Inspection·August 13, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time.Record review of Resident #1's incident report conducted by Administrator/Abuse Coordinator dated 06/26/25 at 7:05 AM, Incident revealed Resident #1 wondered to Resident #2 doorway. When Resident #1 was leaving Resident #2 pushed Resident #1 from behind and caused her to fall to her knees in the hall and causing small abrasions to both knees. Resident #2 is a [AGE] year-old female initially admitted on [DATE] with diagnosis of Alzheimer's Disease with early onset, frontotemporal neurocognitive disorder, dementia with behavior disturbance, restlessness and agitation, insomnia, major depressive disorder, personal history of urinary tract infections.Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 05-severe cognitive impairment and needed extensive assistance with all ADLs no behaviors were noted in the assessment. Record review of Resident #2's Care Plan date initiated 06/26/25 revealed, the resident has an ADL self-care performancedeficit related to a diagnosis of Dementia. Resident #2 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits Resident #2 is at risk for distressed and fluctuating mood symptoms related to anxiety and depression. Resident #2 displays agitation and restlessness and prefers to eat meals away from other residents due to anxiety and noise. Monitor, document, and report as needed any adverse reactions to anti-anxiety therapy like drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and impulsive behavior, hallucinations. judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects include Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Resident #2 is at risk for distressed and fluctuating mood symptoms related to Anxiety and depression. Magnetic Stop sign placed across resident door to alert residents not to enter residentdemonstrated ability to remove stop sign from door to exit and enter room. Record review of Resident #2's progress notes by night nurse LVN dated 06/26/2025 at 4:48 AM revealed Resident #2 to be noted with increased agitation and aggression this morning. Resident pushed another resident in hallway due to other resident wandered into her room. Progress notes dated 06/26/25 At 5:45 AM revealed Resident #2 was noted in hallway by CNA B yelling out get out of my room. Resident seen pushing another resident from the back.Resident stated well she was in my room. Resident redirected back to her room by CNA B. Head-to-toe assessment done with no injuries noted. No c/o pain or discomfort. Director DON and physician were notified patient family responsible party was called and notified. Resident redirected by staff and currently in her room and was put on a one-to-one beginning 06/26/25 that ended on 07/30/25.Record review of Resident #2's Incident report dated 06/26/25 at 7:05 PM, revealed Resident #1 wondered into Resident #2 doorway. When Resident #1 was leaving Resident #2 pushed Resident #1 from behind and caused her to fall to her knees in the hall and causing small abrasions to both knees. Resident # 2 denied pushing Resident #1. Observation on 08/13/2025 at 10:45 AM Resident #2 was observed sleeping in her room with a banner was placed across her doorway with the a stop sign in red letters held with magnets on the door frame. Observation on 08/13/25 at 11:06 AM Resident #1 was observed in the dining room falling asleep in her chair watching TV. In an observation and interview on 08/13/25 at 11:56 AM with Resident #2 revealed she was observed sitting at the dining room table waiting for lunch. Resident #2 looked alert and was able to answer questions. Resident #2 admitted to pushing Resident #1 and stated she was sorry, but she was agitated as Resident#1 had been in her room other times. Resident #2 stated she does not like anyone in her room and was agitated by Resident #1 going in her room, so she told her to leave and pushed her. In an observation and interview on 08/13/25 at 12:05 PM with Resident #1revealed she was sitting at the dining room table waiting for lunch and stared at the wall. The state surveyor attempted to ask her simple questions, and she could not answer any questions. Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675104 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 675104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would just look and the state surveyor and smile. The state surveyor asked other simpler questions, and she still did not respond so the interview was discontinued.In an interview on 08/13/2025 at 11:43 AM with LVN A he stated on his night shift in the 300 women's locked unit on 06/26/25 at 5:15 AM he was called by CNA B to help as a resident had been pushed by another resident to the floor. LVN A stated he was not present when the incident occurred, he was doing other tasks when it occurred. When he arrived, he began to assess the Resident #1 and could not remember if she was on the floor or standing when he arrived but knows he began to assess her. The LVN did not see any major injuries other than some scraps with some redness to both of her knees. The LVN stated Resident #1 did not complain of pain, and administered a range of motion exam which did not show signs of lack of range of motion in her legs. Resident #2 was put on a one-to-one level of supervision for a few days and could not recall how long because he was off from work for some days. Resident #1 was moved to another room down the hall from Resident #2's room to prevent her from wanting to enter Resident #2's room. LVN A stated neither resident had any history of aggression to staff or other residents. The last training on abuse and neglect was given less than a month ago for abuse, neglect, and misappropriation. In a incident of a resident who has fallen the most important concern is the safety of the resident , then assessing the resident for any complaints of pain. If the resident has pain or a body part looks odd should not be move and call ambulance for assistance. In an Interview on 08/13/25 at 1:00 PM with CNA B she stated on 06/26/25 at 5:15 AM she was working in the 300 women's locked unit when an incident between two residents occurred. Resident #1 was wandering around the unit and into Residents #2's room. CNA B stated she kept redirecting Resident #1 each time she tried entering someone's room. The CNA stated as she was done assisting a resident in another room and walking out into the hall, she heard Resident #2 yell out get out of my room and saw Resident #2 push Resident #1 from behind. CNA B stated as she made her way to Resident #1 Resident #2 tried to help her get Resident #1 up and asked Resident #2 to step away. Resident #1 had screamed when she was pushed and fell on her knees. CNA B stated Resident #2 then switch positions and sat on her bottom and waited for nurse to arrive to assess her. CNA B stated LVN A arrived and assessed her, and they both helped her up and she never complained of pain and knees were slightly red. CNA B stated Resident #2 was put on a one-to-one for 4 days. CNA B stated she last received training regarding abuse and neglect the next day after the incident and had another training about 3 weeks ago. CNA B stated if abuse had taken place in any matter the resident was to be removed from the perpetrator and reported to the nurse and try to monitor resident till nurse arrives and if there was someone else involve who caused the injury to keep them away from victim. The CNA stated she knew of no other incidents for either resident in the past with staff or other residents. In an interview on 08/13/2025 at 3:00pm with the DON she said Resident #2 the incident happened during the night shift on 06/26/25 at 5:15 AM in the 300 women's locked unit hall. Immediately after the incident was reported the resident was put on one-to-one to prevent any other altercations. Resident #1 was switched to a room further down the hall so she was not close to Resident #2's room in attempt to prevent Resident #1 from entering Resident #2's room. Resident #1 was asked if she could recall how she sustained her knee scrapes and Resident #1 could not recall the incident or how she fell and scraped her knees. A magnetic banner was put to prevent other residents from entering Resident #2 room and is working very well keeping other residents out of her room. In the past Resident #2 had always just yelled to get out of her room. The DON said Resident #2 stated she never had an altercation with other residents or staff. The DON Stated training was given to all staff regarding abuse neglect and misappropriation the next day. The DON stated Resident #1 is always confused doesn't recognized anyone not even family. The DON stated she get lost (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675104 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 675104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and confused in the unit at times and staff redirect her to the dining room or her room. The DON stated she screams and yells at times when she is touched because she doesn't like to be touched and this was why a head-to-toe assessment was not able to be completed on the resident. The [NAME] said the staff Resident #1 had combative behavior with ADL's when staff attempted to help because she doesn't like to be touch. The DON stated Resident #1 had no history of altercations with other residents and or staff. The DON said preventive measures were care planed and implemented such as the stop sign banner in Resident #2's doorway. Resident #1 stays in the living room, her room, or close to where staff can keep an eye on her. Record review of the facility's Abuse, Neglect and Exploitation policy dated 7/15/25 indicated, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through eh use of technology Event ID: Facility ID: 675104 If continuation sheet Page 4 of 4