Health inspection·January 5, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the side table that was used for serving food and water to the resident. There were about 3 chocolate bars and about a dozen candies on the table next to the wipes. Once the brief soiled with feces was removed, CNA A without changing her gloves picked up wipes one by one from the table to clean the buttocks and perineal area of the resident. When the wipes ran out in between the cleaning process, she removed her soiled gloves, washed her hands, and took a new packet of wipes from the drawer and kept it on the table next to the chocolates and candies. CNA A donned new pairs of gloves and started pulling out wipes directly from the packet and continued the cleaning process. After the completion of cleaning, she changed her gloves and dressed the resident with new brief. CNA A then adjusted Resident #43's linen and bed. She then put back the packet with remaining wipes into the drawer. CNA A collected the plastic bag with all the dirty material for disposal. She neither discarded the chocolates and candies nor sanitized the table before the completion of the task and leaving the room. During an interview on 01/04/2023 at 11:00 a.m., CNA A stated she thought she was doing the incontinent care correctly. CNA A stated she should not have used the food table for this purpose in the first place and keeping food products next to the wipes could contaminate the food items with the soiled gloves while reaching out for wipes. CNA A said the packet of wipes got contaminated with her gloves soiled with feces. CNA A stated that the facility provides infection control training once a month. CNA A stated not following infection control protocols was not good for the residents as there was a danger of spreading diseases through contamination. During an interview on 01/05/2023 at 2:00 pm the DON stated CNA A should have used a different surface other than food table with edible materials on it. The DON stated sanitizing the contaminated surfaces after the completion of incontinent care was part of the infection control procedure. The DON stated there was a huge risk of the transmission of communicable diseases and infection through contamination if proper infection control protocols are not followed during incontinent care. The DON stated an in-service program for all the nursing staff members was initiated to address this issue. The DON said there was a registered nurse trained for this purpose who makes regular rounds on the floor to identify deficient practices done by nursing staff. She stated any deficiency or unprofessional practices were addressed with remedial or disciplinary measures. Review of facility's undated policy titled Peri Care reflected: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown . 10. Re-position resident in supine [on back] position. Change gloves if soiled and continue with perineal care . According to the website https://www.cdc.gov/handhygiene/providers/index.html dated January,2021 the Center for Disease Control (CDC) recommended the following for glove use Glove Use: When and how to wear gloves: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 . Change gloves and perform hand hygiene during patient care, if : Level of Harm - Minimal harm or potential for actual harm gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, Residents Affected - Some moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient. Carefully remove gloves to prevent hand contamination. Review of Resident #41's face sheet, dated 01/03/23, reflected Resident #41 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with Unspecified dementia, Chronic diastolic (congestive) heart failure, Idiopathic chronic gout (a common form of inflammatory arthritis of unknown cause), Gastro-esophageal reflux disease ( stomach acids repeatedly flow back), Essential (primary) hypertension, Chronic kidney disease, Hypothyroidism ( insufficient thyroid hormone production), Iron deficiency anemia, Secondary hyperparathyroidism of renal origin, Stress incontinence , Unsteadiness on feet, Muscle wasting , Adjustment disorder with mixed anxiety and depressed mood, Hypokalemia ( low potassium in blood) ,Seasonal allergic rhinitis and Osteoarthritis (a degenerative joint disease). Review of Resident #31's face sheet, dated 01/03/23, reflected Resident #31 initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with Cerebral infarction(stroke), Chronic kidney disease, Unilateral pulmonary emphysema (a one sided lung disease), Peripheral vascular disease (a blood circulation disorder), Abnormalities of gait and mobility, Muscle weakness, Muscle wasting and atrophy (decrease in size and wasting of muscle tissue ) and Essential Hypertension ( High blood pressure). Review of Resident #58's face sheet, dated 01/03/23, reflected Resident #58 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with Type 2 diabetes mellitus , Altered mental status, Atrial fibrillation (irregular heart rhythm) , Chronic kidney disease, Adjustment disorder ( emotional or behavior response to stress), Panic disorder (sudden anxiety attack), Bilateral primary osteoarthritis of knee ( arthritis of knee from wear and tear), Insomnia, Disease of upper respiratory tract ( diseases of nose or nostrils, nasal cavity, mouth, throat (pharynx), and voice box (larynx), Hypomagnesemia (low magnesium level in blood) Hyperlipidemia ( high fat level) , Seasonal allergic rhinitis ( allergic reactions), Pressure ulcer of sacral region ( pressure ulcer of the portion of your spine between your lower back and tailbone) and Lower abdominal pain. An observation of taking blood pressure using a wrist blood pressure monitor on 01/03/2023 at 10:00 am revealed that CNA B failed to sanitize the wrist blood pressure monitor after using it on Resident #41 and before using it on Resident #31 and Resident #58. CNA B took the blood pressure of Resident #41 with the wrist blood pressure monitor and without sanitizing the monitor she kept it on the top of the medication cart. After administering the medications to Resident #41, she moved on to Resident #31 and used the same blood pressure monitor on her without sanitizing it. After the completion of the process, she moved on to Resident #58. When CNA B went into Resident #58's room and was about to apply the non-sanitized monitor on Resident #58's wrist, the surveyor intervened and explained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 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 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 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 the deficient practice. Level of Harm - Minimal harm or potential for actual harm During an interview 01/03/2023 at 10:45 am CNA B, stated she was aware of the necessity of sanitizing the blood pressure wrist monitor every time after the use on residents. CNA B said she practiced this in her whole career as med aide however forgot to do it today most likely because she was nervous. CNA A stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. CNA B stated she received trainings on infection control procedures two months ago and that included sanitation of medical equipment. Residents Affected - Some During an interview on 01/05/2023 at 2pm the DON stated her expectation was that the nursing staff must follow facility policy/procedure for handwashing and sanitization of medical equipment that includes sanitizing blood pressure monitor every time after the use on residents was essential to stop spreading transmittable diseases. The DON stated the incident of non-sanitization of the blood pressure monitor by CNA B was reported to her on 01/03/2023 and CNA B was in serviced immediately and the in-service was extended to all the nursing staff thereafter. During an interview on 01/05/2023 at 3pm the ADM stated all the staff were expected to follow the infection control policies and procedure in all the nursing care activities and that include sanitizing the bedside table after incontinent care and sanitizing medical equipment between residents. He stated CNA B should not have used the table with food items for incontinent care. The ADM said CNA A and CNA B were already retrained on infection control policy specific to sanitizing medical equipment and incontinent care and these trainings were extended to all other staff members. He stated apart from that the facility would be continuing with the routine infection control training program on a regular basis. Review of facility's policy titled Cleaning and disinfection of resident-care items and equipment dated October 2018 revealed it was stated: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . .1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care . .d) Reusable items are cleaned between residents (e.g., stethoscopes, durable medical equipment) . .3.Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident . .4. Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 4 of 4