Inspection·May 19, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ice inside the walls. The lid, base, and inside seal was visibly soiled with a black substance. Observation of the unit temperature revealed it was within range. 4. Observation on 05/16/2025 at 11:20 a.m. revealed the white deep freezer had an accumulation of ice inside the walls. The lid, base, and inside seal was visibly soiled with a black substance. Observation of the unit temperature revealed it was within range. 5. Observation on 05/16/2025 at 11:25 a.m. revealed the kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. 6. Observation on 05/16/2025 at 11:12 a.m. revealed the switch for the vent hood over the stove was covered with blue tape and marked Do Not Touch, underneath the tape was a metal plate with two openings. During an interview with Dietary [NAME] A on 05/16/2025 at 11:12 a.m., Dietary [NAME] A stated the ice machine has a water leak behind it and water is always on the floor. Dietary [NAME] A stated the vent hood over the stove was inoperable. During an interview with Dietary [NAME] A on 05/16/2025 at 12:20 p.m., Dietary [NAME] A stated the drain behind the ice machine was often clogged which resulted in water from the ice machine leaking onto the floor. She stated the issue had been reported to the Maintenance Director and that the Maintenance Director had unclogged the drain several times in the past. Dietary [NAME] A stated the standing water in the double door refrigerator was a result of water dripping from the top of the unit, confirmed the issue had been reported to the Maintenance Director and to the Dietary Manager, and stated the issue had been like that for a long time. Dietary [NAME] A stated she had noted the accumulated ice in the silver refrigerator but not in the white freezer. During an interview with Dietary [NAME] B on 05/16/2025 at 3:00 p.m., Dietary [NAME] B stated the ice machine had been in disrepair for a few months and the double door refrigerator had been in disrepair since last year. During an interview with the Maintenance Director on 05/16/2025 at 2:20 p.m., the Maintenance Director stated the switch for the vent hood over the stove needed to be replaced, that she was actively looking for the correct part to repair the hood, and that the vent hood had been inoperable for approximately one month. The Maintenance Director stated the water under the ice machine was caused by a clog in the drain line and confirmed the clog was a reoccurring issue. She stated it had currently been clogged for approximately three days. The Maintenance Director stated the door gasket for the double door refrigerator had been broken for approximately six months which resulted in condensation leaking from the top of the unit and puddling at the bottom. She stated she had replaced the gasket, but the repair thought she may have utilized an incorrect part since the issue was still ongoing. The Maintenance Director stated the silver refrigerator appeared to need a new seal and stated she believed this was the cause of the accumulated ice and the black substance on the seal. During an interview with the DON on 05/17/2025 at 3:18 p.m., the DON confirmed the double door standing refrigerator had towels and standing water in the bottom of the unit, the silver refrigerator had an accumulation of ice inside the walls and the lid, base, and inside seal was visibly soiled with a black substance, the white deep freezer had an accumulation of ice inside the walls and the lid, base, and inside seal was visibly soiled with a black substance, and the kitchen floors were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. The DON stated she was new to the facility and was unaware of these issues in the facility kitchen. The DON stated it was important to the health of vulnerable residents to serve them meals prepared in a kitchen which was sanitary with equipment in good repair. The DON stated the facility Administrator's last day had been Friday 05/16/2025 and that an interim Administrator would be in the post beginning Monday 05/19/2025. The DON stated she would report the sanitation and equipment issues to the interim Administrator so they may be resolved. Record review of the facility's policy titled, Food Storage, revised June 1, 2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 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, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 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 675938 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shiner Nursing and Rehabilitation Center Inc 1213 N Ave B Shiner, TX 77984 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 1 of 1 dining room reviewed, in that: Residents Affected - Some The dining room air conditioning vents were visibly soiled. This deficient practice could result in residents living, staff working, and families visiting in an unclean and unpleasant environment. The findings were: Observation on 05/16/2025 at 12:00 p.m. revealed the facility dining room had eight air conditioning vents in the ceiling. Further observation revealed each vent was soiled with a black substance and with rust. Further observation revealed the return vent was covered with dust. During an interview with the Maintenance Director on 05/16/2025 at 2:20 p.m., the Maintenance Director confirmed that the eight air conditioning vents in facility dining room were rusty and soiled, and confirmed the return vent in the dining room was covered with dust. The Maintenance Director stated the Housekeeping Department was responsible for cleaning the return vent and that she was responsible for cleaning the ceiling air conditioning vents. She stated she occasionally wiped the vents and sprayed bleach on the black substance but that it was ineffective in removing the substance, adding that she needed to paint the vents. She stated there was no set schedule for cleaning the vents and the last time it had been completed was in October or November of 2024. The Maintenance Director stated she planned to replace the vents because they were rusty and stated it was important for the vents to be clean because residents and staff breathe air that originates with the air conditioning vents. She stated she has cleaned the return vent with a damp cloth to remove the dust and confirmed that the task was currently overdue to be completed. During an interview with the DON on 05/17/2025 at 3:15 p.m., the DON confirmed the eight air conditioning vents in the dining room ceiling were soiled and rusty, confirmed the return vent was dusty, and stated it was important for these fixtures to be clean so that vulnerable residents had access to air from unsoiled vents. Record review of the facility's policy, Physical environment Safe/functional/sanitary/comfortable environment, dated 11/28/2017, revealed, Preventive maintenance will be completed routinely and according to protocol by the [Maintenance Supervisor] or qualified staff. The facility shall provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675938 If continuation sheet Page 4 of 4