Health inspection·August 6, 2024

F 0812 Review of Dietary Manager Daily Checklist dated 2018 revealed food items in coolers are all labeled and dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facilities reviewed for pests control Residents Affected - Many The facility failed to ensure the facility was free from pests/insects in multiple areas including resident rooms, shower room, dining room and kitchen. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable and non-homelike environment free of pests. Findings include: At 10:39 AM on 08/06/2024, a cricket was observed to be in a resident room on the floor. At 10:43 AM on 08/06/2024, an insect wing was observed on the floor of the kitchen and was light brown color. At 10:49 AM on 08/06/2024, a small bug was observed on the floor of the kitchen. At 11:22 AM on 08/06/2024, a small bug was observed crawling under freezer 1 in the kitchen. At 11:24 AM on 08/06/2024, a small bug was observed crawling on the floor in the dry storage area of the kitchen. At 11:31 AM on 08/06/2024, a small bug was observed on the wall near the sink and a small bug was observed on the wall next to clean trays. At 11:34 AM on 08/06/2024 a cricket was observed on the floor next to the wheel of a clear tray cart. At 12:20 PM on 08/06/2024, a small bug was observed on the floor of resident's room. At 12:39 PM on 08/06/2024, several small bugs were observed crawling to and from the drain of the second floor shower room. At 1:45 PM on 08/06/2024, a small bug was observed crawling on the floor of the dining room after lunch service had concluded. During an interview with Resident #1 on 08/06/2024 at 9:51 AM, she stated that she just saw a cockroach come out in her room. She stated that she saw cockroaches in her room often and they have been on the sides of her drawers when she opens her dresser. During an interview on 08/06/2024 at 10:12 AM, Resident #2 stated that he had seen cockroaches in his room and he believed the facility was aware. During an interview on 08/06/2024 at 11:31 AM, DA stated that the bug on the wall next to the sink was a cockroach. He stated that they were everywhere in the building. He stated that pest control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many only came once and wished they came more often. He stated that when he saw cockroaches he usually just killed them. He stated that he had not seen the cockroaches on clean dishes. He stated that they are in the outlet in the hallway and between the wheels of the trash can. He stated that the bug on the wall was next to a clean tray cart and was also a cockroach. During an interview with AFSS on 08/06/2024 at 11:37 AM, he stated that he has worked at the facility for two to three weeks. He stated that he noticed cockroaches shortly after he started. He stated he had not seen cockroaches in food. On 08/06/2024 at 11:39 AM, during an interview with cook A, she stated that she had seen some cockroaches in the kitchen. She stated that she was unsure why they are in the kitchen but had not seen any in the food. On 08/06/2024 at 12:29 PM, during an interview with MA, he stated the bugs in the second-floor shower room were cockroaches. He stated that pest control came every month for official services and as needed if the facility called. He stated that the pest control logs were located at the nurses station and pest control viewed where the sightings were logged and would treat those areas. He stated that the kitchen, exterior and laundry were treated monthly during the pest control visit. He stated that there should not be cockroaches in the kitchen. He stated that the cockroaches were an ongoing issue. On 08/06/2024 at 2:10 PM, during an interview with the FSS, she stated that she had worked at the facility for four years. She stated that she had noticed an increase in cockroaches this year. She stated that there was a hole in the wall behind the steam table and she saw some cockroaches come from there. She stated that she put in a work order for this to maintenance. She stated that roaches should not be in the kitchen and they have the potential for getting into the food. She stated she had not seen any in the food. She stated she was unsure if she told the administrator about the ongoing roach concern. On 08/06/2024 at 2:16 PM, during an interview with cook B, she stated that there were roaches in the kitchen but had not seen any in the food or on the food preparation areas. On 08/06/2024 at 2:35 PM, during an interview with the MD, he stated that he is not sure how long the cockroaches have been an issue. He stated that he has worked at the facility for the last nine years and he has always seen cockroaches in the building. He stated that he requested the facility get a full treatment from pest control. He stated that a full treatment is when the pest control company treats the entire building. The MD stated that it has been over a year and a half since the last time this was done. He stated that he has seen a lot of roaches in the kitchen when the pest control company comes. He stated that pest control usually goes directly into the kitchen. The MD stated that the pest control person had come more frequently but was unsure how often. He stated that administration was aware and a full treatment was requested. The MD stated that staff write down any pest sightings in the binder located at the nurses station and pest control would treat any of those areas during their monthly treatment. On 08/06/2024 at 2:57 PM, the DON stated that cockroaches were not an ongoing issue. She stated that the facility was an old building. The DON stated that if any pests are seen they are put in the book and pest control comes in. She stated there had not been any issues in the last few weeks with cockroaches. The DON stated it was not okay to have several cockroaches in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 08/06/2024 at 3:09 PM, the ADM stated that roaches were an ongoing issue at the facility. He stated that pest control came in monthly and prn. The ADM stated that the facility had an extensive pest control program. He stated that the facility had been remodeling which included removing old carpet, but it was an ongoing challenge. He stated that the facility had an ongoing pest control program and it is designed to maintain and control in all areas of the facility. He stated that the pest control company could come in and do a special treatment and he believed it was scheduled for next week but did not have confirmation. He stated that the facility worked to address the issue. The ADM stated that there was not a pest control policy but stated they have a contract. During an interview on 08/06/2024 at 3:53 PM with the pest control company's regional manager, he stated that the technician that went out to the facility had applications (treatments) set up between the kitchen hallway and several places on the first and second floor of the facility. He stated that the technician found a pocket (source) of German cockroaches in the kitchen and that he was able to get it cleared out. He stated that the pest control company will be out at least once a week to address the ongoing issue. He stated that it was important for the facility to log any sightings. He stated that typically it was the kitchen that was the source because there was food. He stated that there was a potential for the cockroaches to get onto the carts or trays and travel to resident rooms. He stated that a full treatment has been suggested many times before but there were issues with upper management not wanting to spend for the additional services. He stated that the tech had tried to address this several times but received a lot of push back. He also stated that once roaches are present, they have to be treated to get rid of them. Review of sighting log revealed cockroaches were sighted in various places in the facility on 1/3/24, 2/7/2024, 5/9/2024, 5/1/2024, 6/10/2024, 6/12/2024,6/13/2024, 6/14/2024, 6/21/2024, 6/28/2024, 7/18/2024, 07/19/2024, 7/21/2024, 07/25/2024, 07/26/2024, 08/06/2024. These sightings included, resident rooms on the first and second floor of the facility, care manager office, kitchen service hall, kitchen near food prep, and under shower room sink. Review of service report dated 03/30/2024 reflected perimeter of building was baited for ants. Review of service report dated 05/01/2024 reflected entryway, restrooms, kitchen, dish pit, dry storage and several rooms were treated with activity found in kitchen. Review of service reported dated 06/03/2023 reflected several resident rooms were treated for German cockroaches with moderately high activity in all rooms. Further review reflected German cockroach and small fly found in dish pit area. Review reflected exterior of facility was baited for cockroaches. Review of service report dated 7/19/2024 reflected several rooms were treated including soiled linen rooms and care management office for cockroaches. Entryway, restrooms, kitchen and dish pit area were treated as well as common areas, and nurses station. Review reflected that technician would be reaching out to regional maintenance for full building treatment. Review of service reported dated 07/25/2024 reflected that the facility had a follow up service for small cockroaches. Review also reflected that the kitchen, dish pit, service hall, laundry, storage, nurses station, soiled linen, utility closest and several resident rooms on first and second floor were treated for German cockroaches. Review of contract pest company's service agreement revealed that the contract was signed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 0925 09/20/2016 with initial term of 3 years and renewed yearly after. Service agreement revealed that covered pests included cockroaches, rats, mice and ants. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 6 of 6