09/19/2020 read in part .Eliquis Tablet 5 MG (Apixaban)Give 1 tablet by mouth two times a day related to ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY. Do not crush . Record review of Resident #33's MAR on 02/28/23 at 8:00 AM and dates 02/1/2023-02/28/2023 revealed the Eliquis tablet 5 mg (apixaban) give 1 tablet by mouth. two times daily. Do not crush was scheduled for administration at 8:00 AM and 5:00 PM. Observation of medication administration on 2/28/23 at 5: 32 PM revealed, MA A picked up blister packet punched Eliquis tab 5 mg 1 tablet and other medications, crushed it, then put it in chocolate pudding before administering by mouth to Resident #33 (Resident #33's blister pack for Eliquis had Do not crush). Interview with MA A on 2/28/23 at 6:00 PM regarding Resident #33's Eliquis, medication administration, she said Resident liked his medication crushed. Interview with Resident #33 on 3/1/23 regarding medications being crushed stated, the staff always crush my medication, I do not have a problem swallowing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 5 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0759 Level of Harm - Minimal harm or potential for actual harm Interview via telephone with MA A on 3/2/23 at 10:17 AM, she said she had been the medication aide for the facility for 3 years and she had training then. MA A said she did not have recent training and she knew to check Resident medication and blister packet and compare it with the computer. She said she was not aware that Eliquis should not be crushed. She said she would be very careful. Residents Affected - Few Resident #2 Record review of Resident # 2's admission record revealed he was a [AGE] year-old male who was admitted [DATE] and was readmitted on [DATE]. His diagnoses included other sequelae of other cerebrovascular disease (Stroke), sepsis, urinary tract infection, gastrostomy, major depressive disorder, single episode, dysphasia (difficulty swallowing) following unspecified cerebrovascular disease, type 2 diabetes mellitus, bacteremia, acute kidney failure, metabolic encephalopathy, abnormality of albumin, contracture of muscle, dysarthria and anarthria, multiple sclerosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and convulsions. Record review of Resident #2's quarterly MDS dated [DATE] revealed his BIMS was scored 00 indicating he was severely impaired. Record review of physician's order for Resident #2 dated 2/26/23 revealed an order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube two times a day for Pain. On 8/14/2020 Docusate Sodium Liquid 50 MG/5MLGive 5 ml via G-Tube two times a day for Constipation. Record review of Resident #2's MAR on 03/01/23 at 8:00 AM revealed Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube two times a day for Pain. On 8/14/2020 Docusate Sodium Liquid 50 MG/5ML, Give 5 ml via G-Tube two times a day for Constipation. Observation on 3/1/2023 at 8:30 AM of medications administered via G Tube by ADON, LVN, to Resident #2. She placed Acetaminophen 500 mg 2 tabs in a pouch, crushed and dissolved in water, then poured Docusate liquid 7.5 cc in medication cup and administered all medications via Resident #2's G Tube. Interview with ADON, LVN on 3/1/23 at 12:33 PM regarding medication not given via G Tube as ordered by the physician, ADON, LVN stated I was trying to do it fast and she thought she saw Acetaminophen 500 mg on the MAR Screen and she was working too fast. Interview with the DON on 03/01/23 at 1:44 PM, she said her expectation was for the staff to make sure they administered the medications according to the orders and followed physician orders. The DON stated MA A should be following the 5 rights of medication administration. Interview with the Administrator on 03/01/23 at 2:10 PM, he said he expects the nurses to give medication as ordered by the doctor. Record review of the facility's policy for Administrating Oral Medications (revised date October 2003) revealed in part . Steps in the Procedure . 4. Check the medication dose. Re-check to confirm the proper dose . Record review of the facility's Pharmacy Services/Procedures/Pharmacist/Records dated 11/28/17 read (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 6 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0759 Level of Harm - Minimal harm or potential for actual harm in part, . Objective: to provide the appropriate pharmacy services and safe and effective medication use for each resident admitted to the facility . Policy: . The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident . Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 7 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #6) reviewed for significant medication errors. Residents Affected - Few -The facility failed to ensure that Resident #6's blood pressure medications were administered as ordered by his physician. This failure could affect all residents who received blood pressure medications placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: Record review of Resident #6 's admission face sheet dated 03/01/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified atrial fibrillation, spondylolisthesis, lumbar region, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, paranoid schizophrenia dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Record review of Resident #6's quarterly MDS dated [DATE] revealed his BIMS was 14 out of 15 indicating she was cognitively intact. The resident required extensive assistance of one staff for bed mobility, transfers, and personal hygiene. She was always incontinent of bladder and bowel. Record review of Resident #6's consolidated physician's orders dated 12/20/2021, revealed orders for the following medication: -Cardizem Tablet 60 MG (Diltiazem HCl) Give 1 tablet by mouth two times a day, related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE if SBP less than 100 DBP less than 60 or HR (heart rate) less than 60 hold and call M.D. if SBP (Systolic BP = Contracture of the heart) greater than 160, DBP (diastolic BP = heart relaxation) greater than 110 or HR (heart rate) greater than 110 call M.D (Medical Doctor). Observation of medication administration on 3/1/23 at 7:58 AM revealed MA B took Resident #6's blood pressure (BP was 144/106, Pulse =117). MA B punched the Cardizem Tablet 60 MG (Diltiazem HCl) 1 tablet and administered by mouth with other medication. MA B did not notify the nurse or the M.D about the pulse 117. Interview with MA B on 3/1/23 at 12:42 PM, she said she did not tell anyone about the increased pulse . She said she would be letting the nurse know. MA B said she did not know the consequences of high heart rate and she had medication in-services about one year ago, not recent. Interview on 03/01/2023 at 5:30 p.m. the DON stated she expected the nursing staff to take blood pressure before blood pressure, pulse and medications were given. She said if blood pressures and pulse were not within the range of what the physician order, that the medications should be held. She would not have given the medications but would hold the medication and report it to the her or the nurse. If the blood pressure was within normal range, she would give the medications. The DON said MAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 8 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0760 Level of Harm - Minimal harm or potential for actual harm had not had recent in-service on medication administration. She said she will have to in-service MA's and she could not remember when the last in-service was done. Interview with the Administrator on 3/2/23 at 10:30AM, she said she expects the nurses to administer medication as ordered by the doctor and follow the 5 rights of medications administration. Residents Affected - Few Record review of the facility policy titled Medication Administration Procedures revised 2003, Read in part . Step 13: Administering the Medication Pass . When ordered or indicated, include specific item (s) to monitor ( e.g., blood pressure, pulse, blood sugar, weight), frequency( e.g. , weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 9 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of two medication carts (1 medication carts ) reviewed for drug labeling and storage, in that: -Medication cart for nurses had 2 Fluticasone propionate nasal spray USP 50 mcg open and 2 Hibiclean 4% Chlorhexidine gluconate Solution open with no date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: Observation of the nurse's medication cart on [DATE] at 12:55 PM revealed there were 2 bottles of Fluticasone propionate nasal spray USP 50 mcg open with no date and 2 bottles of Hibiclean solution (used for wound cleaning) open not dated Interview with the ADON, LVN on [DATE] at 1:10 PM, she said she was not sure when the 2 Fluticasone propionate nasal spray USP 50 mcg and Hibiclean solution was open and she was going to find out when the medication was open. She said she was not sure how often she was supposed to check the medication cart and was not sure when was the last time she had medication training on labeling was done. Interview with the DON on [DATE] at 3:09 PM, she said the nurses were responsible for dating medications when open for expired medication. The DON said she will be checking the medication cart and do a lot of in-services. Record review of the facility's policy titled recommended medication Storage (Revised 7/2012) revealed in part . Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 10 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 observation, interview and record review, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: Residents Affected - Some -The oil in the deep fat fryer was black. -Dented cans were stored with undented cans. -Foods that are open and not sealed/dated. -Equipment was not cleaned. -There were flies in the Kitchen. These failures could place the residents who ate from the kitchen at risk of risk serious complications from foodborne illness as a result of their compromised health status. Findings Included: Observation of the kitchen on 02/28/23 between 09:15 AM - 10:00 AM revealed the following: 1. In the walk-in-freezer was an open box with sausage patties in an open box not sealed. 2. In the Dry storage room were dented cans of applesauce and Mexican chili beans stored with undented cans. 3. The sliver looking metal racks in the ovens were black. 4. The deep fryer in the kitchen had dirty black looking grease with brown or dark gray substance around it. 5. The baseboard next to the walk-in-cooler and the baseboard at entrance to the dining room from the kitchen at the service area was off the wall. Interview and Observation with the Dietary Manager on 2/28/2023 at 10:00 am, she said the deep fat fryer was scheduled to be cleaned on Thursdays. She than said she was going to get the fryer cleaned in the afternoon. She said at that point, she sealed the sausage patties and discarded the dented cans. She said the Dry storage room should be checked daily to ensure dented cans were not stored with undented cans. She said that the repairs were brought to maintenance, and they were waiting for approval from cooperate. Observation of lunch service on 03/01/2023 at 12:30PM, revealed flies to the back of the kitchen near the dry storage room. Interview on 3/2/2023 at 12:40PM with the Dietary Manager, she said the flies must have gotten in the kitchen by the staff leaving the back door open. She said the pest control company usually comes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 11 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 Residents Affected - Some to the facility monthly and as needed to treat insects. She said there was fly trap at the door but was removed when the new company took over. She said she was going to call the pest control company to come and treat the flies and ensure the back door was always closed. Record review of the Dietary Services Policies & Procedure Manual dated 2012 read in part . Food Safety: .We will ensure all food purchase shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal and local laws, and regulations. Food shall be handled in a safe manner . 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly . 7. Dented or otherwise damaged cans will not be used, unless inspected by the dietary service manager and found not to be dented on the top or seam, and not perforated. Dented cans will be stored in a separate location and return to the vendor for credit . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 12 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure a person was designated as the infection preventionist had completed specialized training in infection prevention and control for the facility in that: Residents Affected - Few -The facility Infection Control Nurse was not certified. -The facility Infection Control Nurse was not experienced in infection control and did not have the knowledge to perform the role. This failure could have placed the residents at risk for infectious outbreaks as the Infection Preventionist did not have the knowledge necessary to prevent infections from occurring. Findings included: On 3/1/2023 at 1:56 pm the Surveyor presented the ADON who was the designated infection control nurse with a copy of the facility's Antimicrobial Stewardship which contained the protocols for Urinary Tract Infections, Suspected Skin and Soft Tissue Infection, Suspected Lower Respiratory Tract Infection and Fever with Unknown Focus of Infection. The ADON said she did not recognize the protocols nor the facility Antimicrobial Stewardship. Interview with the ADON on 3/1/2023 at 1:57pm, she said she had been doing Infection Control since December. She said the CDC has 20 modules to get certified. About 20 hours. She said she was taking the course and was about halfway through the course. Interview with the DON on 3/1/2023 at 14:00 she said the ADON was doing infection control and it was discussed in the mornings when they had new antibiotics. She said they have hired some new people and were waiting for onboarding as corporate would like for them to be doing their duties. She said they would prefer them doing just their jobs as DON and ADON. She said the expectation for the ADON position was infection control, staffing, monitoring documentation, and perform in-serviced. Interview on with the Administrator on 3/1/2023 at 2:11pm, she said the job responsibilities of the ADON were, infection control and assistant for the DON. She said she was also support for the charge nurses, so they report to her. Interview with the Administrator on 3/2/2023 at 08:52am, she said when someone who takes the role as infection control nurse and was not certified you can have an outbreak and have a very bad outcome with infections with the residents. Interview with the Regional Nurse on 3/2/2023 at 09:10am, he said if an infection control nurse was not certified they could have an outbreak of infections at the facility and this can have an adverse effect on the residents. Record review of the facility's job description titled, Assistant Director of Nursing, dated 2014, read in part . participation in Infection Control. Record review of the facility's infection control policy titled, Antimicrobial Stewardship, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 13 of 14 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2019, read in part licensed nursing staff will receive training related to antibiotic stewardship, the facilities criteria for initiating antibiotics .this training will occur as part of the nurses orientation. Record review of the facility's infection control plan titled, Infection Control Plan: Overview, dated 2019, read in part The facility will establish and maintain an Infection Control Program designed to .help prevent the development and transmission of disease and infection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675899 If continuation sheet Page 14 of 14