Health inspection·February 2, 2025

F 0925 Level of Harm - Minimal harm or potential for actual harm Review of Resident #7's quarterly MDS assessment, dated 12/2/2024, reflected a BIMS of 15, indicating cognition was intact. Review of Resident #7's care plan, revised on 6/26/2023, reflected an ADL self-care deficit related to aspiration pneumonia and COPD. Residents Affected - Some Observation on 2/2/2025 at 10:10am of Resident #1's room revealed an over the bed roll tray positioned to the side of the bed. The area underneath the table and directly under the bed was noted to have 20 live roaches, in various sizes and colors, crawling on the floor and under the bed. Resident #1 laid on the bed appearing to be asleep. Continued observation of the room next door, 2208 revealed one live roach crawling on the connecting wall. During an observation and interview on 2/2/2025 at 12:50pm with the Maintenance Director revealed he was not aware of there being a roach problem on hall 2200. He stated they have been having the building sprayed frequently and he thought the pest issues had improved. Observations were made with the Maintenance Director in Resident #1's room, which had been cleaned since observations earlier in the day. Roaches were not observed. Continued observation while reentering the hallway revealed Resident # 7 approached the Maintenance Director and asked if he had told the surveyor about the nest of roaches they had found today in her room underneath her roll tray table. The Maintenance Director responded I took it out of your room and put it here pointing to a tray table in the hallway outside room [ROOM NUMBER]. During an interview on 2/2/2025 at 10:16am with Resident #7's room, which was across the hall from room [ROOM NUMBER], revealed she does have issues with roaches in her room. Resident #7 stated she does not have as many as she has seen crawling in Resident #1's room but she does have them. She stated they do have people from a pest company come spray the rooms but it was not working whatever they are spraying. During an interview on 2/2/2025 at 10:45am with Resident #6 in room, 2310, revealed she and her roommate have seen some bugs in their room recently. Resident #6 stated there are not as many bugs as there had been previously. During an additional interview on 2/2/2025 at 1:05pm with the Maintenance Director who clarified that no one had told him about the roach problem on 2200 prior to today. He explained the staff are supposed to be documenting any sightings of pest in the Sighting's Log which the technician from the pest control company will look at and initial when they come to spray. During an interview on 2/2/2025 at 1:47pm with CNA A revealed he has seen roaches in the facility second floor and notifies the maintenance person. CNA A stated he also has seen that a pest control company does come out to spray. During an interview on 2/2/2025 at 2:47pm with CNA B revealed she had recently informed the nurse that there were roaches on the 2200 hall. CNA B stated she believed that the roaches are from a previous resident that had been storing food in the wall. CNA B stated she has not personally seen the pest control technician but believes one was coming because the bait traps are being changed. During an interview on 2/2/2025 at 2:55pm with CNA C revealed he currently works with residents on the 2400 hall. He stated they do not have a problem with roaches. CNA C stated he worked with Resident #1 a long time ago he had roaches then too. He stated when he sees pests he reports to the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2025 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 - Some During an interview on 2/2/2025 at 3:23pm with RN D revealed he has not seen any roaches on the 2200 hall. RN D stated if staff told him about seeing roaches he would document in the sightings log. RN D stated as old as the building was that they are in, bugs are expected. He has seen the pest control men spraying the building. During an interview on 2/2/2025 at 3:45pm with the facility DON revealed she knew there were still bugs in the facility and that they had been trying to get rid of them. She stated there used to be pest in the offices and conference rooms and they do not now so she knows the treatments from the pest control company have made a difference. The DON stated they are having the building sprayed frequently as they know the pest are not good for the residents. The DON stated that the building is over [AGE] years old so it is hard to get rid of the pests. She does not know if different types of treatments have been tried. Review of the facility's sighting logs from December 31, 2024, through February 2, 2025, reflected the following: Entered: 1/22/2025 Pest sighting description: room [ROOM NUMBER] insects in bathroom door. Entered: 1/22/2025 Pest sighting description: room [ROOM NUMBER] roaches in ceiling/Bathroom Entered: 1/31/2025 Pest sighting description: room [ROOM NUMBER] roaches Entered: 2/2/2025 Pest sighting description: room [ROOM NUMBER] roaches Review of a facility provided Sales Agreement, with a pest control company, with signatures by facility staff dated 11/2016 and 2/24/2017 revealed the initial term of the agreement was 3 years from the date and will be automatically renewed for additional terms of one year thereafter. Visits from the pest control company since 12/31/2024 were noted on 1/2/2025, 1/6/2025, 1/10/2025 and 1/28/2025. Review of the facility's Exercising Your Rights as a Nursing Facility Resident, undated, reflected the following: Your Right to Safety and Quality Care: Freedom From Abuse, Neglect, and Exploitation: You have the right to be free of abuse, neglect, and exploitation. People inside or outside of the facility must not harm you physically or mentally or misuse your property or money. Your facility must: o Protect you from abuse, neglect, and exploitation. o Train all staff on how to prevent, identify, stop, and report abuse, neglect, and exploitation. Safe Surroundings: You have the right to a safe, clean, and comfortable home environment. The facility must: o Have enough housekeeping and maintenance staff to keep the building clean and safe. o Clean your room daily. o Have a pest control program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2025 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 - Some Quality Care: You have the right to receive all the care necessary for you to have the highest possible level of health. This includes medical care, mental health care, rehabilitative therapies, and supplies. The facility must have enough staff to provide you with care and respond to your needs. Facility staff must be qualified and trained to care for you. Your Right To Be Treated With Dignity and Respect: You have the right to be treated with dignity and respect. You have the right to courtesy and fair treatment from facility staff. Being treated with dignity and respect also means you have the right to make decisions about your life and care. Your facility must respect your choices and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 4 of 4