Inspection·August 7, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired mobility and incontinence. Interventions included conducted skin inspections weekly and as needed and document findings. Review of shower hall schedule reflected Resident #1 had showers scheduled on Tuesday, Thursday and Saturdays. Review of POC response history for Resident #1 reflected Resident #1 refused a shower on 07/18/2025, 07/23/2025, 07/25/2025 and on 08/01/2025. Further review reflected Resident #1 was bathed twice during her stay at the facility and had a bed bath on 07/21/2025 and a shower on 07/30/2025. Review of Resident #1 dated 07/21/2025 H&P reflected Resident #1 was alert and oriented x 1-2 (oriented to self and family) at baseline and disoriented to place, time and situations which was also baseline. Resident was overwhelmed by below knee amputation and inability to ambulate. Review of Resident #1 nursing progress notes dated 07/18/2025 reflected Resident #1 knows her name and place, but does not know the date, time or day. Further review of progress note dated 07/26/2025 by RN A reflected Resident's back was found to be covered in significant rash by resident's (family member) today. During a discussion between floor CNA and RN A and FM, it was determined that the resident had been refusing showers. Review of progress note dated 07/27/2025 reflected Resident #1 was offered a shower and initially refused, staff provided education on importance of showering as Resident #1 was observed with rashes to her right flank area and back. Resident #1 verbalized understanding and declined shower but agreed to bed bath. Resident #1 received a bed bath and treatment nurse was made aware. Review of progress notes reflected Resident #1's family was not notified prior to 07/26/2025 that she refused showers and bed baths. Review also reflected Resident #1's family was not notified of her shower refusal on 08/01/2025. Review of Resident #1 progress notes reflected NP was not notified that Resident #1 was found with a rash on her back. Review of Resident #1 NP progress note dated 07/29/2025 reflected Resident #1 had some skin irritation to her back per wound care nurse likely to resident refusal to shower. During an interview on 08/07/2025 at 10:49 AM, FM stated that Resident #1 had redness on her back and sores that were bleeding. FM stated that she saw the sores when she visited Resident #1 at the facility. FM stated that she was not informed Resident #1 did not want to bath prior to 07/26/2025. FM stated she went to the facility on [DATE] and assisted with Resident #1's bath and Resident #1 was okay with bathing with FM there. FM stated that due to Resident #1's dementia she became anxious. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that when resident refused showers, the nurse was notified so the nurse could talk with the resident. CNA E stated refusals were documented in the POC. CNA E stated that any changes in skin such as rashes were reported to the nurse immediately. During an interview on 08/07/2025 at 1:33 PM, CNA F stated that if a resident refused a shower, then the nurse was notified, and it was documented in the POC as a refusal. CNA F stated any new rashes were reported to the nurse. During an interview on 08/07/2025 at 2:12 PM, CNA I stated if a resident refused a shower, she would give the resident some time and then report to the nurse if they refused again. CNA I stated refusals were documented and the nurse was notified. CNA I stated any changes in skin or rashes were reported to the nurse. During an interview on 08/07/2025 at 2:24 PM, RN A stated when residents refused a shower the nurse was informed by the CNAs. RN A stated she tried to identify a pattern of refusals from the resident and would then ask the resident. RN A stated if a resident refused showers, the approach may change, and RN A did not want secretions like sweat to weaken the resident's skin. RN A stated staff provided paperwork if a resident refused and RN A would sign and acknowledge the refusal. RN A stated if the resident's family was involved and the facility then she would speak with them about the resident refusing showers. RN A stated she recently tried to get Resident #1 to take a shower but Resident #1 did not want to shower. RN A stated that she then asked FMs to get involved in showers. RN A stated that was the only time she spoke with Resident #1's FM about showers. RN A stated the shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 2 of 9 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 08/07/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refusals did not go on for that long and stated it was about three days. RN A stated family was involved and in a agreement to come to facility on shower days with the CNAs so that Resident #1 was comfortable. RN A stated a rash was found on Resident #1's back and it was filled pustules. RN A stated, it looked like it had been there for a long time. RN A stated Resident #1's skin was dry and the rash had some bleeding and she asked the wound care nurse to take care of it. RN A stated she reported this to the wound care nurse but did not report to the physician. RN A stated, I probably should have reported it to the nurse practitioner and may have gotten an order. RN A stated I don't think I did the right thing, and I should have told the nurse practitioner. RN A stated for new skin issues, she was supposed to report to the nurse practitioner and wound care nurse. RN A stated she was supposed to document any time she reported something to the nurse practitioner. During an interview on 08/07/2025 at 2:42 PM, RN B stated that when residents refused showers, staff should ask the resident again or why the resident refused. RN B stated staff should have offered a different time or the resident could refuse. RN B stated in the meeting, the team was notified of any refused showers. RN B stated if refusals were several days in a row, then she would get the resident's RP involved or family. RN B stated that if there were any changes in the resident's skin such as a rash the nurse would go assess and notify the treatment nurse and put in a note. RN B stated any rash should be reported to the provider and document the notification in the nurses notes. RN B stated that education provided to the resident on the importance of taking showers should be documented in progress note. RN B stated showers were important to the resident's health to keep the resident health overall and prevent skin issues. During an interview on 08/07/2025 at 2:53 PM, TN C stated that after notification of skin issues from the charge nurse were received, an assessment was completed, and the TN would notify the NP to put a treatment in place. TN C stated that the assessment would be documented as a skin and wound note or as an assessment. TN C stated she did not treat Resident #1 and that TN D did. TN C stated that a new rash should have been documented in the assessment or progress wound not and active rash would be reported to the NP. During an interview on 08/07/2025 at 3:00 PM, NP stated she did not recall getting a call regarding Resident #1's rash and read it during a chart review. She stated that she asked TN D for clarification about the rash and TN D stated that Resident #1 took a shower and it went away. NP stated she did not physically look a Resident #1 when she saw her on 07/29/2025 and talked with Resident #1's family. NP stated she would have been expected to be notified of a new rash especially if it was bleeding or had puss. During an interview n 08/07/2025 at 3:05 PM, TN D stated that any changes in skin would have to be reported to the NP right away to initiate treatment as needed. TN D stated she received a report about Resident #1 and when TN D assessed Resident #1 her skin was blanchable and pink and she instructed aides to apply lotion because Resident #1's skin was dry. TN D stated she did not observe any pustules and would have reported it right away. TN D stated she thought there was a note that she followed up and stated that she honestly did not think she put a note in and if she had found something she would have put in a note. TN D stated most likely she completed a head-to-toe assessment, but if she did is should be in Resident #1's chart. TN D stated as far as she knew, Resident #1 was compliant with showers and often had bed baths. TN D stated that showers were important to keep residents clean and free of infection. During an interview on 08/07/2025 at 3:52 PM, the DON stated that her expectation for shower refusals included to notify the charge nurse and attempt to get the resident to take a shower and if not the nurse should document the refusal. The DON stated family got involved if the resident refused several days in a row. The DON stated education should be provided by the nurse to the resident on the benefits of a shower. The DON stated that the nurse should document education provided in the progress notes. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 3 of 9 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 08/07/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON stated showers were important to keep resident's clean. The DON stated Resident #1's family encouraged her to accept help from staff but Resident #1 wanted her family to provider her care. The DON stated hat she did not recall receiving a notification about Resident #1 having a rash. DON stated she did not expect staff to notify her of a rash and she would review it weekly on the wound report. The DON stated that she expected staff to get treatment nurse on board, resident's family and the provider. DON sated when there was a change such as a rash, the nurse would be notified and the treatment nurse as well as the provider. DON stated any assessment should be documented on wound or skin assessment. The DON stated she expected the TN to document in a nurses not that nothing was found if there was no issues. During an interview on 08/07/2025 at 5:00 PM, the ADM stated that he expected change of skin such as a rash were to be assessed and notification to physician to obtain orders for treatment. The ADM stated that the potential risk would be that the resident go untreated. The ADM stated showers were discussed as an IDT and noted in the point of care system and approached by the IDT prospective and a nurse manager and charge was sent down to speak with the resident. The ADM stated the facility always had success with that approach. The ADM stated that shower refusals were primarily handled in-house and notification to the family would be provided is the family is involved and would be contacted to assist with showers. The ADM stated he did not recall anything recently of notifying family to become more involved with showers. The ADM stated that the importance for showers was for hygiene issues. The ADM stated the generation that was cared for have injuries or wound and they wanted to keep the area clean. Review of in-service dated 08/07/2025 with topic of skin conditions and reporting reflected to assess skin which included lesions, color, size distribution and excoriation and notify MD and RP was conducted with nursing staff by DON. Review of facility policy titled Notification of Changes with implementation date of 10/24/2022 reflected the purpose of the policy was in ensure the facility promptly informs the residents, consults the resident's physician, and notifies, consistent with his or her authority, the residents representative when there is a change require notification. Circumstances requiring notification include: signification changes in a residents physical, mental or psychosocial status such as deterioration in health, mental or psychosocial condition. Circumstances that requires a need to alter treatment may include new treatment. Further review reflected: Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally. Event ID: Facility ID: 455599 If continuation sheet Page 4 of 9 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 08/07/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 4 (Resident #3, Resident #4, Resident #5 and Resident #6) of 7 residents reviewed for environment. The facility failed to ensure Resident #3, Resident #4, Resident #5 and Resident #6's linens were free of tears, free of holes or not stained on 08/07/2025. These failures placed residents at risk of discomfort, embarrassment and diminished quality of life. Findings included:Review of Resident #3 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Wernicke's encephalopathy (neurological condition caused by vitamin b1 deficiency), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions) and mood disorder (mental health condition characterized by significant disturbances in a person's emotional state). Review of Resident #3 quarterly MDS dated [DATE] reflected a BIMs score of 11 which indicated mildly impaired cognition. Review of Resident #3 care plan dated 03/13/2025 reflected Resident #3 was dependent on staff for meeting emotional, intellectual, physical and social needs. Observation on 08/07/2025 at 9:37 AM revealed Resident #3's sheets had a hole in it. Resident #3 was not in her room at this time. During an observation and interview on 08/07/2025 at 2:10 PM, Resident #3 stated that she did not notice any holes in her blankets or sheets. Resident stated that her linen looked dirty now, but it did not bother her. Resident's bedding was observed with food crumbs. Review of Resident #4's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of schizophrenia (severe mental health condition that significant impact's a person's ability to think, feel and behave clearly), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness). Review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated moderate cognitive impairment. Review of Resident #4's care plan dated 10/11/2021 reflected communication problem related to dementia and schizophrenia with intervention to anticipate and meet needs. During an interview an observation on 08/07/2025 at 1:01 PM, revealed a small hole observed in Resident #4's sheets. Resident #4 stated that there was a hole in her sheet and that it did not make her feel very good. She stated she sometimes has a hole and depending on the time-of-day staff will give her another blanket or sheet. Review of Resident #5 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of major depressive disorder (serious mental health condition characterized by persistent feelings of sadness), and unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions). Review of Resident #5 annual MDS dated [DATE] reflected a BIMS of 0 which indicated a severe cognitive impairment. Review of Resident #5 care plan dated 06/03/2024 reflected Resident #5 had impaired cognitive function and through process related to dementia. During observation an attempted interview on 08/07/2025 at 1:00 reflected a small hole in Resident #5's sheets. Resident was unable to answer questions due to cognition. Review of Resident #6 face sheet reflected a [AGE] year-old mane admitted on [DATE] with diagnoses of vascular dementia (cognitive difficulty with reasoning and judgement caused by an impaired supply of blood to the brain), type 2 diabetes and chronic kidney disease. Review of Resident #6 annual MDS dated [DATE] reflected BIMS score of 5 which indicated severe cognitive impairment. Review of Resident #6 care plan dated 05/08/2023 reflected Resident #6 had an impaired cognitive function related to multiple strokes. Review reflected Resident #6 had communication problem related to slurring, weak or absent voice with intervention to anticipate and meet needs. Observation on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 5 of 9 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 08/07/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 08/07/2025 at 9:26 AM revealed Resident #6's bed was made with grey blanket with tattered edges. Resident was at an appointment and unable to be interviewed. Observation of clean linen on 08/07/2025 at 12:45 PM, reflected beige blanket with tattered edges and folded white flat sheet with a yellow stain. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that she has not seen linen with any holes and if they were observed they would be sent back to laundry. CNA E stated it was not okay for residents to have blankets that were tattered or with holes. CNA E stated she was not aware Resident #6's blanket was tattered. During an interview on 08/07/2025 at 1:33 PM, CNA F stated that he has seen linen with holes, but if he saw them he threw them away. CNA F stated it was not okay for a resident's blanket to be in a tattered condition. During an interview on 08/07/2025 at 2:12 PM, CNA I stated she has not observed linen with holes or stains. She stated if she did observe holes or stains, she would change the linen. During an interview on 08/07/2025 at 2:19 PM, LA G stated that if looked at linen after they were washed and if they still had marks on it they were discarded. LA G stated if linen were observed with holes they were also discarded. LA G stated no linen should be provided to residents with holes or stains and that her supervisor ordered new linen often. During an interview on 08/07/2025 at 2;24 PM, RN A stated she has sometimes seen bedspreads with stains after they were washed but it was not frequent. RN A stated that she had not heard what to do if linen was observed stained. RN A stated that linen with holes was thrown away but has not seen any linen with holes. During an interview on 08/07/2025 at 3:52 PM, the DON stated that she expected staff to get rid of any stained, tattered or linen with holes. The DON stated it was important for residents to have linen without holes or stains because it could be a dignity issues. During an interview on 08/07/2025 at 4:05 PM, HSK H stated that she expected staff to dispose of linen with holes or stains and that they should not return to the residents. HSK H stated she ordered new linen every month. During an interview on 08/07/2025 at 5:00 PM, the ADM stated he expected for torn or stained linen to be disposed of. The ADM stated HSK H ordered linen monthly. Review of facility in-service dated 08/07/2025 reflected all stained linen must be disposed of and it was not to be kept training was conducted with laundry staff. Review of invoice dated 07/03/2025 reflected blankets were shipped on 07/03/2025 to the facility. Review of purchase order dated 07/04/2025 reflected pillowcases ordered were shipped to the facility on [DATE]. Review of purchase order dated 07/04/2025 reflected towels, fitted sheets and washcloths were shipped to the facility on [DATE]. Review of purchase order dated 08/04/2025 reflected, bath towels, flat sheets, fitted sheets, and pillowcases orders was approved by the ADM. Facility provided policy titled Exercising Your Rights by the State Long-Term Care Ombudsman Program dated 10/2024 as their Resident Rights policy. Review reflected you have the right to a safe, clean and comfortable environment and you have the right to be treated with dignity and respect. Event ID: Facility ID: 455599 If continuation sheet Page 6 of 9 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 08/07/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to assess Resident #1 and report a new rash to the physician on 07/26/2025. There were no orders added for rash/skin treatments from 07/26/2025 to 08/07/2025 for Resident #1. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 08/05/2025 with diagnoses of osteomyelitis (bone infection), encounter for orthopedic aftercare following surgical amputation (need for care and monitoring after amputation), encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (need for care and monitoring on outer layers of skin), acquired absence of right leg below knee(amputation of leg below knee), phantom limb syndrome with pain (condition where individuals experience pain in a limb that has been removed), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions), depression (mood disorder characterized by persistent feelings of sadness and loss of interest in activities that were once enjoyable), and adjustment disorder(condition where a person experiences emotional or behavioral symptoms in response to a stressful life event or change). Review of Resident #1 admission MDS dated [DATE] reflected BIMS score of 10 which indicated moderate cognitive impairment. Further review reflected Resident #1 sometimes felt lonely or isolated from those around her. Review reflected Resident #1's current behavior status, care rejection or wandering was worse than previous assessments. Review of section F reflected it was very important for Resident #1 to have family involved in discussions about her care. Review of section m reflected resident was at risk of developing pressure ulcers with only skin alterations as surgical wounds. Review of Resident #1 care plan dated 07/24/2025 reflected Resident #1 did not let staff assist her and preferred wanted family to provider her care. Interventions included to explain or reinforce why behavior or inappropriate or unacceptable to Resident #1. Further review reflected Resident #1 has impaired cognitive function or impaired through processes related to dementia with interviews to communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of care plan dated 08/06/2025 reflected Resident #1 was at risk for impaired skin integrity related to impaired mobility and incontinence. Interventions included conducted skin inspections weekly and as needed and document findings. Review of Resident #1 orders reflected there was no orders added for rash/skin treatments from 07/26/2025 to 08/05/2025. Review of skin assessments reflected no skin assessment was conducted for Resident #1 on 07/26/2025 after the rash was found. Review of Resident #1 skin assessment dated [DATE] reflected no new skin issues were found. Review of Resident #1 skin assessment dated [DATE] reflected no new skin issues were found. Review of Resident #1 dated 07/21/2025 H&P reflected Resident #1 was alert and oriented x 1-2 (oriented to self and family) at baseline and disoriented to place, time and situations which was also baseline. Resident was overwhelmed by below knee amputation and inability to ambulate. Review of Resident #1 nursing progress notes dated 07/18/2025 reflected Resident #1 knows her name and place, but does not know the date, time or day. Further review of progress note dated 07/26/2025 by RN A reflected Resident's back was found to be covered in significant rash by resident's daughter today. During a discussion between floor CNA and RN A and FM, it was determined that the resident had been refusing showers. Review of progress note dated 07/27/2025 reflected Resident #1 was offered a shower and initially refused, staff provided education on Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 7 of 9 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 08/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few importance of showering as Resident #1 was observed with rashes to her right flank area and back. Resident #1 verbalized understanding and declined shower but agreed to bed bath. Resident #1 received a bed bath and treatment nurse was made aware. Review of progress notes reflected Resident #1's family was not notified prior to 07/26/2025 that she refused showers and bed baths. Review also reflected Resident #1's family was not notified of her shower refusal on 08/01/2025. Review of Resident #1 progress notes reflected NP was not notified that Resident #1 was found with a rash on her back. Review of Resident #1 NP progress note dated 07/29/2025 reflected Resident #1 had some skin irritation to her back per wound care nurse likely to resident refusal to shower. During an interview on 08/07/2025 at 10:49 AM, FM stated that Resident #1 had redness on her back and sores that were bleeding. FM stated that she saw the sores when she visited Resident #1 at the facility. FM stated that she was not informed Resident #1 did not want to bath prior to 07/26/2025. FM stated she went to the facility on [DATE] and assisted with Resident #1's bath and Resident #1 was okay with bathing with FM there. FM stated that due to Resident #1's dementia she became anxious. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that any changes in skin such as rashes were reported to the nurse immediately. During an interview on 08/07/2025 at 1:33 PM, CNA F stated any new rashes were reported to the nurse. During an interview on 08/07/2025 at 2:12 PM, CNA I stated any changes in skin or rashes were reported to the nurse. During an interview on 08/07/2025 at 2:24 PM, RN A stated when residents refused a shower the nurse was informed by the CNAs. RN A stated she tried to identify a pattern of refusals from the resident and would then ask the resident. RN A stated if a resident refused showers, the approach may change, and RN A did not want secretions like sweat to weaken the resident's skin. RN A stated staff provided paperwork if a resident refused and RN A would sign and acknowledge the refusal. RN A stated if the resident's family is involved and the facility then she would speak with them about the resident refusing showers. RN A stated she recently tried to get Resident #1 to take a shower but Resident #1 did not want to shower. RN A stated that she then asked FMs to get involved in showers. RN A stated that was the only time she spoke with Resident #1's FM about showers. RN A stated the shower refusals did not go on for that long and stated it was about three days. RN A stated family was involved and in a agreement to come to facility on shower days with the CNAs so that Resident #1 was comfortable. RN A stated a rash was found on Resident #1's back and it was filled pustules. RN A stated, it looked like it had been there for a long time. RN A stated Resident #1's skin was dry and the rash had some bleeding and she asked the wound care nurse to take care of it. RN A stated she reported this to the wound care nurse but did not report to the provider. RN A stated, I probably should have reported it to the nurse practitioner and may have gotten an order. RN A stated I don't think I did the right thing, and I should have told the nurse practitioner. RN A stated for new skin issues, she was supposed to report to the nurse practitioner and wound care nurse. RN A stated she was supposed to document any time she reported something to the nurse practitioner. During an interview on 08/07/2025 at 2:42 PM, RN B stated that when residents refused showers, staff should ask the resident again or why the resident refused. RN B stated staff should have offered a different time or the resident could refuse. RN B stated in the meeting, the team was notified of any refused showers. RN B stated if refusals were several days in a row, then she would get the resident's RP involved or family. RN B stated that if there were any changes in the resident's skin such as a rash the nurse would go assess and notify the treatment nurse and put in a note. RN B stated any rash should be reported to the provider and document the notification in the nurses notes. RN B stated that education provided to the resident on the importance of taking showers should be documented in progress note. RN B stated showers were important to the resident's health to keep the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 8 of 9 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 08/07/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete health overall and prevent skin issues. During an interview on 08/07/2025 at 2:53 PM, TN C stated that after notification of skin issues from the charge nurse were received, an assessment was completed, and the TN would notify the NP to put a treatment in place. TN C stated that the assessment would be documented as a skin and wound note or as an assessment. TN C stated she did not treat Resident #1 and that TN D did. TN C stated that a new rash should have been documented in the assessment or progress wound not and active rash would be reported to the NP. During an interview on 08/07/2025 at 3:00 PM, NP stated she did not recall getting a call regarding Resident #1's rash and read it during a chart review. She stated that she asked TN D for clarification about the rash and TN D stated that Resident #1 took a shower, and it went away. NP stated she did not physically look a Resident #1 when she saw her on 07/29/2025 and talked with Resident #1's family. NP stated she would have been expected to be notified of a new rash especially if it was bleeding or had puss. During an interview n 08/07/2025 at 3:05 PM, TN D stated that any changes in skin would have to be reported to the NP right away to initiate treatment as needed. TN D stated she received a report about Resident #1 and when TN D assessed Resident #1 her skin was blanchable and pink and she instructed aides to apply lotion because Resident #1's skin was try. TN D stated she did not observe any pustules and would have reported it right away. TN D stated she thought there was a note that she followed up and stated that she honestly did not think she put a note in and if she had found something she would have put in a note. TN D stated most likely she completed a head-to-toe assessment, but if she did it should be in Resident #1's chart. TN D stated as far as she knew, Resident #1 was compliant with showers and often had bed baths. TN D stated that showers were important to keep residents clean and free of infection. During an interview on 08/07/2025 at 3:52 PM, the DON stated that she did not recall receiving a notification about Resident #1 having a rash. DON stated she did not expect staff to notify her of a rash and she would review it weekly on the wound report. The DON stated that she expected staff to get treatment nurse on board, resident's family and the provider. DON sated when there was a change such as a rash, the nurse would be notified and the treatment nurse as well as the provider. DON stated any assessment should be documented on wound or skin assessment. The DON stated she expected the TN to document in a nurses note that nothing was found and if there were no issues. During an interview on 08/07/2025 at 5:00 PM, the ADM stated that he expected change of skin such as a rash were to be assessed and notification to physician to obtain orders for treatment. The ADM stated that the potential risk would be that the resident go untreated. Review of in-service dated 08/07/2025 with topic of skin conditions and reporting reflected to assess skin which included lesions, color, size distribution and excoriation and notify MD and RP was conducted with nursing staff by DON. Review of facility policy titled Notification of Changes with implementation date of 10/24/2022 reflected the purpose of the policy was in ensure the facility promptly informs the residents, consults the resident's physician, and notifies, consistent with his or her authority, the residents representative when there is a change require notification. Circumstances requiring notification include: signification changes in a residents physical, mental or psychosocial status such as deterioration in health, mental or psychosocial condition. Circumstances that requires a need to alter treatment may include new treatment. Further review reflected: Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally. Event ID: Facility ID: 455599 If continuation sheet Page 9 of 9