Health inspection·October 4, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NUMBER] had had a male and a female resident (Resident's #2 and #3) observation also revealed there was no privacy curtain in the room to provide privacy when performing care personal care. During an interview on 10/02/2025 at 11:15 am, Resident #3 stated Resident #2 was his female family member and they were sharing the same room. Resident #3 stated there had not been a privacy curtains in their room since they were admitted to the facility. Resident #3 stated his family oversaw them and they had been sharing rooms in other facilities so he could look out for his Resident #2. Resident #3 stated he did not complain about privacy curtains to the facility staff, but he was not bothered by not having privacy curtains, but it might bother Resident #2. During an interview on 10/02/2025 at 11:20 am Resident #2 stated Resident #3 was her and they were in the same room. Resident #2 stated staff have to provide incontinent care for her in the room while (Resident #3) was in the room. Resident #2 stated it bothered her a lot, but she did not have a choice, the facility had chosen that way for she and Resident #3to be in the facility. Resident #2 stated, there was no privacy, , we will get back to privacy. Resident #2 stated, I didn't grow up dressing in front of daddy. I get embarrassed sometimes but that is what they have chosen for us. But [Resident #3] doesn't stare at me when they are providing care. The way I know is I look at him. During an interview on 10/02/2025 at 1:24 pm, CNA B stated she usually works on the 200 hall. CNA B stated she sometimes helps CNA C to provide care for Resident's in room [ROOM NUMBER]. CNA B stated she had provided care for Residents #2 and #3 including incontinent care. CNA B stated there were no privacy curtains in room [ROOM NUMBER] to provide privacy when performing personal care. CNA stated it was not ok not to have privacy curtains in a room with 2 residents. CNA B stated every resident was supposed to have privacy, it didn't matter if it was mom and son or husband and wife, everyone deserved privacy. CMA B stated, To be honest, I have not brought it to the attention of others. I will tell someone now since you have said it. During an interview on 10/02/2025 at 1:32 pm, LVN A stated Residents #2 and #3 were mother and son and they shared the same room. LNV A stated both Residents #2 and #3 required incontinence care. LVN A first stated the staff provided privacy by pulling the curtains when providing personal care. LVN A then went into room [ROOM NUMBER] and came out stating, I thought there was a privacy curtain, but there were no curtains. LVN A stated no matter who the person was, it was not ok not to provide privacy, even if it was 2 males or 2 females in the room or family, they still needed to provide privacy. Observation on 10/02/2025 at 1:45 pm revealed the Assistant Maintenance Director hanging privacy curtains in room [ROOM NUMBER]. During an interview on 10/02/2025 at 1:46 pm, CNA c stated he usually worked the first 7 rooms on the 200 hall. CNA C stated he had provided care for the residents in room [ROOM NUMBER] including incontinence care. CNA C stated he tried to use sheets to provide privacy when performing incontinence care. CNA C stated there has not been privacy curtains in room [ROOM NUMBER] and he thought it was ok because Residents #2 and #3 were related. CNA C stated he got uncomfortable whenever he was providing incontinence for either of the Resident in room [ROOM NUMBER], that is why he tried using sheets to provide privacy by covering some part of the body. CNA C stated that he did not tell anyone there were no curtains in room [ROOM NUMBER]. During an interview on 10/02/2025 at 1:52 pm, the Assistant Maintenance Director stated the Maintenance Director was off today. The Assistant Maintenance Director stated he was just made aware that room [ROOM NUMBER] did not have a privacy curtain. The Assistant Maintenance Director stated he was just told about the privacy curtain, he did not know there were no privacy curtains in room [ROOM NUMBER]. The Assistant Maintenance Director stated he would think it would be better to have curtains in the rooms for privacy even if the Residents were related. The Assistance Maintenance Director stated the staff sometimes verbally notify the team or document it in their system. During an interview on 10/02/2025 at 1:56 pm, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 2 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator stated she was just told by CNA B that there were no privacy curtains in room [ROOM NUMBER]. The Administrator stated she had heard initially that Residents #2 and #3 requested no privacy curtains, but she had been looking through their clinical records and there was no evidence. The Administrator stated she would reach out to Residents #2 and #3's RP to find out he said no curtains. The Administrator stated the facility had to have a care plan that Residents #2 and #3 did not want privacy curtains. The Administrator later stated, according to the regulation, privacy curtains are needed in every room. During an interview on 10/02/2025 at 2:07 pm, the DON stated she did not know didn't know there were no privacy curtains in room [ROOM NUMBER]. The DON stated it was just brought to her attention that there were no privacy curtains in room [ROOM NUMBER]. The DON stated if the Resident request not have privacy curtains, it shouldn't be in their room. The DON stated she did not look into why there were not privacy curtains in room [ROOM NUMBER]. The DON stated the curtains were in the room to provide privacy.The DON stated, if the residents didn't want the curtains to be pulled, it would be care planned. Review of facility's policy tilted Privacy undated reflected: Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and ImplementationResidents shall be treated with dignity and respect.Staff shall promote, maintain and protect resident privacy, during assistance with personal care and during treatment procedures. Event ID: Facility ID: 675118 If continuation sheet Page 3 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain. The facility failed to provide effective pain interventions for Resident #1 on 09/14/2025. Resident #1 called for emergency transfer to the ER for pain management. An IJ was identified on10/03/2025. The IJ template was provided to the facility on [DATE] at 12:34 pm. While the IJ was removed on 10/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because the facility needs to evaluate the effectiveness of the corrective systemsThese failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life.These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life. Findings included Review of Resident #1's face sheet printed 10/02/2025 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx. Chronic pain syndrome (is a long-term condition characterized by persistent pain that lasts for months or years, significantly affecting daily life. It can arise from various causes, including injury, illness, or underlying medical conditions, and may lead to complications such as depression and anxiety), Migraines with aura (is characterized by sensory disturbances that occur before or during a migraine attack, including visual changes, tingling sensations, and sometimes speech difficulties. The auras typically occur 30 to 60 minutes before the onset of a headache.), contracture left wrist (refers to the tightening and stiffening of the soft tissues around the wrist, which can lead to reduced mobility and function), need assistance with personal care and lack of coordination. Review of Resident#1's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score 15, indicating no impairment. Section J (Health Conditions) reflected pain presence was continuous, Pain frequency was frequent, pain interference with therapy activities was frequent, pain effect on sleep was frequent and pain Numerical rating was 7 on the scale with 10 being the worst pain. Review of Resident 1's care plan initiated 08/15/2025 reflected Resident #1 had chronic pain, muscle spasms and neuropathy (is a condition that occurs when the peripheral nerves are damaged, leading to symptoms such as tingling, burning, or numbness in the affected areas, typically the legs, feet, arms and hands.) and Resident #1 took pain medication. It was also reflected Resident #1 was at risk for GI upset (Gastrointestinal -GI encompasses various conditions affecting the digestive system) due to abdominal pain, nausea and vomiting and GERD (GERD-Gastroesophageal Reflex Disease is a chronic disease where the stomach contents flow back to the esophagus, leading to symptoms like heart burns, regurgitation, and inflammation.) with intervention to give analgesia (pain) medication as ordered. Review of Resident #1's physician orders reflected an order dated 08/14/2025 for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #1's Narcotic count sheet reflected Resident #1 was admitted with 5 pills of Oxycodone 5mg on 08/14/2025. It also reflected that Resident #1 Oxycodone 5 mg was administered on the following dates:08/20/2025 at 7:04 pm08/21/2025 at 5:14 am 08//22/2025 at 11:00 pm08/25/2025 at 5:20 am 08/25/2025 at 10:00 pm Review of Resident #1's MAR/TAR reflected:Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain was given on 08/20 and 08/21/2025 for pain level of 7 on the scale 0-10. There was no evidence that Resident #1 was given pain medication in the month of September. Review of Pharmacy receipt for Resident #1 from 08/14/2025 through 10/02/2025 reflected Oxycodone 5 mg was never filled out by the local pharmacy. Review of Resident Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 4 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1's hospital records reflected the following:Hospital record dated 08/31/2025 reflected: Reason for visitAbdominal pain. Diagnosis - Diarrhea. Treatment -Morphine (pain medication) given at 4:49 pm and Hydromorphone (Pian medication) at 5:55 pm andHospital record dated 09/14/2025 reflected: Reason for visit-Abdominal pain and diarrhea. Diagnoses-Chronic abdominal pain Review of Resident #1's Progress notes from 08/14/2025 through 10/03/2025 reflected no evidence that staff had attempted to contact Resident #1's NP or MD regarding triplicate for Resident #1's oxycodone 5 mg. Review of Resident #1's progress notes dated 09/14/2025 reflected written by LVN A reflected: RESIDENT COMPLAINT OF ABDOMINAL PAIN, RESIDENT HAS SOME PRN PAIN MEDICATION, WHICH OXYCODONE 5 MG EVERY 8 HOURS AND TYLENOL 500MG PRN, INSIDE THE CONTROL BOX, THERE IS NO OXYCODONE FIND. NURSE OFFER RESIDENT TYLENOL 500MG SINCE THERE IS NO OXYCODONE. RESIDENT REFUSED AND STATED SHE WILL LIKE TO GO TO HOSPITAL FOR EVALUATION. [XX] PHARMACY WAS CALLED TO ASK IF THE CAN AUTHORIZED NURSE TO TAKEOXYCODONE 5MG. PHARMACY PERSON SAID RESIDENT HAS NOT FILL OXYCODONE BEFORE, NURSE CALLED ON CALL NP. NP STATED SHE CAN'T BE ABLE TO AUTHORIZE. SHE SAID TO GIVE RESIDENT TYLENOL 500MG AND TO DO KUB(Kidney, Ureter and Badder-refers to an x-rays or ultrasound that visualizes these organs, often to diagnose conditions of kidney stones, blockages, or abdominal pain). RESIDENT SAID NO AND STATED THAT SHE WOULD LIKE TO GO TO HOSPITAL.911 NONE EMERGENCY CALLED AND THE CAME AND TRANSFER RESIDENT TO ER FOR EVAL AND TREAT. Review of Resident #1's Assessments reflected that no pain assessment was completed on 09/14/2025 when Resident #1 complained of pain and went to the ER for pain management. Observation of the medication cart on 10/02/2025 at 1:32 pm with LVN A revealed there was no oxycodone for Resident #1 in the facility.Review of pharmacy receipt of medication delivery for Resident #1 reflected Oxycodone 5mg was only delivered on the evening of 10/02/2025. During an interview on 10/02/2025 at 11:26 am Resident #1, she stated I have been asking for my oxycodone, and I have not been getting it. They said it required a triplicate from the Doctor; the doctor will take care of it. Sometimes they would say, maybe the pharmacy will send your oxycodone today. They gave me oxycodone at the beginning of my stay here; I had brought some oxycodone pills with me, and they said it was finished. Resident #1 stated her order for Oxycodone was for every 6 hours as needed, 4 pills a day and she only requested Oxycodone when she was hurting, and it was only 4 pills a day. Last time I had to go to the ER to get pain medication. During an interview on 10/02/2025 at 1:32pm LVN A stated she was the nurse on working with Resident #1 on 09/14/2025 when Resident #1 requested pain medication. LVN A stated there was an order for Resident #1 to get pain medication, oxycodone 5 mg every 6 hours as needed, but there was no Oxycodone available on 09/14/2025 when Resident #1 requested. LVN A stated she called the on-call NP for approval for the triplicate for Resident #1's oxycodone but was told by the on-call NP that that they couldn't send the triplicate to the pharmacy. LVN A stated Resident #1 requested to go to the ER for pain management, Resident #1 called EMS for transport to the ER. LVN A stated she had been talking to the NP regarding Resident #1's Oxycodone, the NP had been calling the pharmacy for refill but, and I didn't know why the pharmacy had not yet sent Resident #1's oxycodone. LVN A stated she spoke with the DON and the ADON regarding Resident #1's oxycodone for pain management not being available. LVN A stated Resident #1 always call EMS to go to the ER for pain management. During an interview on 10/02/2025 at 2:07 pm, the DON stated she had been in her position for about 1 month. The DON stated she was not made aware of Resident #1's pain medication not being available. The DON stated Oxycodone is for pain and was very important. The DON stated she was not told Resident #1 went to the ER for pain management but for things other than pain management. The DON stated Resident #1 not getting her pain medication as ordered had impact on her normal functional daily activities, not being happy, not doing anything normal, would cause the resident refuse ADLs. The DON stated a Focused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 5 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assessment (Pain) on what the resident was complaining of should have been completed, what the pain level and documented to enable staff to know what treatment to provide. On 10/02/2025 at 2: 19 pm LVN A stated she contact Resident #1's MD and requested triplicate for Resident #1's Oxycodone. During an on 10/02/2025 at 2:27 pm the ADON stated he had been in his position for about 1 week. The DON stated If a resident didn't have pain medication as ordered, it would affect the resident's mood and how the Resident interacts with other residents. The ADON stated that the Resident's entire ADLs would be affected, and the Resident wouldn't be able to function. The ADON stated he had not been approached by any nurse or medication aide regarding Resident #1's oxycodone. During an interview on 10/02/2025 at 4:33 pm the MD stated he knew Resident #1 had pain in the past and had been taking pain medication. The MD also stated the facility reached out to him earlier today, 10/02/2025 requesting triplicate/ script for Resident #1's oxycodone. The MD stated he could not remember specifics on if Resident #1 oxycodone had been filled out since she had been in the facility. The MD stated to contact the NP because she had more specific details. During an interview on 10/03/2025 at 09:38 pm the NP stated she was familiar with Resident #1 and Resident #1 had chronic diarrhea that led to abdominal cramps and Resident #1 needed pain medication due to that. The NP stated Resident #1's oxycodone was ordered as needed when Resident #1 was in pain and needed the medication. The NP stated if Resident #1 needed the medication and went to the ER due to the medication not being available, the staff should have contacted her. The NP stated she was not sure if Resident #1's oxycodone was ordered upon admission to the facility. The NP also stated that usually the NP's send the information for triplicate to the MD and the MD signed off on it and sent it to the pharmacy. Review of facility's policy titled Medication Orders dated November 2014 reflected: Purpose The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Review of facility's policy titled Pain Assessment and Management dated reflected: Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.3. Pain management is a multidisciplinary care process that includes the following:a. Assessing the potential for pain;b. Recognizing the presence of pain;c. Identifying the characteristics of pain;d. Addressing the underlying causes of the pain;e. Developing and implementing approaches to pain management;f. Identifying and using specific strategies for different levels and sources of pain;g. Monitoring for the effectiveness of interventions; andh. Modifying approaches as necessary.4. Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure.Standardized pain assessment tool, as indicated per facility protocol; and 2. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Assessing Pain1. Assess the resident at admission and during ongoing assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 6 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment.2. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition.3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain.4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.5. During the pain assessment gather the following information as indicated from the resident (or legal representative):a. History of pain and its treatment, including pharmacological and non-pharmacological interventions.b. History of addiction, past and/or ongoing and related treatment for opioid use disorder (OUD); c. Characteristics of pain: (1) Location of pain;(2) Intensity of pain (as measured on a standardized pain scale);(3) Characteristics of pain (e.g., aching, burning, crushing, numbness, burning, etc.);(4) Pattern of pain (e.g., constant or intermittent); and (5) Frequency, timing and duration of pain;d. Impact of pain on quality of life;e. Factors such as activities, care or treatment that precipitate or exacerbate pain;f. Factors and strategies that reduce pain;g. Symptoms that accompany pain (e.g., nausea, anxiety);h. Physical and psychosocial issues (physical examination of the site of the pain, movement, or activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain);i. Current medical conditions and medications including medication assisted treatment for OUD; andj. The resident's goals for pain management and his or her satisfaction with the current level of pain control. Defining Goals and Appropriate Interventions1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain including whether the pain is acute or chronic.2. Pain management interventions shall address the underlying causes of the residents' pain.3. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. Implementing Pain Management StrategiesEstablish a treatment regimen that is specific to the residents based on consideration of the following: a. The residents' medical condition.b. Current medication regimen. c. History of addiction or opioid use disorder.d. Nature, severity and cause of the pain.e. Course of the illness; andf. Treatment goals. This failure resulted in the identification of an IJ on 10/03/2025. The ADM was notified and provided with the IJ template on 10/03/2025 at 12:34 pm. The following Plan of Removal was submitted by the facility and accepted on 10/03/2025 at 5:00 p m Plan of Removal (POR) - F697 POR Accepted at - 10/03/2025 at 5:00 p m Plan of RemovalImmediate Threat Problem: Medication not available. On 10/3/25, an abbreviated survey was initiated at the facility. On 10/3/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that a condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide effective pain interventions for Resident #1 on 9/14/2025. Resident called for emergency transfer to the ER for pain management. Interventions: One on One in-service with DON and ADON conducted by Administrator regarding oversight of medication order by nurses on 10/3/2025. All nurses and certified medication aides to include PRN, new staff and agency if present are to be in-serviced regarding medication ordering process. The following in-services were initiated on 10/3/2025 by administrator and DON, and any staff member not present or in-serviced on 10/3/2025, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff or PRN staff utilized will receive the following in-services before first shift to be worked.? Nurses and certified medication aides ?Medication Ordering ?Review of orders for new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 7 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admission?Who to report to when medication is needed or not available from e-kit ?Pain management interventions Head to toe assessment to be completed on patient 10/3/2025.Staff will be questioned on in-services randomly, 3x a week for 4 weeks or until compliance is met. Random questioning will be documented and maintained in monitoring binder. Administrator will be responsible for oversight of the staff interviews. DON will conduct competency tests to ensure medication order process is understood and completed. Staff will need to complete tests to identify when medication is to be ordered and identify alternate availability of medication i.e. (e-kit, alternate medication from provider) Medication for resident #1 was obtained in the facility 10/2/2025. The medical director was notified of the immediate jeopardy situation on 10/3/2025 by Administration. Ombudsman was notified of the immediate jeopardy situation on 10/3/2025 by Administration. On 10/3/2025 a complete audit of all narcotic medications for residents was completed with a result of 100% availability of all medications. ADHOC QAPI discussed with IDT on 10/3/2025. Head to toe assessment completed by charge nurse for resident #1 no issues or complaints of pain. All residents that receive pain medications to be assessed for pain by charge nurses and documented into clinical progress notes on 10/3/2025. All residents that receive pain medications to have pain levels assessed Q shift by charge nurses and documented on MARS.Monitoring DON/ADON/ADMIN will interview staff nurses and medication aides weekly for 6 weeks regarding medication ordering procedures, status and any additional concerns. DON/ADMIN/Designee will interview 5 residents weekly for 6 weeks to ensure they are receiving their medication. This will be effective 10/4/2025. VP of Clinical Services will review and monitor weekly monitoring tools for 6 weeks. These monitoring tools will include staff interviews and resident interviews. The Quality Assurance committee will review the findings monthly for 3 months and make changes or recommendations as needed. The Administrator will resolve once no further issues have been identified. Effective 10/4/2025. The Surveyor monitored the POR on 10/04/2025 from 12:20 through 4:15 pm as follows: During an interview on 10/04/2025 at 12:20 pm the DON stated that the Administrator provided 1:1 in service training regarding oversight of medication order by nurses on 10/3/2025. The DON stated she was in-serviced 10/3/2025 by the ADM about the proper way to audit med carts, request medications, check e-kits. Notify MD if resident ran out, but DON can also call pharmacy to reorder. DON completed a competency quiz. New orders are handled by NP and in PCC. DON stated she participated in the skin and pain assessment. DON was responsible for acquiring Narcotics pain medication, responsible for ensuring pain assessment was done daily/q-shift and reviewing orders in PCC and checking that nurses were accessing for pain. The DON stated that all nurses and certified medication aides to include PRN, new staff and agency staff present were in-serviced regarding medication ordering process by the ADON or ADM on 10/3/2025. The DON stated staff present staff present today were the same staff that worked on 10/03/2025 as they work Friday/Sat/Sunday rotation. The DON stated the Licensed nurses completed the pain assessment on all residents on 10/3/2025. The DON stated In-service training of the nurses and CMA was done 10/3/2025 regarding: ?Medication Ordering, ?Review of orders for new admission, ?Who to report to when medication is needed or not available from e-kit, and ?Pain management interventions. New admission yesterday and head-to-the assessment was completed. The DON stated that staff have not been randomly questioned about in-services because in-services were just done. The DON stated she has started conducting competency tests to ensure the medication order process was understood and completed. The DON stated that Medication for Resident #1 was obtained in the facility on 10/2/2025 and proof was provided to the State surveyor yesterday. The DON stated that the medical director and Ombudsman were notified of the immediate jeopardy situation on 10/3/2025 by the Administration. The DON stated that the ADON did a complete audit of all narcotic medications on 10/2/2025 and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 8 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some did follow up on 10/3/2025. The DON stated that the ADHOC QAPI discussed with IDT on 10/3/2025. DON stated all residents that receive pain medications were assessed for pain by charge nurses and documented on the MARS. The DON stated that staff were aware of the monitoring plan and measures in place, but due to the POR accepted less than 24 hours ago, some monitoring has not been done. During an interview on 10/04/2025 at 1:12 pm the Administrator stated all tasks regarding the POR, except for monitoring, had been completed. The Administrator stated some monitoring had been completed. The Administrator stated she notified the Ombudsman and medical director about the IJ. The Administrator stated she provided an in-service to the DON and ADON about narcotic pain medication. The Administrator stated the VP of clinical services provided in-service training to her (Administrator). The Administrator stated that her responsibility regarding acquiring Narcotic pain medication was to contact the pharmacy director about pain medication if her staff exhausted their change of command and could not obtain the pain medication. The Administrator stated nurses would assess pain every shift on the MARS, pain management interventions. The Administrator stated in- services of all nurses and MAs regarding medication orders, how to obtain pain medications would be completed. The Administrator stated she had oversight for monitoring but no direct resident care. The Administrator confirmed each detail on the POR and monitoring plan. The Administrator provided the POR binder, which showed POR details and in-service training. The Administrator stated that the staff interviews for monitoring were documented in the binder. During an interview on 10/04/2025 at 1:22 pm RN D stated she was in-serviced on 10/2/2024 and 10/3/2025 by the DON and ADM about the review of medication, narcotic ordering process, review of orders for new admissions, and who to report to. RN D stated she would review the medications with the provider (MD/NP), and have the provider call in the pain medication to the pharmacy to have it delivered. RN D stated, if resident ran out of pain medication, she would check the Resident for pain, contact the provider to request refill / Triplicate, follow up with pharmacy, and notify the ADON and DON for support to ensure medications were delivered. RN D stated that she completed a test/questionnaire after in-service, and it was reviewed with the DON and ADM to check for understanding. RN D described pain management intervention: repositioning, cold or warm clothes, therapy involved, referrals to pain management to help. RN D participated in the skin and pain assessment that were done 10/2/2025 and 10/3/2025. During an interview on 10/04/2025 at 1:59 pm, LVN E stated she had been in-serviced on 10/4/2025 by the DON and ADM regarding e-kit, when to pull meds out, who to report to about medication ordering, pain management intervention (if resident low on pain medication, when and who to notify about reordering). LVN E stated for new admission, she would call and discuss with the MD, NP, fax orders, call pharmacist to ensure they received the script/Triplicate. LVN E stated, if a Resident was on a PRN narcotic, she would do a pain tool assessment, verify meds, and try to pull the medication out of e-kit. LVN E stated, if residents ran out of pain medication, she would call the pharmacy to get code to pull out of e-kit, reorder or get new script /triplicate by calling the MD and notify DON and ADON. LVN E stated she took a test regarding the in-service and the DON reviewed it with her. LVN stated she participated in the skin and pain assessment on the new admission. During an interview on 10/04/2025 at 2:27 pm MA F stated she normally works the 6 am to 10 pm shift on the weekends, Saturdays and Sundays. MA F stated she was in-serviced today before she started work by the DON on what to do when they are missing pain medications. MA F stated If medications were missing, she had to report to the charge nurse so that they can get it out of the e-kit. MA F stated she would report to the NP if a resident was running out of pain medication. MA F stated if the nurse was unable to pull the pain medication out of the e-kit, she would notify the ADON and DON to get assessment. MA F stated she took a test about the training, and it was reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 9 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with her to make sure she understood the material. During an interview on 10/04/2025 at 2:33 pm MA G works weekend doubles from 6 am to 10 pm shift on Saturday and Sunday. MA G stated she was in-serviced today before she started work by the DON on what to do when they are missing pain medications. MA G stated if medications were missing, she would report to her using her chain of command starting with the charge nurse, ADON, and DON. MA G stated she took a test about the training. During an interview on 10/04/2025 at 2:37 pm the ADON stated he was in-serviced by the DON on 10/3/2025 on narcotic medication ordering, orders for new residents, who to report to if medication was not available. The ADON stated he would call NP for new admissions to call in script/triplicate to pharmacy and medications should come in that night. The ADON stated they have an e-kit that dispenses narcotic pain medication and explained the process to get meds (needs code from pharmacy). The ADON stated he received in-service from the DON on pain management interventions, and he would report to DON and NP if unable to get refills or the medication was not in the e-kit. The ADON stated he participated in skin and pain assessments of resident. He stated the wound care nurse will do skin assessment. The ADON stated his responsibility regarding acquiring Narcotic pain medication was to verify the medication, call the pharmacy, call the provider. The ADON stated the floor nurse was responsible for ensuring pain assessment was done daily. He stated he would audit the process by looking in PCC and reviewing the daily physical paperwork. The ADON stated that he did have a questionnaire/test to complete regarding the in-service training. During a phone interview on 10/04/2025 at 2:51 pm LVN H stated he worked 6 pm to 6 am shifts and was in-serviced by the DON on 10/3/2025 regarding the process for reordering pain medication and the process for new orders and new admissions. LVN H stated it was important to reorder the 7 days before (have 7 days left of pain medication). LVN H stated he would notify the ADON, DON, MD and family members if the medication supply was running low. LVN H stated he would try to get the medication out of the e-kit or from pharmacy. LVN H stated he did not participate in the pain and skin assessments, but he took a test, and it was reviewed with him. During a phone interview on 10/04/2025 at 2:57 pm RN I stated she worked the 6pm to 6am and was in-serviced by the DON on 10/3/2025 regarding the process for reordering pain medication and the process for new orders and new admissions. RN I explained reporting to the ADON and DON if she was unable to obtain pain medication after she confirmed orders with the provider and NP, calling the pharmacy, trying to get it out of the e-kit. RN I stated she completed a questionnaire about the training.Observations of Medication carts revealed sampled Residents pain medications being available. Review of Resident #1's pharmacy receipt reflected Resident #1's Oxycodone 5mg was delivered on the evening of 10/02/2025 in the amount of 60 pills. Review of Resident #1 MAR/TAR reflected Resident #1 was administered Oxycodone 5mg on 10/02/2025 for a pain level of 3. Review of Resident #1's progress notes dated 10/03/2025 reflected the MD was contacted for Resident #1 and pain and skin assessments were completed. Review of sampled Residents progress notes reflected pain and skin assessments were completed on 10/03/2025. Reviewed of facility's POR binder reflected: Reviewed in-service training on oversight of medication orders by charge nurses, reviewing orders for new admission, reviewing received medication, monitoring medications for residents; who to report to when medication is needed or unavailable from e-kit; pain management interventions. Reviewed pain assessment for resident #1. Reviewed staff interviews. Reviewed competency tests. Reviewed medication arrival confirmation, MD notification, Ombudsman notification, narcotic audit, ADHOC QAPI meeting, Resident #1 assessment, resident assessments, and monitoring interviews. An IJ was identified on10/03/2025. The IJ template was provided to the facility on [DATE] at 12:34 pm. While the IJ was removed on 10/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because the facility needs to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 10 of 11 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 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 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 0697 evaluate the effectiveness of the corrective systems Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 11 of 11