Health inspection·March 10, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Administrator on 3/09/22 at 3:00 PM, she said the DON just audited the medication carts last night, on 3/08/2022, and she missed those medication. Interview with the DON on 3/10/2022 at 10:55 a.m. revealed whatever nurse was on shift and the medication aide checked the medication cart for expired medications. The DON said the nurse and medication aide monitored medications and the pharmacist comes to the facility once a month to document and checked for expired medications. The DON knew that giving residents expired medications could change chemical composition of the drugs over time which can render them unsafe or ineffective. DON said expired medications were placed in a Biohazard box and taken to the her Office. Record review of facility policy on storage of medications, dated 2001 MED-PASS, Incorporated. (Revised April 2019) read . store all drugs and biologicals in a safe, secure and orderly manner .#5 .Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676361 If continuation sheet Page 2 of 5 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 676361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Hills Rehabilitation and Healthcare Center 535 S Austin Road Eagle Lake, TX 77434 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, interview and record review the facility failed to 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 infections for 2 of 2 residents (Residents #102 and #24) reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure CNA A washed her hands or used alcohol-based hand sanitizer while performing incontinent care for Resident #102. 2. The facility failed to ensure CNA A washed her hands or used alcohol-based hand sanitizer while performing incontinent and indwelling catheter care for Resident #24. These deficient practices could place residents at risk for infection. Findings include: 1. Record review of the admission sheet for Resident #102 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included tracheostomy status, urinary tract infection, acute embolism and thrombosis of deep veins of upper extremity ( blood clots that travels), candidiasis ( yeast infection grows out of control in moist skin areas of the body), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) , personal history of malignant neoplasm of bladder, personal history of malignant neoplasm ( cancer) of other sites of lip, oral cavity, and pharynx, other abnormalities of gait and mobility and hypothyroidism ( low thyroid) Record review of Resident #102's admission MDS assessment, dated 2/25/22, revealed a BIMS of 14 out of 15, which indicated mild impaired cognition. He required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and was continent of bladder, the resident had a supra pubic catheter. Record review of Resident #102's care plan, dated 2/27/2022, revealed Resident #102 had bowel incontinence related to impaired mobility. Intervention: provide perineal care after each incontinent episode. It also revealed the resident required extensive assistance with one person with personal hygiene. Diflucan Tablet 150 MG (Fluconazole) Give 1 tablet by mouth one time a day every Saturday related to candidiasis (yeast infection grows out of control in moist skin areas of the body), (for 2 Weeks). Do not use harsh detergents, soaps, fragrances, or other irritating substances. Hydrocortisone Cream1 %, apply to affected areas topically two times a day for Rash on both lower arms for 14 Day. Monitor skin rashes for increased spread or signs of infection. Zinc Oxide Ointment 20 % Apply to peri-anal area topically every 12 hours for Rash. Observation on 03/08/22 at 2:07 PM revealed Resident # 102 laid in the bed and the resident pointed to his brief. CNA A entered Resident #102 room to perform incontinent care. CNA A placed a trash bag to lined resident trash can at the bedside, then donned clean gloves without washing her hands. CNA A opened Resident #102's brief, the resident had supra pubic catheter bag lying on the floor at his bed side. The CNA used wet wipes to clean around the penis 3 three times, changed gloves 3 times without using hand sanitizer or washing hands. CNA A did not clean the groin and the inner thighs were beefy red. CNA A then doffed gloves and washed hands, then donned clean gloves. Resident #102 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676361 If continuation sheet Page 3 of 5 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 676361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Hills Rehabilitation and Healthcare Center 535 S Austin Road Eagle Lake, TX 77434 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 repositioned himself to the right side on the bed. Resident #102 had a moderate bowel movement. CNA A cleaned in-between the buttocks 6 times and changed gloves without using hand sanitizer or washing hands. CNA A did not clean around the buttocks. CNA then doffed soiled gloves then used hand sanitizer then donned clean gloves. She then placed a cleaned brief on Resident #102, covered him with the bed linen, then picked up the urine bag from the floor and emptied 800 cc (cubic centimeter) yellow urine in urine jar to discard, Interview with CNA A on 3/8/22 at 2:28 PM revealed she should had done better washing her hands or using hand sanitizer after changing gloves while performing incontinent care. She said she worked PRN (as needed) with the facility and she had training on incontinent care a couple of weeks ago with somebody in the facility. She stated she knew if incontinent care was not done appropriately the resident would have a urinary tract infection, skin breakdown and odors. She said nobody had told her to clean the buttocks and the groin area while the trainer watched her perform incontinent care. Resident #24 2. Record review of the admission sheet for Resident #24 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included seizures (uncontrolled electrical activity between the brain), type 2 diabetic Miletus ( high glucose in the blood), colostomy bipolar disorder, gastro esophageal reflux ( gastric reflux) and hypokalemia ( low potassium). Record review of Resident #24's quarterly MDS assessment, dated 10/21/21, revealed a BIMS of 15 out of 15, which indicated no impaired cognition. He required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always continent of bowel and bladder. Observation on 03/08/22 at 3:15 PM revealed Resident #24 laid in the bed, he had an indwelling catheter with 500 ml of yellow urine to the bedside drainage bag. CNA B performed incontinent and indwelling catheter care. CNA B washed her hands and donned clean gloves from her uniform pocket. She then placed wet wipes on the side of the resident bed, then undid Resident #24's brief. CNA then cleaned the indwelling catheter tubing, not in a circle motion away from the insertion site three times and doffed catheter, without washing her hands or using hand sanitizer. CNA B pulled out clean gloves from her uniform pocket don the gloves and did not open the groin and the buttocks to clean, then fasten the same old brief on. Interview on 3/10/22 at 3:20 PM with CNA B, said she had not completed training for incontinent care. CNA B said she should have washed her hands or used hand sanitizer between gloves changes during incontinent care because it was a risk for infection. C.NA B said she had In an interview on 3/10/22 at 10:06 AM with the ADON/LVN revealed she would be monitoring and in services on incontinent care to CNAs. The ADON/LVN stated it was her expectation that hands be washed or sanitized after removing soiled gloves. The ADON/LVN stated infections could occur. During an interview with the DON on 3/10/2022 at 11:15 AM, the DON said the former ADON just reigned on 2/22/22 and was the one who monitored incontinent care and infection control. She used in-service checklist for CNA A which showed staff were supposed to remove gloves and wash hands or use sanitizer after and before repositioning the resident. The DON stated that it was her expectation the competency checklist be followed. The DON stated not washing or sanitizing hands after removing soiled gloves risked cross contamination and was a concern and it could spread bacteria and infection. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676361 If continuation sheet Page 4 of 5 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 676361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Hills Rehabilitation and Healthcare Center 535 S Austin Road Eagle Lake, TX 77434 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 DON said CNA B just started, and they did not have any skilled check list for incontinent care. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Handwashing/Hand Hygiene policy (Revised August 2019) read in part: .This facility considers hand hygiene the primary means or prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infection. Applying and Removing Gloves- 1. Perform hand hygiene before applying non-sterile gloves . Residents Affected - Few Record review of the facility's Infection Prevention and Control Program (Revised August 2019) read in part: .1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .7. Prevention of Infection- a. Important facets of infection prevention include .: (3). educating staff and ensuring that they adhere to proper techniques and procedures . (7). Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676361 If continuation sheet Page 5 of 5